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Comparative cost-effectiveness of policy instruments for reducingthe global burden of alcohol, tobacco and illicit drug use

DAN CHISHOLM1, CHRIS DORAN2, KENJI SHIBUYA1, & JURGEN REHM3

1Evidence and Information for Policy, World Health Organisation, Geneva, Switzerland, 2School of Population Health,

University of Queensland, Brisbane, Queensland, Australia, and 3Centre for Addiction and Mental Health, Toronto,

Canada

AbstractAlcohol, tobacco and illicit drug use together pose a formidable challenge to international public health. Building on earlierestimates of the demonstrated burden of alcohol, tobacco and illicit drug use at the global level, this review aims to consider thecomparative cost-effectiveness of evidence-based interventions for reducing the global burden of disease from these three riskfactors. Although the number of published cost-effectiveness studies in the addictions field is now extensive (reviewed briefly here)there are a series of practical problems in using them for sector-wide decision making, including methodological heterogeneity,differences in analytical reference point and the specificity of findings to a particular context. In response to these limitations, amore generalised form of cost-effectiveness analysis (CEA) is proposed, which enables like-with-like comparisons of the relativeefficiency of preventive or individual-based strategies to be made, not only within but also across diseases or their risk factors.The application of generalised CEA to a range of personal and non-personal interventions for reducing the burden of addictivesubstances is described. While such a development avoids many of the obstacles that have plagued earlier attempts and in sodoing opens up new opportunities to address important policy questions, there remain a number of caveats to population-levelanalysis of this kind, particularly when conducted at the global level. These issues are the subject of the final section of thisreview. [Chisholm D, Doran C, Shibuya K, Rehm J. Comparative cost-effectiveness of policy instruments forreducing the global burden of alcohol, tobacco and illicit drug use. Drug Alcohol Rev 2006;25:553 – 565]

Key words: alcohol, cost effectiveness, illicit drug, policy, tobacco.

Introduction

The global disease burden of alcohol, tobacco

and illicit drug use

Alcohol, tobacco and illicit drug use together pose a

formidable challenge to international public health.

Whether expressed in epidemiological, economic or

social terms, the combined burden or impact of these

three lifestyle behaviours is enormous. Rates of use or

consumption of course vary across countries and

indeed whole regions of the world, both in terms of

absolute aggregate burden and in terms of the relative

contribution of alcohol, tobacco and illicit drug use to

these aggregated estimates, but nowhere could be said

to be at all free of the often pernicious consequences

placed on society by these lifestyle behaviours.

Studies of the economic and social impact of sub-

stance abuse are plentiful in number, but are essentially

restricted to high-income countries which, together with

significant differences in the methodology used to

estimate costs, limit their usefulness at the global level.

Nevertheless, country-specific studies have demon-

strated the enormous toll on health and welfare services,

as well as broader social impacts including reduced

productivity resulting from morbidity or premature

mortality, and the effects of alcohol or illicit drug use

on rates of domestic violence or criminal behaviour

[1 – 3]. For example, Single et al. [1] estimated that the

misuse of alcohol, tobacco and illicit drugs cost more

Received 12 March 2006; accepted for publication 19 May 2006.

Dan Chisholm PhD, Evidence and Information for Policy, World Health Organisation, Geneva, Switzerland, Chris Doran PhD, School ofPopulation Health, University of Queensland, Brisbane, Australia, Kenji Shibuya PhD, Evidence and Information for Policy, World HealthOrganisation, Geneva, Switzerland, and Jurgen Rehm PhD, Centre for Addiction and Mental Health, Toronto, Canada. Correspondence toDr Dan Chisholm, Health Economist, Costs, Effectiveness, Expenditures and Priority-setting, Department of Health System Financing, Evidenceand Information for Health Policy, World Health Organisation, 1211 Geneva 27, Switzerland. Tel: þ 41 22 791 4938; Fax: þ 41 22 791 4328;E-mail: [email protected]

Drug and Alcohol Review (November 2006), 25, 553 – 565

ISSN 0959-5236 print/ISSN 1465-3362 online/06/060553–13 ª Australasian Professional Society on Alcohol and Other Drugs

DOI: 10.1080/09595230600944487

than Canadian $18.4 billion in 1992, representing $649

per capita or 2.7% of gross domestic product.

At a more genuinely global and comparative level, the

World Health Organisation has quantified the epide-

miological burden associated with alcohol, tobacco and

illicit opioid use as risk factors for disease in different

regions of the world using disability-adjusted life-years

(DALYs) [4]; see also the review by Rehm et al., this

issue). Figure 1 shows the combined burden for three

mega-regions: developed regions with very low child

and adult mortality (representing 22% of the world’s

population); developing regions with low child and

adult mortality (39%); and developing regions with high

or very high child and adult mortality (39%). Even at

this highly aggregate level of estimation, it is clear that

the burden—70% of which is incurred among the

(adolescent and adult) male population—represents a

public health challenge everywhere, even in high-

mortality developing regions (4% of total burden).

It is arguably in this latter groups of countries, where

fledgling markets are strongest and regulatory struc-

tures weakest, that most attention should be paid to

controlling rates of hazardous drinking and preventing

the transition to more elevated stages of the tobacco

epidemic.

Reducing the global burden of alcohol, tobacco

and illicit drug use

Once the attributable burden of alcohol, tobacco and

illicit drug use has been established, two subsequent

questions for decision-making and priority-setting relate

to avoidable burden (the proportion of attributable

burden that could be avoided via scaled-up use of effec-

tive strategies; [5]) and resource efficiency (determining

the most cost-effective ways of reducing burden).

Building on earlier methods and estimates of the

epidemiological burden of addictive substances at the

global level [4 – 6]; see also Rehm et al., this issue), this

review aims to consider the comparative cost-effective-

ness of evidence-based interventions for reducing the

global burden of disease from these three risk factors.

Concerning illicit drug use, cannabis use accounts for

around 80% of illicit drug use world-wide, but the

focus here is on opioid dependence, because it repre-

sents the major illicit drug problem in most regions of

Figure 1. Global disease burden attributable to addictive substances in 2000 (DALYs per thousand population, by level of development, sex

and risk factor). There may be double counting due to interactions in causing some cancer and injury categories. Thus, the combined estimates

of adding the burden of all three substances represent an overestimate. However, the impact of the categories affected by double counting on the

overall estimate is relatively small. For Australia in 1998 – 99, it was estimated that double counting lead to an overestimate of 2.2% of the

total mortality caused by addictive substances [3]. Based on this estimate, the overall effect of alcohol, tobacco and illicit drugs would be 20.19

DALYs lost per 1000 population rather than 20.64 as indicated in the figure (last column). Source: Annex Tables 10 and 12, World Health

Report, 2002 [4].

554 Dan Chisholm et al.

the world in terms of impact on public health and

public order [7].

In order to achieve this aim, a fundamental analytical

requirement is the presence of a standardised evaluative

methodology which can be used to generate consistent

estimates of cost, effect, or their interaction in terms of

cost-effectiveness. Such a standardised method has

been hard to attain, which has effectively confounded

attempts to systematically compare the efficiency of

different interventions across or even within the three

risk factors considered here. As illustrated below,

however, such a method is now available, as a result

of developments in the health sector-wide analysis of

cost-effectiveness, and it has been applied to a number

of key alcohol and tobacco control strategies [8,9].

Preliminary use of these methods has also been partially

extended to the treatment of opioid dependence, results

from which are included here. Analyses such as these

mean that like-with-like comparisons of the relative

efficiency of preventive or individual-based strategies

are now technically feasible, not only within but also

across diseases or their risk factors. While such a

development avoids many of the obstacles that have

plagued earlier attempts and in so doing opens up new

opportunities to address important policy questions,

there remain a number of important caveats to

population-level analysis of this kind, particularly when

conducted at the global level. These issues are the

subject of the final section of this review.

Current cost-effectiveness methods

and results for addictions policy

Current economic evidence related to addictive substances

In the necessarily brief review of the accumulated

literature to date that now follows on the cost-

effectiveness of interventions for reducing the burden

of tobacco, alcohol and opioid dependence, we dis-

tinguish between personal interventions—such as brief

counselling, nicotine replacement therapy and opioid

detoxification—and non-personal interventions such as

excise taxation, advertising bans and clean indoor air

laws, with a view to drawing out key empirical findings

and methodological differences among studies.

Personal interventions

Alcohol. A distinction needs to be made between

personal interventions targeted on the disease entity of

alcohol dependence versus hazardous drinking (a risk

factor for many diseases including but not restricted to

alcohol dependence). Cost-effectiveness analysis of

treatments for alcohol dependence have covered psy-

chosocial treatments such as motivational enhancement

therapy and medications such as acamprosate or

disulfiram [10,11], but are not the focus for this

review, which deals specifically with the globally

more burdensome problem of hazardous or high-risk

alcohol use.

The only personal intervention aimed at hazardous

drinking that has been subjected to economic evaluation

is brief advice or counselling by a primary care physician

[12]. Using effectiveness results from the WHO’s

Drink-less programme, Wutzke et al. [13] estimated

the cost-effectiveness of different strategies for reducing

alcohol consumption (in Australian dollars). Compared

to a do-nothing scenario, the cost per life-year saved was

estimated to be AUS $645 for a control group (no initial

training or ongoing support), AUS $581 for a no-

support group (5 minutes of initial training with no

further contact or support) and AUS $653 for a

maximal-support group (5 minutes training plus alter-

nate telephone and personal visits every 2 weeks).

In a US primary care setting, Fleming et al. [14]

undertook an economic evaluation of brief physician

advice for problem drinkers, in which patient and health

care costs were compared to the monetised benefits

associated with reductions in emergency department

and hospital use, crime and motor vehicle accidents

(reductions in consumption, although substantial, were

not monetised). Summing the total economic costs and

benefits, the average benefit per subject was $1151 and

the ratio of benefits to costs was more than 5 to 1.

Tobacco. Concerning tobacco control, a substantial

evidence base exists for the cost-effectiveness of smok-

ing cessation programmes (in high-income countries at

least), covering brief counselling as well as pharmaco-

logical interventions such as bupropion and various

nicotine replacement therapies (NRT). A recent sys-

tematic review included no less than 17 economic

studies [15], and concluded that between 1 and 3 life-

years are saved per quitter, each of these additional years

of life achieved at quite a low cost (below £1000 for

NRT versus current practice, for example).

A number of studies have adopted a decision-

analytical framework in order to demonstrate the impact

of improved rates of cessation on mortality and morbi-

dity and to extend comparison beyond a placebo control

group. For example, a decision model was developed for

the UK’s National Health Service, which showed that by

comparison to advice or counselling alone, an extra year

of life saved could be obtained at an additional cost of

$1441 – 3455 for NRT, $920 – 2150 for bupropion and

$1282 – 2836 for their combination [16]. More recently

a dynamic population model applied to a Dutch popu-

lation compared the net cost (adjusted for savings from

avoided smoking-related diseases) per life-year and

QALY gained over 1, 10 and 75 years for telephone

counselling, minimal and intensive counselling by a

primary care physician, NRT and bupropion [17].

Comparative cost-effectiveness of policy instruments 555

With the exception of telephone counselling (which was

expected to be both less costly and more effective than

current practice), incremental cost-effectiveness ratios

were found to fall within a similar range (e1400 – 6200

per life-year gained, e1100 – 4900 per QALY gained).

Comparison of smoking cessation interventions to

other, non-personal interventions has rarely been

attempted, although one recently completed study did

compare the cost per QALY of NRT ($4400) with a

smoke-free policy in the work-place ($506) [18].

Opioid dependence. A wide range of approaches to assis-

ting dependent heroin users are available and include

detoxification and relapse prevention treatment pro-

grammes, therapeutic communities, out-patient drug-

free counselling and long-term opiate substitution

(or maintenance).

Using results from the National Evaluation of

Pharmacotherapies for Opioid Dependence (NEPOD)

Project in Australia, a cost-effectiveness analysis has

compared five in-patient and out-patient detoxification

methods [19]. The buprenorphine-based out-patient

detoxification method was found to be the most cost-

effective method overall, and rapid opioid detoxification

under sedation was the most cost-effective inpatient

method. Also in Australia, Doran et al. [20] compared

the cost-effectiveness of detoxification from heroin using

buprenorphine in a specialist clinic and in a shared-care

setting, and found that buprenorphine detoxification in

the shared-care setting was $17 more expensive per

patient than the costs of treatment at the clinic ($236 per

patient), but with no significant differences in outcomes.

The limited economic evaluations of drug-free

treatment have used data from observational studies

of treatment outcomes in samples of patients with

mixed substance abuse problems, including opioids.

For example, one US study calculated a range of

estimated costs for achieving an abstinent year in 408

patients treated at two different treatment facilities in

the United States [21]. For out-patients with the least

severe drug problems, the cost of an abstinent year was

$7000, whereas the same outcome in patients with

more severe problems who received long-term residen-

tial treatment cost $20 000.

Concerning the cost-effectiveness of substitutive

maintenance treatments for opioid dependence, Doran

et al. [2] conducted a cost-effectiveness analysis of

buprenorphine maintenance treatment (BMT) versus

methadone maintenance treatment (MMT), using

change in heroin-free days as the primary outcome

measure, and concluded that buprenorphine provides a

viable and cost-effective alternative to methadone in the

treatment of opioid dependence. The National Evalua-

tion of Pharmacotherapies for Opioid Dependence

(NEPOD) also evaluated a range of maintenance

treatments. The results of the cost-effectiveness analysis

suggest, for the primary outcome measure of change

in heroin-free days, that LAAM (levo-alpha-acetyl-

methadol) and MMT are statistically equivalent in

terms of cost-effectiveness while MMT (and LAAM)

are dominant treatment options compared with

BMT and naltrexone [23]. Finally, Barnett et al. [24]

measured the cost-effectiveness of addiction treatment

in terms of life-years gained or quality-adjusted life-

years and demonstrated that MMT and BMT are cost-

effective treatment options under certain conditions.

Non-personal interventions

While there is a considerable literature documenting the

social and economic costs of substance abuse, economic

analysis of the relative cost-effectiveness of different

policy instruments has rarely been attempted, hampered

by the lack of population-level data on the costs of their

implementation or their expected impact on health

outcomes. An exception to this general statement is a

comparative analysis of the cost-effectiveness of price

increases and other policies undertaken as part of a

World Bank report on the economics of tobacco control

[25]. The authors of this study used a static model to

estimate the number of smoking-attributable deaths that

could be averted by price increases (via tax), NRT and a

package of other non-price interventions such as

advertising bans and information dissemination [26].

Cost-effectiveness was expressed in terms of US dollars

per DALY saved, calculated by weighing approximated

public-sector costs against the years of health life saved.

Price increases were found to be the most cost-effective

intervention ($3 – 70 per DALY saved in low- and

middle-income regions of the world, $83 – 2771 in high-

income countries), considerably more cost-effective in

fact than either NRT ($280 – 870 and $750 – 7206,

respectively) or a package of non-price interventions

other than NRT ($36 – 710 and $696 – 13 924, respec-

tively). Although this study goes beyond others in its

attempt to generate economic evidence relevant to

policy-makers, it is heavily undermined by its assump-

tion that the costs of non-personal interventions can be

expressed adequately as a fraction of GNP (0.005 –

0.02%).

Methodological limitations of the current

economic evidence base

Although the number of published cost-effectiveness

studies in the addictions field is now extensive, briefly

and not at all comprehensively reviewed above, there are

a series of practical problems in using them for sector-

wide decision making [27,28]. The first is that most

published studies take an incremental approach,

addressing questions such as how best should small

changes (almost always increases) in resources be


allocated, or whether a new technology is more cost-

effective than the existing one it would replace. Tradi-

tional analysis has not been used to address whether

existing health resources are allocated efficiently, despite

evidence that in many settings current resources do not in

fact achieve as much as they could [29,30].

The second problem is that most studies are very

context-specific. The efficiency of additional investment

in an intervention aimed at a given health problem

depends partially on the level and quality of the existing

health infrastructure (including human resources). This

varies substantially across settings and is related to a

third problem—individual interventions are almost

always evaluated in isolation despite the fact that the

effectiveness and costs of most will vary according to

whether other related interventions are currently under-

taken or are likely to be introduced in the future.

A fourth methodological limitation all too apparent

from the cursory review above relates to the multiplicity

of health outcome measures used, ranging from the

very specific (change in heroin-free days, for example)

to the very generic (life-years saved or quality-adjusted

life-years gained). This makes it quite impossible to

compare the efficiency of different interventions against

a common standard. Related to this is the decision to

include or exclude other, non-health outcomes, which

is likely to alter radically the findings and implications

of an economic evaluation. By including and measuring

in monetary terms the consequences of brief physician

advice on the incidence of criminal acts and road traffic

collisions, for example, Fleming et al. [14] provide a

very different perspective—a cost – benefit approach—

and set of findings to studies that only considered direct

health effects of brief interventions.

Two final concerns relate to uncertainty and scale

effects. Although there is now increasing attention

given to uncertainty in the theoretical literature on cost-

effectiveness analysis, full and appropriate handling of

uncertainty in published economic evaluations is still

not reported in a majority of studies [31]. This makes it

unclear how certain policy-makers can be that one

intervention is more efficient than another. Uncertainty

when interventions are inter-related in terms of costs

and effects is an even more complex issue. Similarly,

analysts rarely estimate costs and effects at different

levels of coverage or scale, so do not provide policy-

makers with important information about how far they

should expand (or contract) an intervention.

New developments in the generation

of economic evidence for addictions policy

Cost-effectiveness methodological framework

Until quite recently, there had been only a limited

connection made between disease burden estimates

and the generation of cost-effectiveness evidence,

despite this being an overall objective of the Global

Burden of Disease study. In response to this need,

WHO developed a form of economic evaluation called

generalised cost-effectiveness analysis (GCEA),

which—via its CHOICE project (CHOosing Interven-

tions that are Cost-Effective)—was designed to allow

policy-makers to evaluate the efficiency of the mix of

health interventions currently available and to maximise

the generalisability of results across settings [32,33]. At

the same time, it sought to rectify some of the

aforementioned problems of traditional CEA by in-

corporating interactions between interventions in terms

of costs and effects as well as by evaluating interven-

tions at different levels of coverage. GCEA allows for an

assessment of the efficiency of the current mix of

interventions by analysing all interventions and combi-

nations incremental on doing nothing, sometimes

referred to as a null or ‘do nothing’ scenario [32,33].

This does not mean assuming that no interventions

were ever undertaken, something that is not feasible or

necessary. Operationally, the counterfactual that has

been adopted in applied studies is defined in terms of

what would happen to population health if all inter-

ventions being provided now were stopped [8,9,34].

Consider Figure 2, in which two sets of interventions

are depicted, one for reducing exposure to hazardous

alcohol use, the other for reducing exposure to tobacco

use, for a region consisting of Latin American and

Caribbean countries with low levels of child and adult

mortality—designated here as AmrB ([8,9]; underlying

data are also provided in Table 1). The vertical axis is

the yearly cost of the intervention in a standardised

population of 1 million people, in international dollars,

while the horizontal axis measures health improvements

in terms of disability-adjusted life-years (DALYs)

averted. If a country could select its interventions from

scratch and if efficiency were the only objective, it would

first choose the intervention with the lowest slope first,

the lowest cost per unit of health effect (TOB4, a high

rate of taxation on tobacco products). As resources

increase it would move to TOB12 (a combination of

excise tax plus a comprehensive advertising ban), as the

slope of the line TOB4 to TOB12 is lower than that

from the origin to ALC6. Should more resources

become available, it would also purchase ALC6 (a high

rate of tax on alcoholic beverages), the most cost-

effective intervention for reducing hazardous alcohol

use, and this process continues.

Let us assume, however, that a country decided not

to tax alcohol products, relying instead on the enforce-

ment of drink-driving laws via random breath-testing of

drivers (ALC3). Traditional incremental analysis would

suggest that if new resources became available, it would

be most efficient to move from ALC3 to ALC2 (brief

physician advice for heavy drinkers), and then to the


combination of these (ALC9). Without reference to a

common starting point (of doing nothing), however,

such an analysis fails to identify that ALC3 is an

inefficient use of resources compared to other single or

combined interventions for alcohol or tobacco control,

thereby providing decision makers with incomplete and

potentially misleading information.

Accumulated cost-effectiveness evidence for addictive

substances

Generalised CEA has been applied to a range of personal

and non-personal interventions for reducing the burden

of addictive substances. Details of the methods and data

sources employed in the calculation of population-level

costs and effects can be found elsewhere [4,8 – 9,35,36].

Here, we summarise these methods only very briefly,

and then provide results for three illustrative WHO

sub-regions, each representing one of the distinct levels

of economic development used earlier in relation to

disease burden: American sub-region AmrB (countries

with low rates of child and adult mortality, for example

Brazil or Mexico); European sub-region EurA (coun-

tries with very low child and adult mortality, for

example France or Norway); and South East Asian

sub-region SearD (countries with high child and adult

mortality, for example India or Nepal).

Analyses of alcohol and tobacco control strategies

used standard WHO – CHOICE methods and tools,

whereby burden averted via the implementation

of evidence-based interventions was compared to a

counterfactual scenario of no intervention using a state

transition population model [33]. Costs were esti-

mated using a bottom-up, ingredients approach built

up from the prices and quantities of resources needed

at the programme-level, and where appropriate

(e.g. nicotine replacement therapy, brief interventions

for heavy drinkers) at the patient- or facility-level.

Cost-effectiveness analysis of opioid dependence treat-

ments was carried out as part of the second edition of

Disease Control Priorities in Developing Countries [30],

which overlaps closely with CHOICE methodology

but uses US rather than international dollars to report

costs and removes age-weights from the estimation of

DALYs. Here, all costs are expressed in international

dollars (I$)—which seek to adjust for differences in

purchasing power and thereby facilitate comparisons

across settings—and, along with DALYs, are dis-

counted at a rate of 3%. Age-weights were not applied

to health effects for the present analysis, but previous

analyses have shown that over 20% more DALYs are

averted when these are used, due to the fact that

substance use is highest among people of working

age [8,9].

Figure 2. Costs and effects of interventions for reducing alcohol and tobacco use (WHO American subregion AmrB).


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Alcohol use

Intervention analysis carried out to date relates to the

risk factor hazardous (or heavy) alcohol use—defined as

an average rate of consumption of more than 20 g pure

alcohol daily for women and more than 40 g daily for

men [37,38]—which represents at least 75% of the total

attributable burden associated with alcohol use [35].

Recent reviews of measures to reduce alcohol misuse

[12,38] assessed the quality of evidence for four types of

interventions specifically aimed at reducing high-risk

alcohol use: (1) policy and legislative interventions,

including taxation on alcohol sales, drunk-driving laws,

restricted licensing outlets and advertising control; (2)

measures to enforce these laws more effectively, for

example random breath-testing of drivers; (3) mass

media/awareness campaigns; and (4) brief interventions

with individual high-risk drinkers. Based on these

reviews, the following strategies and intervention effects

were included in the analysis [9]: drinking-driving

legislation and random breath testing, taxation on

alcoholic beverages, reduced hours of sale in retail

outlets, and advertising bans (all population-based

interventions) and so-called brief interventions (an

intervention based on personal behaviour). Mass media

or school-based awareness campaigns were omitted, on

the grounds that evidence for its effectiveness was weak,

both in terms of methodological quality and in terms of

their actual effect on consumption (use of such

interventions, however, may still be used to generate

awareness or address the right to be informed)

[12,38,39].

Results for three illustrative WHO sub-regions are

presented in Table 1. There are very substantial

differences in costs and effects (standardised to 1

million population), both between interventions and

between the three sub-regions. The most costly

interventions tend to be random breath testing (due

to the need for regular sobriety checkpoints adminis-

tered by law enforcement officers) and brief advice in

primary care (provision of the intervention itself, plus

programme costs associated with training). Other

interventions including taxation had a cost per capita

in the range I$ 0.04 – 0.45, depending in part on the

efficiency of the taxation collection system and the

degree of anti-drinking sentiment. Where the preva-

lence of heavy drinking is high (more than 5% of the

total adult population, as in Americas sub-region

AmrB and European sub-region EurA) taxation was

the most effective and cost-effective strategy (each

DALY averted costs less than I$ 500). By contrast, tax

is actually least effective and efficient in South East

Asia sub-region SearD, where low rates of heavy

consumption appear to favour more targeted ap-

proaches such as breath-testing and brief physician

advice.

Tobacco use

Countries that have adopted comprehensive tobacco

control programmes—involving a mix of interventions

including a ban on tobacco advertising, strong warnings

on packages, controls on the use of tobacco in indoor

locations, high taxes on tobacco products and health

education and smoking cessation programmes—have

had considerable success in reducing tobacco-related

mortality [25,40]. The costs and effects of each of these

strategies have been assessed [4,8]. Concerning taxa-

tion, three rates were evaluated: the current average

level across six WHO regions (a 79% mark-up), the

current maximum observed across these regions

(a mark-up of 300%) and double the current maximum

(a mark-up of 600% corresponding to a situation where

taxes account for 89% of the final retail price).

The benefits of anti-smoking interventions for

population health (in terms of DALYs) were estimated

through the impact of reduced smoking on the

incidence of cardiovascular disease, respiratory disease

and various forms of cancer. The interventions, not

surprisingly, have a larger impact on population health

in regions with a high prevalence of tobacco use,

especially those in the second or third stage of the

tobacco epidemic (including Americas sub-region

AmrB and South East Asia sub-region SearD).

As with alcohol control strategies, but to a much

lesser extent, costs and cost-effectiveness vary across the

three sub-regions shown in Table 1, not only because of

variations in exposure to tobacco but also differences in

the efficiency of the tax collection system, the degree of

anti-tobacco sentiment and the amount of smuggling. If

only one intervention can be chosen, taxation is the

intervention of choice in all regions. Not only does it

have the greatest impact on population health, but it is

also the most cost-effective option (one DALY is

averted at a cost of less than I$ 100). Taxation also

raises revenue for governments. To achieve greater

improvements in population health, the combination of

taxation, comprehensive bans on advertising, and

information dissemination activities would be affordable

and cost-effective in all of the sub-regions illustrated

here. Although nicotine replacement therapy is not a

very cost-effective intervention, and would considerably

add to the cost of other anti-smoking activities, the

additional expense would be justified on purely cost-

effectiveness grounds in higher-income sub-regions.

Opioid dependence

Concerning the potentially avoidable disease burden

from opioid dependence, two pharmacological mainte-

nance treatments have been assessed using a cost-per-

DALY method (methadone and buprenorphine; MMT

and BMT). Oral methadone maintenance treatment


(MMT) substitutes a long-acting, orally administered

opioid for (the shorter-acting) heroin, with the aim of

stabilising dependent heroin users so that they are amena-

ble to rehabilitation. Buprenorphine is a mixed agonist –

antagonist that also blocks the effects of heroin. Meta-

analyses have found that buprenorphine is effective in the

treatment of heroin dependence [41] and of equivalent

efficacy to MMT when delivered in primary health care

and specialist treatment settings in Australia [42].

For the disease modelling exercise, prevalence data

and population attributable fractions related to opioid

dependence were taken from the comparative risk

assessment [43]. Using a baseline treatment coverage

rate of 50%, maintenance treatment is estimated to

reduce the average level of disability associated with

opioid dependence by a quarter, and mortality by 25%

(methadone) and 20% (buprenorphine), respectively

[36]. Cost estimates were based on an earlier economic

evaluation [22], which estimated the cost of MMT at

AUS $1415 and BMT at AUS $1729 for 6 months of

treatment. These estimates were subsequently con-

verted into international dollars and annual estimates of

treatment cost.

Results are presented in Table 1. There are again

quite wide discrepancies in DALYs averted between

regions, which primarily reflect differences in popula-

tion attributable fractions. The cost-effectiveness ana-

lysis suggests that for MMT the cost per DALY averted

ranges from a low of I$ 458 in America’s sub-region

AmrB to more than I$ 2500 in South East Asia sub-

region SearD. Because the methods and data used to

estimate avoidable DALYs are subject to certain

limitations (see Discussion), the results should be

considered preliminary.

Sectoral comparison of intervention cost-effectiveness

for addictions control

Use of a standardised approach to the evaluation of

costs and effects provides the opportunity to make like-

with-like comparisons of interventions across different

health conditions. Figure 3 depicts the costs, effects and

cost-effectiveness of selected interventions for reducing

alcohol, tobacco and drug use for one of the regions

discussed above, WHO European sub-region EurA

(countries with a combined population of 410 million

that have very low rates of child and adult premature

mortality). Here, costs and effects are plotted on a

logarithmic scale in order to provide a ‘bird’s eye’ view

of the comparative cost-effectiveness of the various

Figure 3. Costs, effects and cost-effectiveness of selected interventions for reducing alcohol, tobacco and drug use in WHO European sub-

region EurA. Note: Perforated diagonal lines are cost-effectiveness isoquants, each of which represents one order of magnitude difference in the

cost associated with one averted DALY. For example, interventions falling below the isoquant closest to the south-east corner have a cost-

effectiveness ratio below I$ 100 per DALY averted. Source: see Table I.


strategies. Each diagonal isoquant represents one order

of magnitude difference in cost-effectiveness terms,

ranging in this instance from I$ 100 – 10 000 per DALY

averted. While lacking precision, use of such a broad-

brush perspective can usefully inform policy-makers

about what really makes a difference and what does not,

and in fact may represent a more appropriate informa-

tion set than exact ratios given the inherent uncertainty

surrounding point estimates of cost-effectiveness.

In this region of Europe, for example, total costs and

total effects per 1 million population vary substantially

(for example, cost per capita ranges from I$ 0.2 to more

than I$ 4, while effects range from a few hundred to a

few thousand DALYs). Taxation has the highest impact

on population health and the lowest cost of implemen-

tation (cost per DALY 5 I$ 500), while personal inter-

ventions such as nicotine replacement therapy, brief

physician advice and opioid maintenance treatment are

the least cost-effective (cost per DALY 4 I$ 1000).

Although such findings may appear intuitively obvious

in a population with relatively high rates of substance

abuse, this analysis provides some underlying evidence

for these pre-sentiments.

Discussion

The limits and limitations of economic modelling

At the methodological level, the application of a broad

sectoral approach using whole regions of the world as

the unit of analysis clearly places important limits on its

use in specific country contexts, as demographic,

epidemiological or treatment characteristics may not

coincide with estimates for the region as a whole. In

addition, extrapolation of intervention effect sizes from

relatively information-rich countries to other socio-

cultural settings lessens the precision of derived

estimates of population-level health gain. Work is now

under way in a number of developed and developing

countries to ‘contextualise’ regional estimates down to

the national level, whereby local investigators replace

regional epidemiological rates, cost estimates and effect

sizes with locally derived values [28].

A further methodological issue that invariably courts

its fair share of debate is the use of the DALY, both as a

summary measure of population health and as a

primary measure of intervention outcome [45]. Some

of the most heated debate is around issues that can be

rather easily dealt with (such as use or not of age

weights and the preferred discount rate), but there

remain important constraints concerning the scope of

DALYs as an outcome measure, such as its inability to

capture potential health gains beyond the person at-

risk (such as informal caregivers). As a strictly

health-related measure, by definition it is also not

equipped to capture non-health outcomes, which in the

context of substance abuse may constitute an im-

portant component of the relative superiority of one

intervention over another.

On this note, there remain considerable challenges in

the appropriate measurement of certain societal costs

and effects falling outside the boundaries of the health

system. Thus, the present analysis has not been able to

capture potential reductions in (work-force and house-

hold) productivity losses among high-risk drinkers or

illicit drug users, nor does it incorporate the economic

costs associated with addiction-related crime, violence

and harm reduction. Assuming these consequences

could be measured and valued reliably, their inclusion

within the evaluative framework of a comparative

economic analysis would certainly shift the goal posts,

particularly as the key consequences in question

(e.g. property damage, violence, injuries) apply to

alcohol and opioid use but not to tobacco use.

Compared to analyses that only consider health

benefits, their inclusion would also have the effect of

enhancing the relative efficiency and policy attractive-

ness of these strategies vis-a-vis other potential areas of

health investment that do not exhibit these negative

spill-over effects. Building in part on previous develop-

ments in the area of costing the social costs of substance

abuse [1 – 3], work is under way at WHO to develop

internationally applicable guidelines and methods for

measuring and valuing these non-health consequences.

Turning to measurement issues, it is important to

note that despite the adoption of the same overarching

methodological standards, there remains room for

divergence in the analytical assumptions that can be

and are made. Two examples relating to cost measure-

ment and valuation will suffice here. First, as seen in

Table 1 and Figure 3, there are quite notable differences

in the costs of taxation policies for alcoholic versus

tobacco products. These differences, which vary in

magnitude across regions, can be accounted for by the

fact that the assumed quantity of manpower and other

resources needed to administer and enforce tobacco

taxation were calculated before the adoption of a more

generic set of WHO – CHOICE quantity assumptions

for tax enforcement (which were used for the alcohol

analysis). Secondly, and owing to the shortage of

available data from low- and middle-income countries,

opioid maintenance treatment costs are based on a

single cost estimate from a cost-effectiveness study

undertaken in Australia, subsequently extrapolated and

adjusted to the relative price levels pertaining in other

regions of the world. Such an approach evidently carries

stronger assumptions than one based on a bottom-up

analysis of quantities and their respective prices, and

may lead to an under-estimation of the actual expected

costs that would be incurred in significantly scaling-up

the availability of opiod maintenance treatment in

settings where this has yet to happen.


Although a sector-wide approach to cost-effectiveness

analysis sets out to provide data on a wide range of

interventions (including combination strategies), a

number of potentially applicable interventions were

not covered in this analysis because of lack of evidence.

This is especially true for illicit drugs, where not only

treatments of non-opioid substances were excluded, but

also interventions aimed at preventing drug abuse (due

in part to an inexact understanding of what components

of a combined policy response have been successful).

For example, Switzerland simultaneously witnessed a

massive expansion of methadone maintenance treat-

ment, the introduction of heroin-assisted treatment, a

massive expansion of needle exchange, the opening of

several safe injection facilities as well as changes in the

way that repression activities were conducted [46].

A final constraint of sector-wide approaches is its

emphasis on whole populations, which may be at the

expense of sub-populations that are at particular risk

(including adolescents and indigenous populations in

countries such as Australia and the United States).

There is, of course, nothing from a methodological

point of view that precludes such a focus on sub-

populations, but there remain gaps in both the

epidemiology and intervention effectiveness literature

for these selected groups.

Policy implications

The present analysis offers a novel approach to the

generation of economic evidence capable of broadly

informing substance abuse public health policy in a

wide range of epidemiological settings. Resulting

estimates of cost-effectiveness—pitched in order-of-

magnitude terms—can inform policy-makers, not only

in relation to the efficiency of existing strategies (with

respect to health outcomes), but also by identifying

priorities for substance abuse interventions in the

future. In this respect, it should be noted that in each

of the sub-regional populations considered, the most

efficient interventions for responding to the three risk

factors considered here are projected to show a

favourable ratio of cost to effect (each DALY averted

by these efficient strategies costs less than average

annual income per capita, a threshold proposed by the

Commission on Macroeconomics and Health for an

intervention to be considered very cost-effective [47]).

Furthermore, use of a common methodology enables

some comparability with cost per DALY estimates for

other risk factors or disease entities, which may

constitute an important argument in considering

priorities in the reallocation of scarce health care

resources to increase levels of population health. Of

course, if it is possible to achieve better standardisation

of cost assessment, the comparability will be further

improved.

A primary policy conclusion to be drawn from the

analysis is that, in regions with high or moderate rates of

tobacco and high-risk alcohol use, there are a number

of intervention strategies that can have a notable impact

on population health, including both individual-based

interventions such as nicotine replacement therapy or

brief physician advice as well as population-wide

measures such as taxation of alcoholic or tobacco

products. Of these, taxation has the most sizeable and

least resource-intensive impact on reducing the aver-

table burden of tobacco and high-risk alcohol use.

In regions where high-risk alcohol use represents less of

a public health burden, other intervention strategies

that restrict the supply or promotion of alcoholic

beverages appear to be promising and relatively cost-

effective mechanisms, although there is a clear need for

greater empirical support for the efficacy of these

interventions in these localities before their widespread

implementation could be considered.

Another clear conclusion from this analysis is that

governments have an important role in encouraging risk

reduction strategies for legal substances. Clearly, many

of the most cost-effective strategies are linked to

government actions; this is not only true for taxation

but also for strategies such as bans on advertisement,

random breath testing or reduction of access to legal

goods. Unfortunately, this often leads to a dilemma in

the sense that the described governmental interven-

tions, especially in the area of alcohol control, are often

unpopular and face considerable resistance from the

respective industries and their lobby groups [48]. As a

result, governments faced with considerable harm

caused by legal substances have often chosen the ‘way

of least resistance’ and implemented less cost-effective

measures such as mass-media campaigns [38,48].

In the area of illicit drug use, many of the cost-

effective government options for reducing substance-

related harm are not specifically relevant for the reason

that illegal substances cannot be controlled via mechan-

isms such as taxation or advertisement bans. That does

not mean, however, that governments should not plan

interventions in other areas such as developing the most

cost-effective repression strategies, nor does it mean

that prevention and harm reduction is impossible.

However, for future improvements there would be a

need for not only more empirical evidence on various

options (including consistent assessment of key non-

health outcomes), but also a lesser role for ideologically

motivated policy decisions.

Overall, substance abuse-related burden of disease

and social harm could be further reduced by a con-

siderable degree. This contribution tried to summarise

the knowledge on the differential cost-effectiveness of

various policy options. While the methodology was

shown as promising, its further application to addic-

tions policy is only likely to yield fruit if a wider


evidence base for the implementation of different

interventions in less-resourced countries is established.

Disclaimer

The views expressed in this paper are those of the

authors and not necessarily those of the World Health

Organisation.

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