COLOMBIA Y LA DANZA

Figure 23 - Illustration of recurrent communication styles – Fear arousing appeal. Source: DORS

3.2.2 Cost-effectiveness of the PSAs

So what are the conditions necessary for a PSA campaign to successfully encourage healthy behaviours against smoking in the long term? To what extent can the successes and failures of previous campaigns be useful in teaching important lessons to those planning PSA anti-smoking campaigns in the future?

It remains poorly understood what are the key elements for an efficient PSA against tobacco consumption – even though the evident differences between a PSA and a commercial advertising are well known, since they are grounded on their opposite nature (and this of course implies also a different assessment of their cost-effectiveness).

PSAs, in fact, are non-commercial advertising aimed at achieving attitudinal and behavioural changes in the citizens - rather than the purchase intentions and consumer behaviour: for instance, large amounts of money, time and effort are poured into mass media campaigns, both local and national in scope, each year in various attempts to get the public to stop smoking. However, as already mentioned, past experience has shown that the success of these types of interventions has varied greatly and that often the effectiveness of such efforts is difficult to measure (Hornik, 2002).

Generally, the effectiveness of an anti-smoking campaign is measured on the basis of the gain obtained in the public health after having aired the campaign, as well as on the basis of the changes in attitudes, beliefs or behaviour (increases in awareness, change of the negative attitudes, increase in the number of calls to quit lines, etc.) and, finally on the basis of the media impact (positive discussion and appreciation in social media).

In order to measure the effectiveness of a campaign, standard economic evaluation designs are usually applied, such as Cost-Effectiveness Analysis (CEA), Cost Utility Analysis (CUA) or Cost Benefit Analysis (CBA) – source: Atusingwize et al. (2015).

CEA is calculated in terms of incremental cost per outcome (eg, cost per additional quitter) in relation to natural units (eg, life years

CBA benefits are converted to monetary units to be compared with costs, deriving a cost benefit ratio.

Concerning the first two indices, CEA and CUA, the main result is usually expressed as an incremental cost effectiveness ratio (ICER), which is the ratio of the change in costs to incremental benefits of an intervention.

Governments or other Institutions could use these resources by making a judgment about the maximally acceptable cost per unit of outcome. Even if no clear ICER thresholds are declared, those could be deducted by funding allocation, for instance Australia is likely to have a threshold of AU$69900/QUALY, New Zealand NZ$20000/QUALY and Canada CAN$80000/QUALY (Cleemput et al., 2008)

Concerning the PSAs collected in the database (see paragraph 5.2.5) created by Brainsigns for the SFB project, for 3 out of 20 of them, a cost-effectiveness analysis has been performed (so related data results are available):

1. Truth Orange (USA, 2000-current) – (Holtgrave et al., 2009)

2. Australian National Tobacco Campaign (NTC) (Australia, 1997)⁵⁷

3. Centers for Disease Control and Prevention (CDC) (USA, 2012-2015)⁵⁸

Concerning the “Truth” campaign, Holtgrave and colleagues (Holtgrave et al.,2009) performed standard methods of cost and cost–

utility analysis, in accordance with the U.S. Panel on Cost-Effectiveness in Health and Medicine. Main results provided by the authors highlighted that during the period 2000–2002, the total expenditures were approximately $324 million, aimed at developing, delivering evaluating, and litigating the truth campaign - but it is estimated that the campaign recouped its costs and that approximately $1.9 billion in medical costs was averted for society.

Therefore, the base-case cost–utility analysis result indicated that the campaign was cost saving.

Concerning the “NTC” campaign, instead, Hurley and Matthews (Hurley and Matthews, 2008) applied the quit benefits model (QBM), a Markov-cycle simulation model was used to predict the benefits of smoking cessation; additionally measures of effectiveness considered were cases of lung cancer, acute myocardial infarction (AMI), stroke and chronic obstructive pulmonary disease (COPD) avoided; deaths prevented, and life-years and quality-adjusted life-years (QALYs) gained. Furthermore, they conducted an estimation of the savings in healthcare costs obtained by prevention of the four abovementioned smoking-associated diseases: the authors calculated that the NTC campaign, notwithstanding the AU$9 million spent for being realized, brought to the prevention of around 55 000 deaths, a gain of 323 000 life-years and 407 000 QALYs, and healthcare cost savings of AU$740.6 million. The NTC, therefore is considered to be both cost saving and effective.

Concerning the “CDC” campaign, Xu and colleagues(Xu et al., 2105) estimated the number of sustained cessations; premature deaths

averted; undiscounted life years

(LYs) saved; and quality-adjusted life years (QALYs) adjusted by the campaign. In view of the $48 million cost for the campaign, CDC

57 Hurley and Matthews, 2008

58 Xu et al., 2015

spent approximately $480 per quitter, $2,819 per premature death averted, $393 per LY saved, and $268 per QALY gained. Furthermore, from a health perspective, the campaign saved about 179,099 QALYs and prevented 17,109 premature deaths.

Summarizing the results: CDC was concluded to be cost-effective and successful at reducing smoking-attributable morbidity and mortality. The sum of these three cases, calculating the percentage of the costs for the campaign in comparison to the medical cost saved, states that effective campaigns amount to small percentages of the savings: approximately 17% Truth, 1.2% NTC and 33.3% CDC. Anti-smoking campaigns can be extremely cost-effective, although unfortunately it is difficult to compare different studies, so as to define which types of campaigns are most cost-effective.