Cost–Utility Analysis of the National truth® Campaign to Prevent Youth Smoking

Introduction 

The truth® campaign, launched in February 2000 by the American Legacy Foundation (ALF), is the largest national youth smoking prevention campaign and the only national campaign not directed by the tobacco industry. Its goal is to capitalize on the desire of youth aged 12–17 years to be rebellious and independent, by exposing them to facts about the industry's deceptive practices and encouraging them to make their own choices about tobacco. The campaign was created by the ALF, which was founded as a result of the 1998 Master Settlement Agreement between the tobacco industry, 46 states, and five U.S. territories.

In February 2005, the results of an evaluation of smoking behavior were published in the American Journal of Public Health.1 The evaluation found that 22% of the overall decline in youth smoking that occurred between 1999 and 2002 was directly attributable to the truth campaign launched in 2000.1 By 2002, smoking rates among youth were 1.6% lower than they would have been in the absence of the campaign: this equates to approximately 300,000 fewer youth smokers in 2002 as a result of truth.1

A key question about any prevention program is whether the economic investment in the program can be justified by the public health outcomes. Although there are some economic evaluation studies of smoking cessation and of prevention programs in small geographic areas,2 no economic evaluation of a national social marketing campaign (such as truth) has been done in the U.S. Therefore, this paper retrospectively addresses the following questions: (1) What were the total costs of developing and delivering the truth campaign; (2) What is the cost per quality adjusted life year (QALY) saved by the truth campaign; and (3) How does this cost per QALY saved compare to other public health and medical interventions.

Results 

The cost analysis and cost–utility results are displayed in Table 1, Table 2. During 2000–2002, expenditure data reveal that just over $324 million was spent to develop, deliver, evaluate, and litigate the truth campaign. The base-case result demonstrates that the campaign was cost saving. Indeed, the estimate from the current study is that the campaign recouped its costs and that just under $1.9 billion in medical costs was averted for society. The optimistic case also yields cost-saving results, estimating that almost $5.4 billion in medical costs were saved over and above the campaign costs.

By definition, the pessimistic case cannot yield cost-saving results because it assumes that when a smoking career is prevented, the client lives longer and thereby incurs additional medical resources. However, the pessimistic-case analysis yields an estimate that the cost per QALY saved is $4302. This cost per QALY saved is an order of magnitude under any readily accepted standard for determining whether an intervention is cost effective to society (so even if the parameter of a $2609 cost per smoking career prevented increased tenfold, the result would still indicate cost effectiveness in the pessimistic case).

Discussion 

The cost–utility analysis conducted here indicates that even though more than $324 million was expended over 3 years to deliver the truth antismoking advertisement campaign, the expenditures yielded excellent returns. The base-case and optimistic-case analyses both indicate that the campaign was cost saving to society. The pessimistic-case analysis (which was constructed in a very cautious manner that did not allow for the possibility of a cost-saving finding) indicates that the cost per QALY saved would clearly be considered cost effective. It is worth noting that, by assigning a cost for medical care to each potential tobacco-attributable death averted, this pessimistic case fails to account for the many benefits these lives represent to society.

Of course, this study is subject to several limitations. Of necessity, a prospective economic evaluation is preferable to a retrospective one. However, a historically unique campaign is being examined here, so a prospective analysis is by definition impossible. Still, very cautious estimates have been employed in this retrospective analysis, and it is not believed that a prospective analysis would not have led to a different overall qualitative conclusion.

Another potential limitation is that the original estimate of the number of youth who were prevented from becoming smokers is based on the Monitoring the Future survey,13 which is conducted in schools with students in Grades 8, 10, and 12; those data do not reflect youth who have dropped out of high school nor those in Grades 9 or 11. As such, they may be somewhat limited in their ability to represent the entire U.S. youth population. However, this data collection method is considered one of the most valid and comprehensive surveillance mechanisms available for tracking youth substance use trends. Another limitation of the study is that it makes use of repeated cross-sections rather than longitudinal survey data, which reduces the strength of the causal inference about the effect of truth exposure on youth smoking behavior.1

The cost utility of the truth campaign has major policy implications for a variety of reasons. First, the campaign has led to far fewer youth initiating smoking, and thus it will avert future healthcare costs of roughly $1.9 billion (and perhaps ranging as high as $5.4 billion). Collectively, these nonsmokers will be spared marked levels of human suffering, disability, and death. Under the pessimistic analysis, the cost per QALY is substantially below the cost of other major prevention interventions (e.g., breast cancer screening14; see also https://research.tufts-nemc.org/cear/default.aspx for a comprehensive registry of cost–utility analyses). Therefore, this intervention should be sustained and indeed expanded to maximize its positive effect.

The campaign was created by the ALF, a public charity established through litigation between state Attorneys General and the tobacco industry in a negotiated settlement. Under this settlement, funding to the ALF was dependent on the collective total market share of the four tobacco manufacturer participants reaching 99.05 or higher—an extremely unlikely scenario. As a result, the ALF received its last payment from the settlement in April 2008 and has been slowly reducing its expenditures on the truth® campaign over the past few years. In 2009, the ALF and its truth campaign will be funded solely from income generated from its reserve fund. Maintaining a reserve fund to support the ALF and its efforts was implemented to guarantee its existence in perpetuity or at least until youth and adult smoking rates reach negligible levels.

Given the efficacy and cost effectiveness of the truth campaign and other potential mass public education campaigns like it,15 support should be provided through public funds, philanthropy, and air time donated by the various media outlets. At present, only an estimated 17 seconds of air time is donated per hour by networks for all non–sponsor paid public service announcements.16 At present, there is only one major federally funded health-related public education campaign that is supported by the Office on Drug Control Policy to reduce youth substance abuse. However, the messages do not address tobacco and alcohol use—the two substances most used by youth and that cause the greatest disease and death. A successful CDC-funded campaign focused on increasing physical activity, “VERB,” was de-funded several years after it was developed.17 Similarly, a federally funded HIV/AIDS televised public education effort was short lived. The potential public health utility of mass education efforts designed to increase knowledge and encourage attitude and behavior change has been largely unexploited. This study suggests that truth and other future programs like it can be cost effective and markedly improve the public's health.