Costs Associated With Continued Smoking in Patients With Cancer


Key Points

  • The highest failure rates attributable to smoking were found in conditions in which expected cure rates with first-line treatment ranged from 50% to 65% among nonsmoking patients.
  • Modeling indicated an attributable cost of $2.1 million per 1,000 total patients, yielding an additional $10,678 per smoking patient.

In a study reported in JAMA Network Open, Warren et al quantified incremental costs of first-line cancer treatment failure attributable to continued smoking in patients with cancer.

Study Details

The study involved development of a model to identify attributable incremental costs of subsequent cancer treatment associated with continued smoking by patients with cancer. The model used data from a 2014 U.S. Surgeon General report that included assessment of expected failure rates of first-line cancer treatment in nonsmoking patients, smoking prevalence, odds ratios (ORs) for first-line treatment failure attributed to smoking vs nonsmoking, and cost of cancer treatment after failure of first-line treatment.

Incremental Costs of Treatment

It was found that the rate of treatment failures attributable to continued smoking were higher under conditions in which higher vs lower cure rates in first-line treatment were expected in nonsmoking patients. Thus, for example, the modeling predicted 5.1 attributable failures per 1,000 patients in a cohort with 10% expected first-line failure rate among nonsmoking patients, 10% smoking prevalence, and an OR of 1.6 (median OR across cancer sites and treatments in Surgeon General report) for failure of treatment among smoking patients. This was compared with 3.5 attributable failures in a 1,000-patient cohort with a 90% expected first-line failure rate among nonsmoking patients. The predicted attributable failure rates followed a curvilinear pattern across expected cure rates for nonsmoking patients, with the highest attributable failure rates found in conditions in which expected cure rates with first-line treatment among nonsmoking patients ranged from 50% to 65%.

Modeling using data from the 2014 U.S. Surgeon General report showed that given an expected 30% first-line failure rate among nonsmoking patients, smoking prevalence of 20%, an expected 60% increased risk of first-line failure among smoking patients (OR = 1.6), and a mean cost of $100,000 for treating first-line treatment failure, the incremental cost per 1,000 patients was $2.1 million, representing an additional mean cost per smoking patient of $10,678. Across attributable failure estimates, incremental costs increased with increasing ORs, with peak values observed for conditions in which expected first-line cure rates were between 50% and 65% for nonsmoking patients. Using the estimates above, there would be an estimated $3.4 billion in incremental costs among the estimated 1.6 million patients annually diagnosed with cancer.

The investigators concluded, “The findings suggest that continued smoking among patients with cancer and the increase in attributable first-line cancer treatment failure is associated with significant incremental costs for subsequent cancer treatments. Additional work appears to be needed to identify optimal methods to mitigate these incremental costs.”

Graham W. Warren, MD, PhD, of the Department of Radiation Oncology, Medical University of South Carolina, is the corresponding author for the JAMA Network Open article.

Disclosure: The study authors’ full disclosures can be found at

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