Preventive Medicine 33, 558–570 (2001) doi:10.1006/pmed.2001.0922, available online at http://www.idealibrary.com on The Cost-Effectiveness of Intensive National School-Based Anti- Tobacco Education: Results from the Tobacco Policy Model 1 Tammy O. Tengs, Sc.D., 2 Nathaniel D. Osgood, Ph.D., and Laurie L. Chen, M.S. Health Priorities Research Group, University of California, Irvine, California 92697-7075 Published online September 13, 2001 In the 1960s and early 1970s, programs were based on Objectives. School-based anti-tobacco education the premise that adolescents who smoked apparently using the “social influences” model is known to reduce failed to comprehend the Surgeon General’s warnings smoking among youth by 5–56%. Program effective- on the health hazards of smoking [2]. Educators’ natu- ness, however, dissipates in 1–4 years. Consequently, ral response was to develop curricula to inform young opinion leaders have questioned whether a more inten- people about the serious physical consequences of smok- sive national educational effort would be economically ing, but these efforts proved largely ineffective. Later efficient. To address this question, we evaluated the programs were based on the assumption that adoles- cost-effectiveness of enhanced nationwide school- cents smoke cigarettes because their self-perceptions based anti-tobacco education relative to the status quo. are somehow compatible with health-compromising be- Methods. To estimate cost-effectiveness, we created havior like smoking. These programs sought to increase the Tobacco Policy Model, a system dynamics computer adolescents’ feelings of self-worth and to establish a simulation model. The model relies on secondary data and is designed to calculate the expected costs and health-related value system that would support a young public health gains of any tobacco policy or interven- person’s decision not to smoke. This approach also tion over any time frame. proved ineffective [3]. Results. Over 50 years, cost-effectiveness is estimated More recent programs use a new approach: the “social to lie between $4,900 and $340,000 per quality-adjusted influences” model. Educational efforts using this model life-year (QALY), depending on the degree and longev- seek to inform youth about the effects of outside influ- ity of program effectiveness. Assuming a 30% effective- ences such as advertising on their behavior, teach them ness that dissipates in 4 years, cost-effectiveness is that smoking is not the norm, and give them the skills $20,000/QALY. Sensitivity analysis reveals that cost- to refuse cigarettes. The U.S. Surgeon General’s report, effectiveness varies with cost, survival, and quality- “Preventing Tobacco Use Among Young People” [3], per- of-life estimates but cost-effectiveness ratios generally formed an exhaustive review of the literature on the remain favorable. effectiveness of the social influences model. The review Conclusions. Although not cost saving, a much more included several individual research reports, literature intensive school-based anti-tobacco educational effort reviews, and meta-analyses. The report concluded that would be an economically efficient investment for the nation.  2001 American Health Foundation and Elsevier Science the prevalence of smoking is as much as 50% lower among groups receiving social influences-based educa- tion relative to controls. Effects, however, tend to dissi- INTRODUCTION pate in 1 to 4 years. School-based educational programs have had mixed While it is clear that school-based programs can be success in reducing tobacco use among teenagers [1]. effective, at least in the short term, it is unclear whether such programs are cost-effective. To be successful, a 1 The California Tobacco-Related Disease Research Program (Grant 6PT-3005) and the National Institute of Drug Abuse (PHS Grant DA school-based program would have to be more intensive 13332) supported this work. than current efforts and thus might be prohibitively 2 To whom reprint requests should be addressed at Health Priorities expensive. For example, such a program would use spe- Research Group, School of Social Ecology, University of California at cially trained tobacco educators who would go into the Irvine, Irvine, CA 92697-7075. Fax: (949) 824-8286. E-mail: tengs@ uci.edu. schools to deliver a curriculum known to be effective. 558 0091-7435/01 $35.00  2001 by American Health Foundation and Elsevier Science All rights reserved