Systematic critical review of previous economic evaluations of smoking cessation during pregnancy

Objective: To identify and critically assess previous economic evaluations of smoking cessation interventions delivered during pregnancy. Design: Qualitative review of studies with primary data collection or hypothetical modelling. Quality assessed using the Quality of Health Economic Studies checklist. Data sources: Electronic search of 13 databases including Medline, Econlit, Embase, and PubMed, and manual search of the UK's National Institute of Health and Care Excellence guidelines and US Surgeon General. Eligibility criteria for selecting studies: All study designs considered if they were published in English, evaluated a cessation intervention delivered to pregnant women during pregnancy, and reported any relevant economic evaluation metric (eg, cost per quitter, incremental cost per quality adjusted life year). Results: 18 studies were included. 18 evaluations were conducted alongside clinical trials, four were part of observational studies, five were hypothetical decision-analytic models and one combined modelling with within-trial analysis. Analyses conducted were cost-offset (nine studies), cost-effectiveness (five studies), cost-utility (two studies), and combined cost-effectiveness and cost-utility (two studies). Six studies each were identified as high, fair and poor quality, respectively. All interventions were demonstrated to be cost-effective except motivational interviewing which was dominated by usual care (one study). Areas where the current literature was limited were the robust investigation of uncertainty, including time horizons that included outcomes beyond the end of pregnancy, including major morbidities for the mother and her infant, and incorporating better estimates of postpartum relapse. Conclusions: There are relatively few high quality economic evaluations of cessation interventions during pregnancy. The majority of the literature suggests that such interventions offer value for money; however, there are methodological issues that require addressing, including investigating uncertainty more robustly, utilising better estimates for postpartum relapse, extending beyond a within-pregnancy time horizon, and including major morbidities for the mother and her infant for within-pregnancy and beyond.