Pharmaceutical economics & health policy Original research| Volume 34, ISSUE 8, P1803-1814, August 2012

Cost-Effectiveness of Varenicline Versus Bupropion, Nicotine-Replacement Therapy, and Unaided Cessation in Greece



      Varenicline was designed to relieve symptoms of nicotine withdrawal, including cigarette craving, and to block the reinforcing effects of continued nicotine use. The cost-effectiveness of varenicline in some countries has not been studied.


      The aim of this study was to compare the cost-effectiveness of varenicline to that of bupropion, nicotine-replacement therapy (NRT), and unaided cessation in the Greek health care setting. The analysis takes into account a societal security (third-party payer) perspective.


      To perform the analyses of the benefits of smoking cessation in terms of smoking-related morbidity, mortality, and associated medical costs, a Markov model was used that simulated the progress of a hypothetical cohort of current smokers making a single attempt to quit smoking at the beginning of the timeframe of the analysis. The robustness of the results was assessed using a series of 1-way sensitivity analyses.


      Varenicline was associated with the potential prevention of 14.1, 14.2, and 35.1 additional cases of the 4 smoking-related diseases incorporated into the model, per 1000 smokers willing to quit, versus bupropion, NRT, and unaided cessation, respectively. Potentially avoided smoking-related deaths with varenicline were estimated at 3.24, 3.26, and 7.5 per 1000 quitters versus the 3 comparators. Varenicline led to a potential gain of 33.78, 33.91, and 83.97 QALYs per 1000 persons willing to make a quit attempt versus the 3 comparators. Varenicline was associated with cost-savings against both active comparators for the lifetime horizon. Overall, the cost per additional quitter with varenicline, considering only the costs of the smoking-cessation strategy, was €2659 (€1015) for a lifetime horizon compared with bupropion (NRT); however, when all direct costs were incorporated into the analysis, varenicline was cost-saving.


      The findings from the present study suggest that, compared with the widely used treatment options bupropion and NRT, as well as unaided cessation, varenicline may enhance smoking-cessation treatment outcomes while substantially reducing the overall costs of smoking to the health care system.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Therapeutics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • World Health Organization (WHO)
        WHO Report on the Global Tobacco Epidemic, 2009: Implementing Smoke-free Environments.
        (Accessed April 4, 2011)
        • Bolin K.
        • Lindgren B.
        Smoking, healthcare cost, and loss of productivity in Sweden 2001.
        Scand J Public Health. 2007; 35: 187-196
        • Orme M.E.
        • Hogue S.L.
        • Kennedy L.M.
        • et al.
        Development of the health and economic consequences of smoking interactive model.
        Tob Control. 2001; 10: 55-61
        • US Dept. of Health and Human Services
        The Health Benefits of Smoking Cessation: A Report of the Surgeon General.
        US DHHS, Atlanta, Ga1990
        • World Health Organization
        World Health Organization Policy Recommendations for Smoking Cessation and Treatment of Tobacco Dependence 2003.
        (Accessed April 12, 2011)
        • Fiore M.
        • Jae′n C.R.
        • Baker T.B.
        • et al.
        A clinical practice guideline for treating tobacco use and dependence: 2008 update.
        Am J Prev Med. 2008; 35: 158-176
        • Stead L.F.
        • Perera R.
        • Bullen C.
        • et al.
        Nicotine replacement therapy for smoking cessation.
        Cochrane Database Syst Rev. 2008; 1 (CD000146)
        • Vemer P.
        • Rutten-van Mölken M.P.
        Crossing borders: factors affecting differences in cost-effectiveness of smoking cessation interventions between European countries.
        Value Health. 2010; 13: 230-241
        • Raw M.
        • Regan S.
        • Rigotti N.
        • et al.
        A survey of tobacco dependence treatment guidelines in 31 countries.
        Addiction. 2009; 104: 1243-1250
        • Jorenby D.E.
        • Hays J.T.
        • Rigotti N.A.
        • et al.
        Efficacy of varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: a randomized controlled trial [published correction appears in JAMA. 2006;296:1355].
        JAMA. 2006; 296: 56-63
        • World Health Organization (WHO) Regional Office for Europe
        The European Tobacco Control Report 2007.
        (Accessed March 29, 2012)
        • Athanasakis K.
        • Souliotis K.
        • Kyriopoulos J.
        Economic consequences of smoking on health systems: an appraisal for Greece [in Greek].
        Iatriki. 2010; 98: 109-115
        • Martínez-Sánchez J.
        • Fernández E.
        • Fu M.
        • et al.
        Smoking behaviour, involuntary smoking, attitudes towards smoke-free legislations, and tobacco control activities in the European Union.
        PLoS One. 2010; 5: e13881
        • Howard P.
        • Knight C.
        • Boler A.
        • et al.
        Cost-utility analysis of varenicline versus existing smoking cessation strategies using the BENESCO simulation model: application to a population of US adult smokers.
        Pharmacoeconomics. 2008; 26: 497-511
        • World Health Organization (WHO)
        European Detailed Mortality Database (DMDB) (updated June 2011).
        (Accessed December 12, 2011)
        • Fernández de Bobadilla Osorio J.
        • Sánchez-Maestre C.
        • Brosa Riestra M.
        • et al.
        Cost effectiveness analysis of varenicline (Champix) for the treatment of smoking in Spain [in Spanish].
        An Med Interna. 2008; 25: 342-348
        • Hoogendoorn M.
        • Welsing P.
        • Rutten-van Mölken M.P.
        Cost-effectiveness of varenicline compared with bupropion, NRT and nortriptyline for smoking cessation in the Netherlands.
        Curr Med Res Opin. 2008; 24: 51-61
        • Sichletidis L.
        • Tsiotsios I.
        • Gavriilidis A.
        • et al.
        Prevalence of chronic obstructive pulmonary disease and rhinitis in northern Greece.
        Respiration. 2005; 72: 270-277
        • Minas M.
        • Koukosias N.
        • Zintzaras E.
        • et al.
        Prevalence of chronic diseases and morbidity in primary health care in central Greece: An epidemiological study.
        BMC Health Serv Res. 2010; 10: 252
        • Vemmos K.N.
        • Bots M.L.
        • Tsibouris P.K.
        • et al.
        Stroke incidence and case fatality in southern Greece: the Arcadia Stroke Registry.
        Stroke. 1999; 30: 363-370
        • Truelsen T.
        • Piechowski-Jóźwiak B.
        • Bonita R.
        • et al.
        Stroke incidence and prevalence in Europe: a review of available data.
        Eur J Neurol. 2006; 13: 581-598
        • AIRTUM Working Group
        Italian cancer figures, report 2010: Cancer prevalence in Italy.
        Epidemiol Prev. 2010; 34: 1-188
        • Ferlay J.
        • Shin H.R.
        • Bray F.
        • et al.
        GLOBOCAN 2008, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10.
        (Accessed May 10, 2011)
        • de Marco R.
        • Accordini S.
        • Cerveri I.
        • et al.
        Incidence of chronic obstructive pulmonary disease in a cohort of young adults according to the presence of chronic cough and phlegm.
        Am J Respir Crit Care Med. 2007; 175: 32-39
        • National School of Public Health
        Panhellenic Survey for the Evaluation of Health and Health Services.
        National School of Public Health, Athens, Greece2011
        • Thun M.J.
        • Apicella L.F.
        • Henley S.J.
        Smoking vs other risk factors as the cause of smoking-attributable deaths: confounding in the courtroom.
        JAMA. 2000; 284: 706-712
        • Feenstra T.L.
        • Hamberg-van Reenen H.H.
        • Hoogenveen R.T.
        • et al.
        Cost-effectiveness of face-to-face smoking cessation interventions: a dynamic modeling study.
        Value Health. 2005; 8: 178-190
        • Orme M.E.
        • Hogue S.L.
        • Kennedy L.M.
        • et al.
        Development of the health and economic consequences of smoking interactive model.
        Tob Control. 2001; 10: 55-61
        • Gonzales D.
        • Rennard S.I.
        • Nides M.
        • et al.
        Varenicline, an alpha4beta2 nicotinic acetylcholine receptor partial agonist, vs sustained-release bupropion and placebo for smoking cessation: a randomized controlled trial.
        JAMA. 2006; 296: 47-55
        • Nides M.
        • Glover E.D.
        • Reus I.V.
        • et al.
        Varenicline versus bupropion for smoking cessation: a pooled analysis.
        Am J Health Behav. 2008; 32: 664-675
        • Silagy C.
        • Lancaster T.
        • Stead L.
        • et al.
        Nicotine replacement therapy for smoking cessation.
        Cochrane Database Syst Rev. 2004; (CD000146)
        • Foulds J.
        • Burke M.
        • Steinberg M.
        • et al.
        Advances in pharmacotherapy for tobacco dependence.
        Expert Opin Emerg Drugs. 2004; 9: 39-53
        • Maniadakis N.
        • Fragoulakis V.
        • Pallis A.G.
        • et al.
        Economic evaluation of docetaxel-gemcitabine versus vinorelbine-cisplatin combination as front-line treatment of patients with advanced/metastatic non-small-cell lung cancer in Greece: a cost-minimization analysis.
        Ann Oncol. 2010; 21: 1462-1467
        • Maniadakis N.
        • Tzanakis N.
        • Fragoulakis V.
        • et al.
        Economic evaluation of tiotropium and salmeterol in the treatment of chronic obstructive pulmonary disease (COPD) in Greece.
        Curr Med Res Opin. 2006; 22: 1599-1607
        • Drummond M.F.
        • Sculpher M.J.
        • Torrance G.W.
        • et al.
        Methods for Economic Health Evaluation of Health Care Programmes.
        3rd ed. Oxford University Press, Oxford2005
        • Fiscella K.
        • Franks P.
        Cost effectiveness of the transdermal nicotine patch as an adjunct to physicians' smoking cessation counselling.
        JAMA. 1996; 275: 1247-1251
        • Spencer M.
        • Briggs A.H.
        • Grossman R.F.
        • et al.
        Development of an economic model to assess the cost effectiveness of treatment interventions for chronic obstructive pulmonary disease.
        Pharmacoeconomics. 2005; 23: 619-637
        • Mannino D.M.
        • Buist A.S.
        • Petty T.L.
        • et al.
        Lung function and mortality in the United States: data from the First National Health and Nutrition Examination Survey follow up study.
        Thorax. 2003; 58: 388-393
        • Trippoli S.
        • Vaiani M.
        • Lucioni C.
        • et al.
        Quality of life and utility in patients with non-small cell lung cancer.
        Pharmacoeconomics. 2001; 19: 855-863
        • Duncan P.W.
        • Lai S.M.
        • Keighley J.
        Defining post-stroke recovery: implications for design and interpretation of drug trials.
        Neuropharmacology. 2000; 39: 835-841
        • Tengs T.O.
        • Lin T.H.
        A meta-analysis of quality-of-life estimates for stroke.
        Pharmacoeconomics. 2003; 21: 191-200
        • Gage B.F.
        • Cardinalli A.B.
        • Owens D.K.
        Cost-effectiveness of preference-based antithrombotic therapy for patients with nonvalvular atrial fibrillation.
        Stroke. 1998; 29: 1083-1091
        • Hay J.W.
        • Sterling K.L.
        Cost effectiveness of treating low HDL-cholesterol in the primary prevention of coronary heart disease.
        Pharmacoeconomics. 2005; 23: 133-141
        • Maniadakis N.
        • Ekman M.
        • Fragoulakis V.
        • et al.
        Economic evaluation of irbesartan in combination with hydrochlorothiazide in the treatment of hypertension in Greece.
        Eur J Health Econ. 2011; 12: 253-261
        • Rasch A.
        • Lenz C.
        • Greiner W.
        Health economic model of smoking cessation treatment with varenicline in Germany.
        Value Health. 2008; 10: A472-A473
        • Bolin K.
        • Wilson K.
        • Benhaddi H.
        • et al.
        Cost-effectiveness of varenicline compared with nicotine patches for smoking cessation—results from four European countries.
        Eur J Public Health. 2009; 19: 650-654
        • Keating G.
        • Lyseng-Williamson K.A.
        Varenicline: a pharmacoeconomic review of its use as an aid to smoking cessation.
        Pharmacoeconomics. 2010; 28: 231-254
        • Lundborg P.
        Does smoking increase sick leave?.
        Tob Control. 2007; 16: 114-118