OBJECTIVES: Tobacco addiction is the leading preventable cause of death and disability in the US. A major 2019 UK RCT found e-cigarettes more effective than standard nicotine replacement therapy (NRT) in achieving abstinence. Very few cost-effectiveness studies have been performed regarding these interventions, and none in the US context. This study evaluated the cost-effectiveness of e-cigarettes with counselling compared to NRT with counselling as cessation aids for low-income smokers enrolled in Medicaid in California.

METHODS: Effectiveness data from the UK RCT and relevant literature was used to construct a Markov model-based cost-effectiveness analysis from a US health services perspective. A hypothetical cohort of 1000 smokers entered the model at age 25. Smokers were given one intervention in accordance with standard treatment length, with no further treatment. A lifetime horizon was used, and smokers were followed to different health states to the cohort’s natural lifespan. Following US guidelines, costs were expressed in USD inflated to 2020 prices, health outcomes expressed in QALYs, and discounting was performed at 3% annually. The impact of uncertainty on model results was assessed via deterministic and probabilistic sensitivity analysis and scenario analysis.

RESULTS: The base-case analysis found e-cigarettes with counselling more cost-effective by US thresholds, compared to NRT with counselling, with an ICER of $11,454 per additional QALY gained over lifetime. Results were sensitive to smokers’ healthcare costs, model start ages, discount rate, and QALY weights. At the lowest US threshold, e-cigarettes had a 98% probability of being cost-effective after 1000 Monte Carlo simulations.

CONCLUSIONS: E-cigarettes used as a cessation treatment by current smokers were more cost-effective than standard NRT. However, e-cigarette use as a treatment is currently unapproved by the FDA and their long-term safety remains unclear. Continuing research on the safety and long-term effectiveness of e-cigarettes is urgently needed.