Introduction:
Tobacco consumption remains one of the most important risk factors of mortality and morbidity, worldwide and in Western Europe. Despite knowledgeable about the dangers of tobacco, a third of European adults, and 12% of US, Canadian and European adolescents still smoke. In order to reduce the smoking prevalence and its consequences, smoking prevention policies have been suggested, but some are not implemented at a large scale due to concerns of high costs and limited effectiveness. In this study we aimed at estimating the costs and cost-effectiveness of five smoking prevention policies (bans on smoking in public places, bans on sales to minors, bans on point-of-sale advertising, bans on smoking at school premises, and school prevention programs), implemented in seven European countries (Finland, Ireland, Netherlands, Belgium, Germany, Italy, and Portugal) in 2016.

Methods:
We retrospectively collected costs related to (1) the inspection activities and legal procedures related to public bans, (2) the monitoring of the school bans and sanctioning of non-compliant students, and (3) education activities related to smoking prevention programs. We used an “ingredients-based” approach, identifying each resource used, quantity and unit value for one full year, under the State perspective. Costs were measured at national, local, or school-level, and were complemented with qualitative data on how these activities were performed in reality. Cost estimates were estimated at a 17-years’ time horizon to reflect the total number of years of implementation done in the cohort (to cover all groups that have 0 to 17 years old at year 0), discounted at a 3.5% annual rate. Effectiveness was estimated using the DYNAMO-HIA tool, departing from data on short-term prevalence reduction, collected from the literature. The simulation followed the whole population since year 0 until when the last person of the cohort died, estimating the number of healthy life years gained by each intervention, comparing with a no-intervention scenario. Cost estimates were then divided by the total number of healthy life years (QALY) gained by the cohort after the implementation of these policies.

Results:
Costs varied between from €0.02 to €0.74 per person for public non-school bans, €0 to €0.48 for school bans, and €0.65 to €5.12 for school programmes, accordingly to the number of person-hours allocated to the implementation of these policies. If effectively implemented, all policies would be cost-effective in all seven countries and levels. School bans would be the most cost-effective interventions, with €0 to €347.50 per QALY. Public non-school bans would cost €0.96 to €1911.18 per QALY, and school programmes would cost €7.08 to €4546.07 per QALY, which are substantially lower than the thresholds proposed by the literature.

Conclusions:
Smoking prevention policies targeting adolescents are low cost and highly cost-effective interventions. Investing in these policies and implementing them effectively can tackle one of the main causes of morbidity and mortality in Western Europe.