• nicotine replacement therapy

The efficacy of nicotine replacement therapy (NRT) as a smoking cessation aid has been convincingly demonstrated in a large number of studies, including many randomised trials.¹ Findings from these studies have prompted suggestions that widespread access to NRT could substantially increase quitting in a population, thereby reducing population smoking prevalence.² Hence when NRT became available over-the-counter in pharmacies in the USA (rather than by prescription only), a large increase in quitting activity was expected.³ However, Thorndike and colleagues⁴ found that in Massachusetts the switching of NRT from prescription only to over-the-counter availability did not result in increases in either quitting activity in the population, the use of NRT in quit attempts, or the success of quit attempts overall. The authors argued that there are barriers to NRT use, other than having to visit a doctor to obtain a prescription. They suggested that the cost of NRT was a likely barrier. The impact of over-the-counter sales on effectiveness of NRT for smoking cessation is further called into question in a recent study of the Californian population.⁵ The study observed an increase in reported use of NRT after over-the-counter sales were introduced, but not the long term population cessation outcomes that might have been anticipated. The authors identified levels of motivation and compliance with manufacturers guidelines for use (including duration of use and use of adjuvant counselling), as important potential differences between the general population of California and trial participants.

NRT is not subsidised under the Australian Pharmaceutical Benefits Scheme (PBS) and a 10 week course of patches costs the consumer A$310 (recommended retail price (RRP); approximately US$170). Anecdotally, the cost of NRT is often cited by smokers using South Australian cessation services as a major impediment to accessing NRT and to quitting. In response to these concerns, as part of a South Australian workplace based smoking cessation programme conducted in 2000-01, employees of participating organisations were offered free Quit Smoking courses and subsidised (half RRP; approximately US$85) 10 week courses of nicotine patches (the manufacturer’s recommended period for successful cessation). Interested employees had to enrol in and attend a Quit Smoking course, conducted at their own or a nearby workplace, and complete the Fagerstrom test for nicotine dependence.⁶ Vouchers were distributed within a week of attending a course, by mail or via the workplace, to individuals indicated to be addicted to nicotine. The vouchers could be redeemed for discounted NRT patches at any store of a widespread participating pharmacy chain.

Interest in subsidised NRT was very high among programme participants, with 93% of the 301 course participants completing the Fagerstrom test in order to be assessed for eligibility, and 83% of those (232 participants) found to be eligible. Hence, 232 books of 10 vouchers were distributed to smokers, giving a total of 2320 vouchers. Vouchers indicated an expiry date of 31 March 2001, giving smokers a period of 3–7 months to redeem their vouchers. Tracking of the numbered vouchers revealed that a total of 355 individual vouchers were redeemed, representing 15% of all vouchers distributed. Overall, 39% of the 232 smokers redeemed one voucher or more, leaving 61% of voucher recipients who did not redeem any vouchers at all. Among smokers who did redeem at least one voucher, the total number redeemed by an individual ranged from 1–10, with a mean of 4 vouchers. When a random sample of 33 voucher recipients (response rate 66%) were followed up nine months after the courses began, they were asked why they had not redeemed all or any of their vouchers. Responses indicated that many recipients (54%) had decided to make a quit attempt without using all or any of the patches, but almost half (46%) had changed their mind about making a quit attempt and continued to smoke. It is noteworthy that although bupropion (Zyban) became available under PBS subsidy during this period (February 2001), only one respondent surveyed said that they had not used their patches because they decided to use bupropion instead.

These findings suggest that cost may not be the barrier to accessing NRT that it is often claimed to be. Rather, individual readiness to quit may be a very important factor in determining use, and should be taken into consideration when planning programmes involving free/subsidised NRT.