Where can you get cheap nicotine replacement therapy?

One of the main reasons motivating smokers to quit is money. A pack a day smoker in my home state of New Jersey who is purchasing his or her cigarettes on a daily basis is likely paying around $8 per pack. That’s $56 per week, $243 per month, or just under $3,000 per year.

So it clearly makes sense to quit for health and financial reasons. But as I’ve discussed on this site previously, your best chance of successfully quitting will be to get counseling support and to use at least one FDA-approved smoking cessation medicine. If you don’t want to have to go to the doctor for a prescription, your choices will be limited to the “Over-The-Counter” products: nicotine patch, gum or lozenge. When you go to a local pharmacy you will often find that the sticker price for a branded box of NRT, which typically last around 2 weeks (e.g. a 14-day supply of nicotine patches) is around $50, and possibly slightly higher. That sticker shock can put some people off. So are there less expensive ways of obtaining NRT?

One thing you should be aware of, is that all the major pharmaceutical manufacturers have programs that enable them to supply free medicines to people on very low incomes and no other way to pay (e.g. insurance). You can find out about these via the companies website. It typically involves completing a reasonable amount of paperwork, supplying some verification of financial situation, and I think requires a doctors office to ship it to. But it does work, and is a way for people on a very low income to get the medicines they need.

If you are fortunate enough to live in a state with a good/comprehensive tobacco control program, it is possible that the smoking cessation services can provide free or low cost medicine (e.g. free nicotine patches via the quitline or face-to-face counseling services). In some states, people covered by Medicaid can get their medicines covered. Similarly some private insurance policies cover the medicines. Some cover them all, and some just cover the prescription-only products (nicotine inhaler, nasal spray, and bupropion or varenicline). So if you have insurance, call your policy number and inquire about what is covered.

But if you are going to have to go to the pharmacy and purchase your own NRT, there are still some bargains to be had out there. Many pharmacies have vouchers giving $5 or $10 off branded NRTs. The other thing to do is to get an idea of what is available is to go to the online store of one of the leading chains and see what they have. I just went on the Walmart website and typed on the search words “smoking cessation”, and among the 91 “hits” were some interesting options. Among the best value were:
1. A box of 170 pieces of 4mg original flavor nicotine gum “Equate” for $30, which can be shipped to my home for 97cents.
2. A box of 20 pieces of 4mg Mint flavor “Equate” nicotine gum was only $8! That truly equated one for one with the cost for cigarettes!
3. 14 day supply of Equate 21mg nicotine patches for $26.
So if you were a heavy smoker and wanted to combine the nicotine patch with 4mg gum, an adequate 2-week supply would cost $56. That’s still half as expensive as buying a pack of cigarettes per day for 2 weeks in New Jersey.

There were numerous other options of brands, flavors and prices available on that site. I was a bit surprised to find that a form of e-cigarette also came up on my search. I did not realize until recently that Walmart were selling e-cigarettes and I think it is inappropriate for them to be sold as “smoking cessation aid” when they are not approved by FDA for that purpose. Interestingly, however, the user feedback in response to a question was quite positive.

Labels: cheap, Equate, Jonathan Fouds, nicotine, nicotine patch, NRT, Walmart

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A Smokefree Future: Comprehensive Tobacco Strategy

Last week the UK Government announced a new comprehensive tobacco control strategy for England. This document should be of interest to other countries around the world as England has been at the cutting edge of tobacco control and smoking cessation over recent years. Adult smoking prevalence fell from 28% in 1998 to 21% in 2008, and youth smoking rates fell from 11% to 6% following the previous tobacco control strategy announced in 1998. During that time frame a nationwide network of smoking cessation services was set up, comprehensive smoke-free workplace legislation was implemented (including bars and restaurants), tobacco advertising severely restricted, and large pictorial health warnings introduced on packs. In 2006 the UK ratified the World Health Organization Framework Convention on Tobacco Control.

The UK government has set ambitious targets to be reached by 2020:
1. To reduce the proportion of 11-15 year-olds to 1% (currently 6%)
2. To reduce adult smoking prevalence to 10% (currently 21%)
3. To have two-thirds of households in which parents smoke be smoke-free by 2020 (i.e. even smoking households having a policy of not smoking indoors).

One of the main components of the strategy for England is to motivate and assist every smoker to quit. Over the past 10 years the UK smoking cessation service have helped arrange over 4 million quit attempts. These services are unique in international comparisons in that they are based on a network of locally based face-to-face tobacco treatment services.

The new strategy plans to expand these services by using an expanded marketing campaign, but perhaps the most radical aspect is the plan to broaden the number of routes to cessation by encouraging smokers to (a) cut down their smoking, perhaps over a long period, by substituting cigarettes with nicotine replacement therapy (e.g. nicotine gum (b) encouraging smokers to use safer nicotine delivery products like nicotine gum in places where they are not allowed to smoke and (c) encouraging all smokers to reduce the amount of environmental smoke they emit, by replacing smoking of cigarettes to use of nicotine replacement therapy.

In order to fit in with these new pathways to cessation, the UK government plans to change the way the face-to-face smoking cessation services work, such that longer courses of behavioral and pharmacological support will become available to suit the needs of those smokers who are not yet ready to quit completely.

This last part is a fairly radical step for a government. Most countries don’t even have a government funded smoking cessation service, never mind one that also serves to help smokers reduce their smoking. Overall, so long as scarce resources are not diverted away from smokers who are seeking help to quit completely, I think the UK has broadly got it right, and many other countries should take a look at what is being achieved there and consider adopting a similar approach.
You can access the details of the strategy at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111749

Labels: England, jonathan foulds, NHS, Smokefree strategy, UK

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New study shows that longer duration nicotine replacement leads to better quit rates

A new study was published in Annals of Internal Medicine this week, showing that having access to nicotine patches for 24 weeks leads to higher quit rates at 24 weeks (32%) that using the patch for the more typical duration (8 weeks), which led to only 20% being quit at 24 weeks. This study, by Dr Robert Schnoll and colleagues at University of Pennsylvania, recruited 568 healthy adult smokers (smoked an average of 21 cigarettes per day). They were all given a standard treatment consisting of 8 counseling sessions over 6 months, and a 24 week supply of patches. Half of the participants had full strength 21mg nicotine patches for 24 weeks (extended duration) and half had full strength nicotine patches for 8 weeks, and 16 weeks of placebo patches that were packaged to be identical to the nicotine patches. The study was conducted in a double-blind manner meaning neither the researchers not the participants were aware of who received the extended duration treatment, until after the study was completed.

This study examined a range of outcome measures, and produced some interesting findings. For example, while the quit rates were similar between the two groups up to week 8, , from weeks 9 to 24, the relapse rate was slower among those still using the nicotine patches. Then from weeks 24 to 52 (when all participants had ceased patch use), the relapse rates were again similar, although slightly higher in those who had extended duration nicotine patches up to week 24. From weeks 9 through 24, those smokers who continued to have access to nicotine patches but had a lapse cigarette were more likely to recover abstinence, than those using placebo patches.
The authors defined abstinence as either “point prevalence” (no tobacco use in prior 7 days at a point in time) “prolonged abstinence” (allows some smoking during first 14 days, then a period of abstinence, ending with 7 consecutive days of smoking…a relapse) and “continuous abstinence” (not a puff from the quit date to a follow-up point). Extended duration patch treatment led to higher rates of prolonged abstinence at one year (29% v 21%). It was noteworthy that only 1% of each group achieved continuous “not a puff” abstinence for 52 weeks!

There were a few odd aspects to this study. The researchers attempted to estimate the costs of the treatment as well as the additional medical costs incurred by participants as a result of participation in the study. It seems very unlikely that these were fully and/or accurately measured. For example, the total estimated cost for counseling was $120. No details were provided on how this estimate was arrived at, but its hard to see how the TOTAL cost of the behavioral part of the intervention would be so low. Even if only the 8 counseling sessions were included, that would imply that a counseling session costs $15. This is clearly an underestimate of true staff costs, and of course doesn’t take into account the potential impact/cost of the additional recruitment/assessment and follow-up procedures, which although strictly a part of the research process, likely influenced outcome.

One other thing that was slightly odd was that the discussion section of the paper began with the statement that “smokers who received extended therapy with transdermal nicotine were about twice as likely as those who received standard therapy to achieve abstinence 24 weeks after their quit date.” Given that the point prevalence quit rates were 32% vs 20%, neither this nor any other outcome measure was twice as likely in those receiving extended duration patches. Presumably the authors were referring to the “odds ratio” (1.8) but that is not a straightforward “likelihood” in the sense that most people understand it.

One other weakness of the study was that only healthy smokers were included in the study. For example, all volunteers who were already taking any medication or had a psychiatric disorder were excluded. As a result, of 3276 smokers who were screened, only 575 (18%) were included in the study. However, although that limits generalizability of the findings, I have some confidence in the result, partly because here at UMDNJ a research study by Dr Michael Steinberg and colleagues focusing on smokers with medical illness obtained a similar finding (extended duration treatment with patch plus bupropion plus nicotine inhaler gave better outcomes at 6 months than standard duration nicotine patch).

However, despite these minor quibbles, this was an excellent study yielding some very interesting results. These results are consistent with the view we that tobacco dependence is best treated as a chronic illness, and for some smokers, that means continuing the medication for as long as is necessary.

Reference
Schnoll et al (2010). Effectiveness of extended-duration transdermal nicotine therapy: a randomized trial. Annals of Internal Medicine, 153: 144-151

Labels: extended duration, jonathan foulds, nicotine patch, Nicotine Replacement, NRT, Schnoll, smoking cessation

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Classic paper: health consequences of smoking1-4 cigarettes

The journal Tobacco Control has on its website a list of the top 10 most read articles each month. One paper that has been near the top ever since it was published in 2005, was written by Dr Kjell Bjartveit and his colleague Dr Tverdal, on “Health consequences of smoking 1-4 cigrettes per day.”

The study included 23 521 men and 19 201 women, aged 35–49 years when they were initially screened for cardiovascular disease risk factors in the mid 1970s and followed them up to 2002. The researchers calculated the total risks of death and relative risks adjusted for confounding variables, of dying from ischaemic heart disease, all cancer, lung cancer, and from all causes, and examined the effects of regular smoking of only a few cigarettes per day.

The study found that both men and women who smoked 1-4 cigarettes per day were about 3 times as likely as people who never smoked of dieing from a heart attack, 3-5 times as likely of dieing from lung cancer, and overall about 50% more likely to have died from any cause during the study period.

As in many other studies, the risks were greater the more the participants smoked. For example, people who smoked over 25 cigarettes per day were 37 times more likely to die of lung cancer than people who never smoked.
The study was important in that it showed that there really isn’t a threshold of cigarette consumption below which its safe to smoke.

The full version of this paper and many other influential tobacco research papers can be found by cutting and pasting this link:
http://tobaccocontrol.bmj.com/reports/most-read

If you would like to find blog posts on other topics, try typing the subject words into the “Search Health Experts” box on the right. If your interest is in smoking, be sure to enter a relevant key word, e.g. smoking, nicotine, etc.

Labels: cigarettes, health effects, Jonathan Fouds, Kjell Bjartveit, light smoking, tobacco control

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Tobacco surely was designed to poison and destroy mankind

Tobacco surely was designed

To poison and destroy mankind
Philip Freneau (1752–1832)

This is the most famous excerpt from a poem by Philip Freneau. I don’t think I’m allowed to copy the whole poem here, but he was clearly ahead of his time in identifying (a) that tobacco, whether smoked or chewed is harmful to the body and (b) that it was very hard to give up once you have started (i.e. in modern language, addictive).

Freneau was quite an interesting man. His father was a French wine merchant and his mother was Scottish. He was raised in Monmouth County, New Jersey and attended Princeton University (then called College of New Jersey) in 1768. As a patriot, he was imprisoned by the British and both James Madison and Thomas Jefferson enlisted his help as an editor of various publications which aimed to further the cause of independence for the Americans from the British. He was never afraid to speak his mind and apparently became strongly disliked by people in power, including President George Washington, whose policies he had criticized.

He died at the age of 80, apparently freezing to death after trying to walk home from a tavern while drunk and getting lost in the forest. He and his family were buried in Matawan, New Jersey. The Matawan Post Office on Main Street, New Jersey, has a sculpture on the wall of Freneau. It features him with black slaves as he became strongly opposed to slavery later in life.

Labels: jonathan foulds, Philip Freneau, poet

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