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Technical Paper 2:
Tobacco Control in Australia: making smoking history

3.3.2 Systems for delivering therapies

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In a country where the right to health care is universal, we need a combination of services, training, referral arrangements, remuneration and subsidies that will work together in the Australian context to deliver the best possible result for the population as a whole.

Several medications and forms of support are effective in helping smokers quit (and better ones may become available in time), but a far greater challenge is getting smokers to use them[350] and, preferably, to use those that are most cost-effective.

Referrals by professionals to Quitlines

Quitlines are now advertised on every cigarette pack as part of required consumer information. Mass media advertising also drives calls to the Quitline.[314, 351] However, more could be done. The Quitline is still an underutilised service in Australia, partly because of a lack of understanding about what the service offers.[350]

For several years, governments in the UK,[352] the US,[342, 353] New Zealand[354] and Australia[355, 356] have periodically updated and promoted detailed clinical guidelines for doctors on how best to treat tobacco dependence. An important innovation in the Australian clinical guidelines[356] is the offer of two evidence-based strategies for providing cessation assistance: within the consultation, and/or referral to specialist cessation services. GPs can use fax-referral forms to trigger a phone call to their patients from a trained Quitline adviser. For referrals, the Quitline calls the smoker and discusses options for assistance, which allows callers to be directed to or offered the most appropriate form of support.[357]

GP referral to the Quitline has improved patients’ chances of quitting.³⁸ [359] In a Victorian pilot program, referral to the Quitline has resulted in cessation rates two to three times that which resulted from efforts to encourage GPs to provide in-practice management.[360] The effect was due to the smokers getting extra help to quit from outside the practice, while getting the same amount of help from within it; the combination of the extra help increased both the number and success of quit attempts. The beneficial effect on quitting in the referral condition was sustained over time. The findings add to the growing body of evidence that health professional referral of patients who smoke to evidence-based Quit services is effective and acceptable to smokers.[361, 362]

A large-scale demonstration project across six states in the US has recently demonstrated that smokers doubled their success rates when given subsidised NRT and access to a Quitline, with savings in healthcare costs justifying full Medicare coverage of low-cost NRT and referral to Quitline services.[363]

Treatment in hospital

As is the case for general practice, advice to quit from treating physicians in hospitals can also motivate many people to quit.[364]

Hospitals in New South Wales and Queensland have developed systems to identify and advise all patients who smoke to quit and to offer NRT to help them comply with smoke-free policies. Much could be improved in these systems,[365] and much less progress in hospitals is evident in other jurisdictions.
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Subsidy of treatments

Providing access to subsidised pharmacotherapy is another very powerful method of increasing usage and also increasing the proportion of quit attempts that are successful. Over the past eight years, different countries have taken different approaches to this strategy.

NRT became available in the UK on NHS prescription in 2001, soon after the inception of the NHS Stop Smoking Services in 1999.[366] NRT can also be purchased from pharmacies and, with the classification of some NRT products in the general sale category, from several other outlets.[367] West et al. estimate that following the listing of NRT, the proportion of smokers using medicines to aid smoking cessation more than doubled from 8% in 1999 to 17% in 2002.[368]

In New Zealand, vouchers for NRT are provided to people calling the NZ Quitline, and are redeemed at pharmacies for the heavily subsidised cost of $10. Initially, the vouchers were available only from the Quitline or from GPs who had received training in smoking cessation.[354] Since December 2007 they have been available through both the Quitline and all GPs.[369]

In the US, 40 of the 44 states include a subsidy for at least one form of NRT in Medicaid arrangements.[370]

In the state of New York, which set an ambitious target to reduce the number of smokers by one million over the 10 years to 2010,[371]³⁹ the NY Quitline sends free NRT directly to clients at the rate of around 360 shipments per day. In 2007 almost 80,000 clients received NRT starter kits, over 30,000 through on-line ordering. The NRT has been donated by one of the pharmaceutical companies, including stock that might otherwise exceed its sell-by date.

The evaluation of programs in New York,[372, 373] Minnesota[374] and New Zealand suggests that the provision of vouchers for free or subsidised NRT can significantly increase the numbers of smokers calling counselling services and the numbers making a quit attempt.[375] Such initiatives would appear to be effective with low-income groups.[376]

In Australia NRT has not been subsidised.⁴⁰ In contrast, bupropion marketed as Zyban (and more recently Clorpax and Bupropion-RL) was listed on the Pharmaceutical Benefits Scheme (PBS) in February 2001, and varenicline marketed as Champix in February 2008. By the end of June 2008, total PBS subsidies for bupropion totalled more than $140 million, nearly half of this figure in the five months to June 2001.

Table 5: Prescriptions for and spending on bupropion, February 2001 to June 2007

	Services	Expenditure, $s
Feb to June 2001	277,602	66,438,824
2001–02	129,174	29,110,602
2002–03	74,992	16,914,598
2003–04	83,844	12,108,290
2004–05	102,334	5,019,783
2005–06	106,467	4,864,776
2006–07	95,054	3,645,604
2007–08	69,211	2,590,349
Total to June 2007	938,678	140,692,826

Source: PBS data item 8465M and 8710K[378]

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Established contraindications for bupropion⁴¹ [379] and worrying reported side-effects for varenicline⁴² limit the numbers of people that can be prescribed these medications, whereas NRT can be used by virtually any smoker. Given the unsuitability of these PBS-listed treatments for many groups and the costliness of NRT for very low-income people in general, some commentators have suggested that NRT should be added to the PBS in Australia.[380] Alternatively (or in addition), Australia could establish a system similar to that in New Zealand or New York. Quitlines could distribute NRT, if this could be provided free or (with greater administrative complexity) at a discount. This model would have the advantage of enabling the Quitline to use free product in promotions to attract additional callers.


Action proposed

Greater use of Quitline
Quit campaigns should find ways to more effectively promote the Quitline to low SES smokers.

Increased use of NRT
Commission a study on the pros and cons, feasibility and benefits for various stakeholders of various possible options for the subsidy of NRT in Australia. The aim would be to maximise the use of both the Quitline and NRT by low-income smokers. A model incorporating a variety of delivery and subsidy mechanisms could be considered.

In the meantime, fund an initiative to provide vouchers to obtain free NRT to those for whom spending on tobacco products is causing significant financial stress. This could be introduced at the same time as any large increase in excise duty on tobacco. The NRT could be available free through the Quitline, and the vouchers could be provided through duty social workers staffing services for people in distress.

Consider offering to match any donations of NRT by pharmaceutical companies to the Quitline with offers to purchase equivalent quantities of stock.

Improved quality of use of NRT
Quitlines could explore age – and culturally-appropriate interventions to help people better manage medicines – such as prompts delivered through SMS (text) messages to remind people to take the medication at the times they need to and to use it as directed – as a way of increasing quality of use of NRT and other treatments.

³⁸Referrals from other health professionals, however, have been less successful.
358 Young J, Girgis S, Bruce T, Hobbs M and Ward J. Acceptability and effectiveness of opportunistic referral of smokers to telephone 
cessation advice from a nurse: a randomised trial in Australian general practice. BMC Family Practice. 2008;9 16. Available from: http://www.biomedcentral.com/content/pdf/1471-2296-9-16.pdf.
³⁹Of a total population of just under 20 million people.
⁴⁰Patches went on PBS earlier this year solely for Indigenous smokers, as it was accepted by PBAC that they more frequently have objections to or problems with oral preparations.
377. Pharmaceutical Benefits Advisory Committee, Sydney: Letter concerning listing of NRT patches for Indigenous smokers. The Cancer Council Australia, 2008.
⁴¹Bupropion is contraindicated in patients with a current seizure disorder or any history of seizures, patients with a known central nervous system (CNS) tumour, patients undergoing abrupt withdrawal from alcohol or benzodiazepines, patients with a current or previous diagnosis of bulimia or anorexia nervosa and patients taking monoamine oxidase inhibitors (MAOIs), a common treatment for depression.
⁴²Safety of varenicline (marketed in Australia as Champix and in the US as Chantix) for patients with pre-existing psychiatric conditions has not been established, and physicians have been advised to be cautious after widely reported cases of severe psychiatric episodes, including some in patients with no previously reported history of psychiatric illness.

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