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PHARMAC and tobacco control in New Zealand: Government policy
‘up in smoke’
Shaun Holt, Matire Harwood, Sarah Aldington, Richard Beasley
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Abstract
There is increasing concern amongst the medical profession
in New Zealand about the adverse effect that PHARMAC has on the health of New
Zealanders through restricting the availability of medications. In this article,
the circumstances surrounding the restrictions limiting the availability of the
smoking cessation treatment bupropion are presented. The authors conclude that
the decision by PHARMAC not to fund bupropion is directly contrary to Government
policy and is inconsistent with evidence-based medicine and international
recommendations. It is suggested that the PHARMAC decision seriously questions
the Ministry of Health’s commitment to smoking cessation and the health of
disadvantaged groups in New Zealand, particularly Maori.
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Drug:
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Bupropion (Zyban)
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Indication:
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Treatment of smoking cessation
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Recommended
dose & duration:
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Bupropion SR 150 mg daily for 3 days, then 150 mg bd for
7–12 weeks, together with behavioural therapy
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Clinical
efficacy:
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Bupropion is an antidepressant which is an effective
treatment for smoking cessation, resulting in a two-fold greater rate of smoking
cessation compared with placebo.1-5
Bupropion may be more effective than nicotine replacement
therapy (NRT) in achieving smoking
cessation.6
Bupropion has been shown to be effective in Maori with a
risk ratio for abstinence of 2.4 over 12
months.7
Rare serious adverse events such as seizures can occur,
resulting in its contraindication in patients with a history of or significant
predisposition to seizures.8,9
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Background:
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Tobacco smoking is a major public health problem in New
Zealand, being the single greatest preventable cause of premature
death.
In New Zealand, smoking kills around 4,500 persons per
year.10
The situation is of particular concern in Maori in whom it
has been estimated that one in three deaths is due to
smoking.11
The rate of smoking in Maori adults is around 50%, compared
with around 20% in non-Maori.12
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Government
policy:
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The New Zealand Health Strategy highlights a reduction of
smoking as one of the 13 population health
objectives.13
The Ministry of Health goals for tobacco
control14 are:
- To
significantly reduce the levels of tobacco consumption and smoking
prevalence.
- To
reduce inequalities in health outcomes.
- To
reduce the prevalence of smoking among Maori, to at least the same level as
non-Maori.
- To
reduce New Zealanders’ exposure to secondhand smoke.
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In its 5 year plan for tobacco control, the Ministry of
Health states14 that it will:
- Give
substantial weight to interventions for which there is strong scientific
evidence of effectiveness.
- Give
weight to interventions that benefit a large proportion of the community.
- Give
weight to cost-effective interventions.
- Strive
to maximise the benefits of targeted interventions (people with the greatest
health needs such as Maori and low income New Zealanders) and minimise potential
adverse effects.
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Current
situation:
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New Zealand:
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Bupropion has been registered and approved for use in New
Zealand since May 2000, however is not yet funded by
PHARMAC.15
The National Health Committee endorsed the use of bupropion
in clinical practice in 2002.15
Following a review of adverse reactions to bupropion, the
Medicines Adverse Reactions Committee (MARC) recommended in 2002 that bupropion
should only be considered as a second-line intervention (after unsuccessful
trials with smoking cessation treatment including
NRT).15
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International:
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In the United States and United Kingdom, bupropion is the
only non-nicotine drug recommended as first-line pharmacotherapy, with strength
(A) evidence as an efficacious smoking cessation treatment that patients should
be encouraged to use.16,17
Nortriptyline is recommended as a second-line agent in the
US Guidelines because it is not registered for smoking cessation in the US and
there are more concerns about potential side effects than with first-line
medications.
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Access/supply:
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Bupropion can be obtained through the private
pharmaceutical market, on prescription. A full 7-week course costs about
NZ$330.15
Nicotine replacement therapy (NRT) is subsidised by
the Government.
There is evidence of efficacy with the
antidepressant nortriptyline, however it was not registered for use in New
Zealand as a smoking cessation adjunct until 2003. Until then nortriptyline
could only be prescribed for this purpose under Section 25 of the Medicines Act
1981 which allows off-label prescribing for non-approved
indications.15
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Economic
analysis:
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Bupropion is more cost-effective than the majority of
treatments currently funded by PHARMAC in terms of cost per life year saved.
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Other
issues:
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The study demonstrating the efficacy of bupropion in
Maori7 is the first randomised, double-blind,
placebo-controlled trial of a pharmacotherapy in the Maori population.
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Comment:
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The decision by PHARMAC not to
fund bupropion is directly contrary to Government policy and is inconsistent
with evidence-based medicine and with US and UK guidelines. The PHARMAC decision
seriously questions the Ministry of Health’s commitment to smoking
cessation and the health of disadvantaged groups in New Zealand, particularly
Maori.
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Author information:
Shaun Holt, Director, P3 Research, Wellington; Matire Harwood, Senior
Research Fellow; Sarah Aldington, Senior Research Fellow; Richard Beasley,
Director, Medical Research Institute of New Zealand, Wellington
Correspondence:
Professor Richard Beasley, Medical Research Institute of New Zealand, PO
Box 10055, Wellington. Fax: (04) 472 9199; email: richard.beasley@mrinz.ac.nz
References:
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RD, Sachs DPL, Glover ED et al. A comparison of sustained-release bupropion and
placebo for smoking cessation. N Engl J Med. 1997;337:1195–202.
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JS, Harris KJ, Catley D et al. Sustained-release bupropion for smoking cessation
in African Americans. JAMA. 2002;288:468–74.
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S, Farsang C, Klaene G, et al. Bupropion SR for smoking cessation in smokers
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S, Timu-Parata C, Ryder-Lewis S, Weatherall M, Beasley R. Efficacy of bupropion
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Accessed May 2005.
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of Health. Clearing the smoke: a five-year plan for tobacco control in New
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Accessed May 2005.
- Guidelines
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MC, Bailey WC, Cohen SJ et al. Treating tobacco use and dependence. Clinical
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