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Should the Pharmaceutical Benefits Advisory Committee extend the range of free nicotine replacement therapies available for Aboriginal and Torres Strait Islander people?

Jan A Robertson, David J MacLaren and Alan R Clough
Med J Aust 2009; 191 (5): 293.

To the Editor: In March 2008, nicotine patches (15 mg per 16 hours) were authority-listed for Aboriginal and Torres Strait Islander people by the Pharmaceutical Benefits Advisory Committee (PBAC) as part of efforts to improve access to medications.1,2 Although timely and welcome, the decision to list only 15 mg patches should be revisited, as it is not consistent with current smoking cessation clinical guidelines.3-5 Neither is it consistent with evidence from a 2008 tobacco survey that we conducted in remote Aboriginal communities in Arnhem Land, Northern Territory.

Clinical guidelines advise that smokers will require more intensive support to quit smoking if they: (i) demonstrate a high level of dependency; (ii) have had more than one short quit attempt; (iii) still smoke or experience cravings when using nicotine replacement therapy (NRT); and/or (iv) are frequently exposed to other smokers.3,4 This support includes appropriate medication and counselling, which are more effective in combination.5 Under-dosing is a common problem, given that NRT products deliver nicotine plasma levels well below that delivered by a cigarette.3 Higher-dose NRT products (eg, 4 mg gum) or combination nicotine therapies (eg, patches with gums) are effective for highly dependent smokers.3,5

In the Arnhem Land survey, we interviewed 397 people (aged ≥ 16 years) about tobacco. Of these, 77% were current smokers. Among the current smokers, 17% were attempting to quit or had tried to quit, and 58% were contemplating quitting. Dependency was common, with 55% of smokers reporting they smoked first thing in the morning or during the night. With many dependent smokers, high rates of smoking and widespread “cue” exposure, there is a high need for intensive quit support.

We also interviewed 24 smokers interested in quitting who were offered 21 mg patches, and 4 mg and 2 mg gums and lozenges. All used the gums; four combined gum with 21 mg patches, with one of these initially trying lozenges. Modest increases in periods of abstinence and reduction in daily consumption were documented in the 11 participants followed up so far. This evidence, albeit limited, challenges the PBAC rationale for listing patches but not gums for Aboriginal and Torres Strait Islander people, namely: “this population eschews oral aids for smoking cessation”.1

Some Aboriginal and Torres Strait Islander smokers wanting to quit may benefit from combination NRT or gums alone. A wider range of NRT products including gums should therefore be considered by the PBAC.

Jan A Robertson, Research Development and Project Manager (Public Health)
David J MacLaren, Researcher (Public Health)
Alan R Clough, Researcher (Public Health)
School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Cairns, QLD.
Correspondence: 
Acknowledgements: 

The research was supported by the National Health and Medical Research Council (NHMRC) (project grant no. 436012). We thank our co-investigators on this project: Professor Rob Sanson-Fisher and Professor Robert Gibberd (University of Newcastle), Professor Sandra Eades (Baker IDI Heart and Diabetes Institute), and Associate Professor Rowena Ivers (University of New South Wales) and Associate Professor Kate Conigrave (University of Sydney). We also thank Associate Professor Renee Bittoun (University of Sydney).

Reference Text: 
Pharmaceutical Benefits Advisory Committee. Positive recommendations made by the PBAC — March 2008. Canberra: PBAC, 2008. http://www.health.gov.au/internet/main/publishing.nsf/Content/pbacrec-mar08-positive (accessed Feb 2009).
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1
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National Prescribing Service. Nicotine patches for Aboriginal and Torres Strait Islander people. Canberra: NPS, 2008. http://www.nps.org.au/health_professionals/publications/nps_radar/issues/current/december_2008/brief_item_nicotine (accessed Feb 2009).
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2
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Latt N, Conigrave K, Saunders J, et al, editors. Addiction medicine. Oxford: Oxford University Press, 2009.
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3
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New Zealand Ministry of Health. New Zealand smoking cessation guidelines. Wellington: the Ministry, 2007. http://www.moh.govt.nz/moh.nsf/indexmh/nz-smoking-cessation-guidelines?Open (accessed Apr 2009).
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4
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Reference Text: 
Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Rockville, Md: US Department of Health and Human Services. Public health Service, 2008. (accessed Apr 2009).
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5
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