Enhancing public health impact by increasing use of medications

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Enhancing public health impact by increasing use
of medications

• Saul Shiffman, Ph.D.
• University of Pittsburgh
• Pinney Associates
• Consulting to GlaxoSmithKline

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• The most effective treatment, if not used,
• makes no contribution to tobacco control
• or
• public health

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Enhancing Public Health Impact

• Impact ( of quits)
• Efficacy ( quit)
• X
• Utilization ( using method)

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Use of Cessation Medications in Most Recent Quit
Attempt
Survey of national household panel, N10,061, 2001
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Trends in Use of Pharmacologic Aids
Vapor inhaler 3/98
Zyban 5/97
Gum OTC4/96 2 patches OTC8/96 Nasal spray8/96
Patches 1/92
Estimated Assisted Quit Attempts(in thousands)
Gum (4mg) 3/93
Gum (2mg) 2/84
OTC switches
Based on sales data
Burton et al, MMWR, 2000
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OTC NRT vs. Placebo
Hughes et al, in press
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OTC NRT vs. Rx NRT
Hughes et al, in press
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Australia NRT Utilization Enhanced by both
Access Promotion
Ads
Pharm
Rx
Australia Based on sales data
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Adequate Utilization?

• Medications not used for as long as directed
• Medications not used in directed amounts

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Why Dont More Smokers Use Pharmacotherapy?

• Perceived lack of efficacy
• Perceived health risk of medications
• Cold Turkey norm
• Lack of physician support
• Cost
• Limited appeal of options

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Efficacy Perceived Efficacy

• Expectations reality
• Impression formation
• Individual vs. population perspective
• The glass is twice as full
• The glass is 90 empty

Davidson et al, 1998
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Consumer Information about Pharmacotherapy
Anti-smoking drug deaths triple
The number of people who have died after taking
the anti-smoking drug Zyban has more than tripled
in a year. BBC, January 18, 2002
Nicotine patches and gum may pose health
hazards Press release, American Chemical Society
, March 27, 2002
Nicotine the culprit in lung cancer
USA Today, January 2, 2003
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Smokers believe nicotine causes cancer
Nicotine is a cause of cancer.
Hyland, Cummings, Giovino et al, BAND Survey
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Smokers believe NRT more likely than smoking to
cause heart attack
Are nicotine PATCHES more or less likely to cause
a heart attack as cigarettes?

Hyland, Cummings, Giovino et al, BAND Survey
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Cold Turkey Norm

• Should not need treatment just willpower
• Comparisons
• Weight loss
• Problem drinking alcoholism
• Other drug dependence
• Promoted by minimal intervention ethic

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Physician Promotion of Treatment NOT!

• Physicians do not promote quitting
• Only 30 of smoking patients were counseled to
  quit
  
• Physicians do not promote treatment
• Only 2.4 were given NRT in 1995, when
  prescription was the only way to get treatment!
  
• Physicians do not provide support
• Among those getting NRT prescription (1994)
• 23 No instructions, 39 No quit advice

Thorndike, Rigotti et al, 1998
Shiffman et al, 2002
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Cost May be a Barrier for Some Smokers

• Cost vs. outlay
• Daily cost of NRT roughly on par with daily cost
  of a pack of cigarettes
  
• Initial outlay for NRT is much higher
• Cost decrease alone may not be enough
• Generic patches are 28 cheaper, but have not
  increased utilization
  
• Medicaid 64 have coverage - 2 utilization in
  1999
  
• Boyle (2002) Adding coverage did not increase use

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What Smokers Want from Treatment

• Cheap
• Effective
• Safe
• Easy
• Fast
• Pain relief
• Pleasant

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Enhancing Utilization of Behavioral Treatment

• Little demand for clinics
• Very low reach 1.8 of quit efforts
• Need convenient outreach
• Phone counseling proactive calls work
• Printed or web materials
• Untailored material is ineffective
• Tailored materials work
• 500,000 users of the Committed Quitters Program
  (but only 3-5 utilization)

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Summary

• Increase supply
• New medications
• Easy access
• Increase demand
• Promotion of quitting and medications
• Accurate information about risks and benefits
• Attractive products with consumer appeal
• Along with efficacy, utilization determines
  public health impact

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Needs

• Research
• To understand decision-making about treatment
• To develop treatments with broad utilization in
  mind
  
• Action
• To encourage use of treatment
• To communicate effectively about treatment

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• Even if we build it,they will not necessarily
  come.
  
• We have to make it accessible, affordable, and
  appealing.
  
• And then promote it.