Use and reimbursement costs of smoking cessation medication under the Quebec public drug insurance plan.
Tremblay, Michele ; Payette, Yves ; Montreuil, Annie 等
In order to combat a smoking epidemic that claims more than 37,000
lives in Canada each year, (1) a variety of intervention measures are
needed to help current smokers free themselves of their addiction. (2)
Smoking cessation medication, such as the nicotine patch, nicotine gum
and bupropion are important tools for smokers who want to stop smoking.
Numerous studies have shown that these medications double the rate of
quitting success. (3-5)
The Framework Convention on Tobacco Control states that countries
that ratify the treaty will work to facilitate access to affordable
treatment for tobacco dependence, including pharmacotherapy. (2)
Complete reimbursement of smoking cessation medication, as opposed to
partial reimbursement or non-reimbursement, is associated with an
increased use of smoking cessation medication, a greater number of
cessation attempts and higher abstinence rates. (6)
In October 2000, the nicotine patch, nicotine gum and bupropion
were added to the general list of medications reimbursed under
Quebec's public drug insurance plan, the Regime public
d'assurance medicaments du Quebec (RPAMQ). (7) The RPAMQ reimburses
the cost of smoking cessation medication for 12 consecutive weeks, once
a year, when prescribed by a health professional. In 2000, Quebec was
the only province in Canada to offer reimbursement of smoking cessation
pharmacotherapy as part of a provincial drug insurance plan.
In Quebec, individuals who have access to a private insurance plan,
often available through employers, must subscribe to that plan. Others
are covered by the RPAMQ and must pay an annual premium, a monthly
deductible and a co-insurance, which varies depending on the class of
insured persons to which they belong. In 2004, 43% of the Quebec
population aged 15 and over was insured under the RPAMQ, and the classes
of persons insured broke down as follows: 15% were employment assistance
recipients, 34% were seniors, and 51% were "other" plan
participants (who are under the age of 65, are not employment assistance
recipients but do not have access to a private insurance plan, e.g.,
freelance workers, children under the age of 18). Five percent were in
the 15-19 age group, 6% were aged 20-24, 14% were 25-34, 14% were 35-44,
14% were 45-54, 14% were 55-64 and 34% were 65 or older. Fifty-five
percent were women. These proportions did not change appreciably between
2000 and 2004.
The present study was undertaken to describe the use of the
reimbursement measure in Quebec by people insured under the RPAMQ during
the first four years of the program (2000-2004). Costs to the RPAMQ in
reimbursing these medications to Quebeckers are also described. This
article stems from a government report published in 2007. (8)
METHODS
Data source
The database of smoking cessation medications reimbursed to persons
15 and over insured by the RPAMQ between October 1, 2000, and December
31, 2004, was provided to the authors by the Regie de l'assurance
maladie du Quebec (RAMQ). Medical insurance numbers were encrypted to
safeguard anonymity.
Study variables
Medication Characteristics
Characteristics of reimbursed smoking cessation medication included
type of medication (nicotine patch, nicotine gum, bupropion) and dose
(for nicotine patch 7 mg, 14 mg, 21 mg; for nicotine gum 2 mg, 4 mg; for
bupropion 150 mg). A prescription is a quantity of medication sold to a
person at a given time. The duration of treatment was estimated using
the date when a person requested the medication from a pharmacist and
the planned duration of treatment based on the quantity of medication
prescribed.
Characteristics of Insured Persons Under the RPAMQ
Characteristics of insured persons were 1) sex, 2) age group and 3)
class of insured person (employment assistance recipients, seniors aged
65 and over, "other" plan participants). We estimated the
proportion of smokers insured under the RPAMQ on the basis of smoking
rates in Quebec from the 2003 Canadian Community Health Survey (CCHS)
(Cycle 2.1). The estimated proportion of smokers among employment
assistance recipients corresponds to the proportion of smokers in the
lowest income category in CCHS. The estimated proportion of smokers aged
65 years and over corresponds to the proportion of smokers in this age
group. The estimated proportion of smokers among "other" plan
participants corresponds to the proportion of smokers in the general
population.
Costs of Reimbursement
Costs to the RPAMQ included medication costs and pharmacists'
service costs. They did not include the contributions of insured
persons.
Use Threshold
We estimated the proportion of persons who passed a use threshold
corresponding to the end-point of a smoking cessation process as set out
in manufacturers' instructions (9) and guidelines published by
expert groups. (3,10) We retained two criteria in our analysis
algorithm, based on the premise that users take one patch a day and that
treatment is uninterrupted: 1) the last nicotine patch dose must have
been 7 mg, and 2) the nicotine patches must have been bought for eight
weeks or more.
Analyses
The RAMQ data were analyzed using Visual Foxpro 8 software, and
statistical analyses were done with SPSS 12.0.
RESULTS
Use of smoking cessation medication among Quebeckers insured under
the RPAMQ
Between October 1, 2000 and December 31, 2004, there were 306,824
different Quebeckers aged 15 and over insured under the RPAMQ who were
reimbursed, for a total of 1,747,515 prescriptions for smoking cessation
medication (Table 1). A reduction of 20% in the number of users was
observed between 2002 and 2003, followed by a 16% reduction between 2003
and 2004. Nicotine patches were by far the preferred smoking cessation
medication, constituting the choice of 80% of users. There was a
significant reduction in the use of bupropion, from 52% in 2000 to 25%
in 2001 and 7% in 2004. This reduction may be related to reports
released by Health Canada in 2001 of suspected adverse drug reactions
associated with bupropion. (11)
During the 2000-2004 period, employment assistance recipients, who
accounted for about 15% of persons insured under the RPAMQ, made up 30%
of users, double their proportion within the RPAMQ. On the other hand,
seniors accounted for 34% of persons insured under the RPAMQ but only
13% of smoking cessation product users (Table 1).
Use of smoking cessation medication among smokers insured under the
RPAMQ
On the basis of our estimates, some 706,800 smokers were insured
under the RPAMQ in 2004. (8) Between 2001 and 2004, a yearly average of
14% of smokers insured under the public plan received reimbursement for
smoking cessation medication. The proportion of smokers who were
reimbursed was higher among employment assistance recipient smokers
(27%) than among seniors (11%) or "other" plan participant
smokers (15%). The proportion was also slightly higher among women
smokers (16% vs. 13% among men), as well as among smokers aged 35 to 64
(19% vs. 14% or less in other age groups).
Subsequent use of smoking cessation medication
The distribution of users in terms of first-time use or repeat
treatment is shown in Table 2. In 2004, 49% of nicotine patch users had
been reimbursed for this medication at least once in the previous four
years, and past use rates for bupropion and nicotine gum were 34% and
20%, respectively. The average annual number of nicotine patches
purchased by users increased with each use episode: from 37 patches in
the first episode to 53 patches the fourth time out (data not shown).
Use threshold
The proportion of users who reached a use threshold corresponding
to the end-point of a smoking cessation process increased from 26% in
the first use episode to 42% in the fourth use episode (Table 3). The
most important increase, from 29% to 49%, was observed among employment
assistance recipients.
Costs
Between 2000 and 2004, reimbursements totalling $55 million were
made by the RPAMQ to 306,824 Quebeckers, representing an average of $181
per user over the four-year period (Table 4). Two trends emerge. First,
from 2001 to 2002, the total cost increased despite a stable number of
users. This can be explained by a sharp decrease in the number of
bupropion users (from 30,000 to fewer than 10,000, Table 2) coupled with
an increase in the number of nicotine patch users (from 87,000 to
102,000), which costs twice as much as bupropion for the RPAMQ (Table
5).
Second, despite a decrease in the total cost and in the number of
users between 2002 and 2004 (from $15 million for 112,000 users to $11
million for 75,000 users), the yearly average cost per user actually
increased, from $136 to $142. Given that drug costs did not change
appreciably during this period (personal communication: RAMQ, 2007),
this increase may be linked to an increase in the proportion of repeat
users of the nicotine patch (Table 2), a group that uses more of this
medication in a use episode than new users.
Nicotine patches accounted for 90% of all RPAMQ costs for
prescription smoking cessation medication between 2000 and 2004 (Table
5). During this period, the average cost per user per year was higher
for the nicotine patch ($138) than for nicotine gum ($58) or bupropion
($67). Three reasons may explain this situation: 1) the nicotine patch
tends to be used for longer periods of time than nicotine gum; 2) the
daily cost of the nicotine patch is generally one and a half times
higher than bupropion (personal communication: RAMQ, 2007); and 3) the
reuse rate of the nicotine patch was greater during this four-year
period than that of nicotine gum or bupropion (Table 2).
Employment assistance recipients and other plan participants
accounted for the largest share of smoking cessation medication costs
between 2000 and 2004 (just under $25 million for each category) (Table
5). While employment assistance recipients accounted for 30% of users
insured under the RPAMQ, this group generated 42% of all costs.
"Other" plan participants generated 44% of costs, even though
they accounted for 58% of all users. The average RPAMQ reimbursement
cost per user per year was greater for employment assistance recipients
($167) than for "other" plan participants ($103), mainly
because deductibles, co-insurance costs and maximum contributions paid
by insured persons are lower for employment assistance recipients than
for "other" plan participants. (8)
DISCUSSION
According to our results, employment assistance recipients (a group
more likely to encounter economic barriers to the use of smoking
cessation medication) tend to avail themselves of the reimbursement
measures in a greater proportion than seniors or "other" plan
participants. Close to half of all persons in this group who used the
nicotine patch for a fourth try reached a use threshold corresponding to
the end-point of a smoking cessation process. Since clinical studies
show that the nicotine patch doubles quitting success rates and that
several attempts are often needed to successfully stop smoking, (3,12)
it is reasonable to assume that the reimbursement provisions put in
place in Quebec in 2000 are responsible for many successful cessations,
particularly among employment assistance recipients, a group whose
smoking prevalence rate is particularly high.
The nature of tobacco addiction requires measures that are known to
be effective, such as professional counselling and pharmaceutical
medication. (3,13,14) The conditions that currently govern the
reimbursement of smoking cessation medication in Quebec require smokers
to consult a doctor or a smoking cessation specialist to obtain a
prescription. In so doing, smokers also receive smoking cessation
counselling, an intervention that is provided free of charge to
Quebeckers. The cost of these two interventions combined is comparable
to that of other smoking cessation services in Quebec that are
considered important (15) and 10 to 12 times lower than the cost of
treating other diseases, such as hypercholesterolemia. (5)
The administrative data analyzed in this study cannot be used to
evaluate the specific contribution of the reimbursement provisions in
reducing the smoking prevalence in Quebec from 30% in 2000-2001 to 25%
in 2005. (16) Furthermore, over the past 10 years, Quebec has gradually
introduced other measures to help smokers quit, such as annual media
campaigns, "Quit and Win" contests, a telephone helpline, quit
smoking centres and encouragement to health care professionals to offer
counseling to their smoking patients. Future research should evaluate
the impact of reimbursing smoking cessation medications on smoking
prevalence in a context where complementary services are likely to
interact with each other in helping smokers quit.
Correspondence and reprint requests: Michele Tremblay, Institut
national de sante publique du Quebec, 190 Cremazie East, Montreal, QC
H2E 1P2, Tel: 514-8641600, ext. 3509, Fax: 514-864-5190, E-mail:
michele.tremblay@inspq.qc.ca
Acknowledgements: The authors thank the Regie de l'assurance
maladie du Quebec for the use of their database.
Received: May 25, 2009
Accepted: August 26, 2009
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Michele Tremblay, MD, Yves Payette, MSc, Annie Montreuil, PhD
Authors' Affiliation
Institut national de sante publique du Quebec, Montreal, QC
Table 1. Breakdown of Smoking Cessation Medication by Users
Insured under the RPAMQ, by Medication and Class of Insured
Persons, Quebec, 2000-2004
2000 * 2001 2002
Total number of users 42,906 111,899 111,731
Number of prescriptions 107,761 406,194 490,038
Breakdown of users by medication,
([double dagger]) %
Nicotine patch 47.6 72.6 88.5
Nicotine gum 0.2 2.1 3.3
Bupropion 52.2 25.2 8.2
Breakdown of users by class of
insured persons, ([section]) %
Employment assistance recipients 36.0 30.8 31.1
Seniors 15.5 12.9 12.2
"Other" plan participants 48.5 56.3 56.6
2003 2004 Total
2000-2004
Total number of users 89,289 75,255 306,824
([dagger])
Number of prescriptions 401,049 342,473 1,747,515
Breakdown of users by medication,
([double dagger]) %
Nicotine patch 89.1 89.2 80.4
Nicotine gum 3.3 3.5 2.7
Bupropion 7.6 7.4 16.9
Breakdown of users by class of
insured persons, ([section]) %
Employment assistance recipients 32.2 33.0 29.7
Seniors 12.2 11.4 12.6
"Other" plan participants 55.4 55.3 57.6
Source: RAMQ data
* Last three months of the year, starting on the date the
reimbursement provisions came into force.
([dagger]) The total number of separate users for the 2000-2004
period is different from the sum of all users in each year, since
some users repeated the treatment from year to year.
([double dagger]) Users who consumed medication from more than
one category during the same year are included in the category of
the first product used.
([section]) Fewer than 5% of insured persons changed categories
between 2000 and 2004; those who did were still considered part
of the first category until the end of the year in which the
change occurred, and included in the total for 2000 to 2004.
Table 2. Breakdown of Smoking Cessation Medication by
Users Insured under the RPAMQ According to First
Use Episode or Repeat Treatment, Quebec, 2000-2004
2000 * 2001 2002
Nicotine patch users, %
1st use episode 100 97 79
2nd use episode 3 21
3rd use episode 1
4th use episode
Total reuse in 2004
No. of patch users 21,616 86,780 102,042
Nicotine gum users, %
1st use episode 100 99 95
2nd use episode 1 5
3rd use episode <0.1
4th use episode
Total reuse in 2004
No. of gum users 78 2554 3797
Bupropion users, %
1st use episode 100 97 73
2nd use episode 3 27
3rd use episode 1
4th use episode
Total reuse in 2004
No. of bupropion users 23,711 30,118 9399
2003 2004
Nicotine patch users, %
1st use episode 61 51
2nd use episode 30 31
3rd use episode 8 14
4th use episode <0.1 4
Total reuse in 2004 49
No. of patch users 81,777 68,845
Nicotine gum users, %
1st use episode 86 80
2nd use episode 12 14
3rd use episode 2 5
4th use episode <0.1 1
Total reuse in 2004 20
No. of gum users 3076 2680
Bupropion users, %
1st use episode 68 66
2nd use episode 25 23
3rd use episode 7 9
4th use episode <0.1 2
Total reuse in 2004 34
No. of bupropion users 6976 5696
Source: RAMQ data.
* Last three months of the year, starting on the date the
reimbursement provisions came into force.
Table 3. Proportion of Users Who Tried the Nicotine Patch
for At Least Eight Weeks and Whose Last Dose Was
7 mg, by Use Episode and Class of Persons Insured
under the RPAMQ, Quebec, 2000-2004
Nicotine Patch Employment Seniors Other Total
Assistance Plan
Recipients Participants
%
1st use episode 29.0 32.9 22.4 25.7
2nd use episode 38.1 34.5 25.7 31.4
3rd use episode 45.3 38.4 30.7 38.3
4th use episode 48.7 38.9 30.9 41.5
Source: RAMQ data.
Note: A person who changes categories between two use episodes is
included in the first category for the purposes of this table.
Table 4. Costs to the RPAMQ for the Reimbursement of Smoking
Cessation Medication--Nicotine Patch, Nicotine Gum and
Bupropion--Quebec, 2000-2004
2000 * 2001 2002
Costs for all users, $ 3,948,424 13,239,160 15,201,330
Number of users 42,906 111,899 111,731
Cost per user, $ 92 118 136
Total
2003 2004 2000-2004
Costs for all users, $ 12,387,887 10,688,588 55,465,387
Number of users 89,289 75,255 306,824
([dagger])
Cost per user, $ 139 142 181
Source: RAMQ data.
* Last three months of the year, starting on the date the
reimbursement provisions came into force.
([dagger]) The total number of separate users for the 2000-2004
period is different from the sum of all users in each year, since
some users repeated the treatment from year to year.
Table 5. Costs to the RPAMQ for the Reimbursement of Smoking
Cessation Medication, by Medication and Class of Insured Persons,
Quebec, 2000-2004
Total Costs
for All Users Breakdown of
from 2000 to 2004 Users
$ %
Medication
Nicotine patch 49,700,838 80.4
Nicotine gum 708,806 2.7
Bupropion 5,055,743 16.9
Class of insured persons *
Employment assistance recipients 23,170,450 29.7
Seniors 7,672,858 12.6
"Other" plan participants 24,482,988 57.6
Total 55,465,387 100
Proportion of Average Cost per
Total Costs User per Year
% $
Medication
Nicotine patch 89.6 138
Nicotine gum 1.3 58
Bupropion 9.1 67
Class of insured persons *
Employment assistance recipients 41.8 167
Seniors 13.8 141
"Other" plan participants 44.1 103
Total 100 129
Source: RAMQ data.
* The sum of costs for the three doses of insured persons
($55,326,296) is different from the sum of costs for the three
classes of medication ($55,465,387) due to missing information on
the class of insured persons.
