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Cost of pharmacological treatments appears to influence usage, with lower cost increasing usage.

Despite the cost-effectiveness associated with smoking cessation interventions, an expert consensus report on NRT policy noted that cost is a significant barrier to NRT use (Kozlowski et al. 2007). This report suggested supplying NRT in packages that contain fewer dose units as one way to overcome this obstacle and create easier access to NRT.

Several studies in the US have shown that cost is a barrier to NRT usage. Evidence for the importance of acquisition cost as a barrier can be found in analyzing price-demand elasticities in the retail setting. Tauras and Chaloupka (2003) found the own-demand elasticity for a nicotine patch and nicotine gum to be -2.33 and -2.46 respectively; modifying the price of NRT has a significant impact on demand for and use of NRT. For example, in 1991 Hughes and colleagues demonstrated that decreasing the cost of nicotine gum increased the incidence of obtaining and using the gum and the amount used, and also increased attempts at cessation as well as short-term cessation rates (Hughes et al., 1991). Furthermore, a study of participants in a smoking cessation program led by family physicians, reported significantly higher one year success rates among those who had received nicotine gum free than among those who had purchased the gum themselves (Cox & McKenna, 1990).

A number of studies have assessed the the impact of reducing the costs of providing or using smoking cessation treatment by health care financing interventions on the use of smoking cessation treatments and smoking cessation. Curry and colleagues (1998) compared insurance coverage on the demand for and use of smoking cessation services. They demonstrated that the highest rates of smoking cessation services were found with full coverage. Although the rate of smoking cessation among the benefit users with full coverage was lower than the rates among users with plans requiring co-payments, the effect on the overall prevalence of smoking was greater with full coverage than with the cost-sharing plans (presumably because uptake was greater with full coverage, the co-payment users were probably more motivated). Schauffler and colleagues (2001) also demonstrated that covering the cost of treatments was a relatively low cost strategy for significantly increasing quit rates, quit attempts and use of nicotine gum and patch in adult smokers.

A recent example of an effective policy intervention was demonstrated in a study of the Medicaid population in Massachusetts between 2006 and 2008. During this time period, approximately 70,000 smokers in Massachusetts took advantage of a newly available Medicaid benefit that mandated tobacco cessation coverage for the Medicaid population. This coverage included both behavioral counseling and several pharmacotherapy options. The authors found significant decreases in smoking rates during the study timeframe and attributed the decreases to the increased coverage (Land et al., 2010.)

Not all studies have found this, however. One study carried out in Minnesota (Boyle et al., 2002) reported that insurance coverage for pharmacotherapy alone did not affect usage of pharmacotherapies or quitting rates. The authors suggested that this may have reflected inadequate publicity of the scheme or the fact that behavioral support was not covered. This merits further research. Cornuz et al. (2006) concluded in a multinational study of the incremental cost of adding pharmacotherapy to counseling that although several variables affected cost-effectiveness, tobacco cessation pharmacotherapy would be regarded as favorable compared with other common preventive pharmacotherapies.

Cummings (Cummings et al., 1997; Cummings & Hyland, 2005) point out that among other barriers, perceived high cost of NRT keeps smokers from using the products in great numbers in the US, where fewer than one in five use NRT as a cessation aid. The World Bank suggested that countries should consider making NRT available at reduced prices or free, for limited periods, to low income smokers who were motivated to quit (World Bank, 1999). In the UK, NRT was made reimbursable on the National Health Service in April 2001 (all NRT products are available OTC with some available on general sale - see McNeill & Bates, 2000; McNeill et al., 2005). A 2005 study of utilization of pharmacotherapy in the UK after cessation medications were made reimbursable showed a marked uptake in their utilization of 80,000 additional treatment weeks “purchased” per month, but did not detect any impact on prevalence (West et al., 2005).

In one Cochrane review assessing the effects of health-care financing systems for increasing the utilization of smoking cessation treatment (Redda et al., 2009), covering the full cost to smokers of using smoking cessation treatment increased the number of biochemically validated successful quitters; the number of participants making a quit attempt; and the use of smoking cessation treatment at low cost when compared with no financial coverage.  Further, U.S. clinical practice guidelines recommend that effective treatments be included as covered services in public and private health benefit plans (Fiore et al., 2008).
A growing body of evidence supports the public health benefit of state and local programs providing NRT free to callers of quitlines (Cummings et al. 2006). Several recent program evaluations have demonstrated that offering free NRT through state quit lines can attract participants and improve quit rates (An et al., 2006; Cummings et al., 2006; Miller et al., 2005; Swartz et al., 2005; Tinkelman et al., 2007). In 7 U.S. states, a telephone quitline in conjunction with low-cost pharmacotherapy was the most effective means of reducing smoking in the elderly (those > 65 years of age) (Joyce, 2008). The Quitline arm cessation rates at 6 months and 12 months significantly outperformed Performed Provider Counseling + Pharmacotherapy arms. At 12 months, quit rates, were 10% for Usual Care, 14% for Provider Counseling, 16% for Provider + Pharmacotherapy and 19% for the Quitline arms.

In many countries where the tax on tobacco is very low, for example, China, the comparatively high cost of NRT will be even more of a barrier to use than in industrialized countries. Ideally policy to try to persuade governments and/or the pharmaceutical companies to reduce or subsidize products prices ought to be coupled with attempts to persuade governments to increase tax on tobacco.

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Boyle RG, Solberg LI, Magnan S, Davidson G, Alesci NL. Does insurance coverage for drug therapy affect smoking cessation? Health Affairs. 2002; 21: 162-168.

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Cummings KM, Hyland A. Impact of nicotine replacement therapy on smoking behavior. Annu Rev Public Health. 2005; 26: 583-599.

Curry SJ, Grothaus LC, McAfee, Pabiniak C. Use and cost effectiveness of smoking-cessation services under four insurance plans in a health maintenance organization. N Engl J Med. 1998; 339: 673-679.

Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

Hughes JR, Wadland WC, Fenwick JW, et al. Effect of cost on the self-administration and efficacy of nicotine gum: a preliminary study. Prev Med. 1991; 20: 486-496.

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Land T, Warner D, Paskowsky M, Cammaerts A, Wetherell L, Kaufmann R, Zhang L, Malarcher A, Pechacek T, Keithly L. Medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in smoking prevalence. PLoS One. 2010; 5(3): e9770.

McNeill A, Bates C. Smoking cessation in primary care: how to spend NHS money much more effectively. London: ASH. 2000.

McNeill A, Whybrow J, Bailey P. A national strategy for smoking cessation treatment in England. Addiction. 2005; 100(Suppl 2): 1-11.

Miller N, Frieden TR, Liu SY, Matte TD, Mostashari F, Deitcher DR, et al. Effectiveness of a large-scale distribution programme of free nicotine patches: A prospective evaluation. Lancet 2005; 365: 1849-1854.

Reda AA, Kaper J, Fikretler H, Severens JL, van Schayck CP. Healthcare financing systems for increasing the use of tobacco dependence treatment. Cochrane Database of Systematic Reviews 2009, Issue 2.

Schauffler HH, McMenamin S, Olson K, et al. Variations in treatment benefits influence smoking cessation: results of a randomised controlled trial. Tob Control. 2001; 10: 175-180.

Swartz SH, Cowan TM, Klayman JE, Welton MT, Leonard BA
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Tauras JA, Chaloupka FJ. The demand for nicotine replacement therapies. Nicotine Tob Res.  2003; 5: 237-243.

Tinkelman D, Wilson SM, Willett J, Sweeney CT. Offering free NRT through a tobacco quitline: Impact on utilization and quit rates. Tob Control. 2007; 16(Suppl 1): i42–i46.

West R, DiMarino ME, Gitchell J, McNeil A. Impact of UK policy initiatives on use of medicines to aid smoking cessation. Tob Control. 2005; 14(3): 166-171.

World Bank. Curbing the epidemic: Governments and the Economics of Tobacco Control. World Bank Development in Practice Series. Washington, DC: World Bank. 1999. logo
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