Suffice it to say, the more people we can get off of tobacco, the less it will cost society, and the healthier EVERYONE (smokers and non-smokers) will be. The United States Surgeon General has made tobacco cessation a goal in his most recent Health People 2010 (http://www.health.gov/healthypeople/).

Next is the issue of coverage. Smoking cessation pharmacotherapy is NOT a covered benefit in the managed care network. Smoking cessation pharmacotherapy is NOT a covered benefit in the NMOP. IF patients are going to receive tobacco cessation pharmacotherapy under TRICARE, their ONLY option is the MTF and that's IF the MTF has it on their formulary. There are efforts to include smoking cessation as a covered benefit but no definitive changes have been made to date.

There is a DoD/VA CPG on tobacco use cessation available on the web. The website is http://www.cs.amedd.army.mil/Qmo/smoke/tabac/index.htm. If you need any CPG implementation materials, contact the US Army MEDCOM Quality Management Office at DSN 471-6195.

An important part of any tobacco cessation program is counseling or behavior modification. Providers (including pharmacists) should use the Five "As" - Ask, Advise, Assess, Assist, and Arrange in ALL patients who are current smokers. In patients not yet motivated to quit, you can use the five "Rs" - Relevant, Risks, Rewards, Roadblocks, and Repeating. These methods are discussed more in depth in other places.

IF you decide to offer smoking cessation pharmacotherapy, you'll probably ask or be asked which agents and which dosage forms are the most cost effective. The following table lists the various pharmacological agents for use in tobacco use cessation and corrects them for the background quit rate (those who would quit anyway without drug or behavioral therapy) and the rate for those who would quit using behavior modification therapy alone (no drugs). It then calculates a cost efficacy ratio for each agent.

Table 8. Cost efficacy ratios for tobacco use cessation agents

A = Drug    B = 1 yr quit rate  C = Regimen drug cost Background Quit Rate  D = Quit rate for behavior therapy alone    E = Adjusted Quit Rate  F = (B-[D+E])  G = Cost Efficacy ratio (C/F)

          A                                 B           C            D        E         F         G      
Bupropion SR                     0.231   $ 95.00      0.025   0.09    0.116   $ 819  
BUP SR + nicotine patch    0.355   $ 206.00    0.025   0.09    0.24      $ 858  
Nicotine GUM                     0.21     $ 126.00    0.025   0.09    0.095    $ 1,326
Nicotine PATCH                  0.205   $ 140.00    0.025   0.09    0.09      $ 1,556
Nicotine SPRAY                  0.26     $ 240.00    0.025   0.09    0.145    $ 1,655
Nicotine INHALER               0.13     $ 565.00    0.025   0.09    0.015    $ 37,667 

Cost efficacy defines as cost for each patient who's smoke-free at one year (successful treatment)   
(Dr Eugene Moore, PEC, 2001)

This chart does NOT include clonidine or nortriptyline. These agents have been used in smoking cessation but are not FDA approved for this indication. There are concerns about potential adverse events with first line use of these agents. The long term (1 year) quit rates with these agents need further study.

Another way of displaying this information is graphically using an efficiency frontier graph. An efficiency frontier graphs cost on the horizontal "X" axis and efficiency on the vertical "Y" axis. A line is drawn connecting the origin and the points farthest to the left of the graph. Anything points to the right of the line are less effective and/or more expensive. If a new therapy comes out and it's point is to the right of the current line, then a new line is drawn including the new point.

Let me try to further illustrate the efficiency frontier graph with a couple of examples. If a new drug costs $200 and it's adjusted quit rate (efficiency measure) is 0.1, the point would be to the RIGHT of the current frontier and hence, less cost effective. If a new drug costs $100 and it's adjusted quit rate is 30% (0.3), then the current frontier would be moved to the LEFT to include this point. The current buproprion SR plus patch point would be excluded from the line because a more effective and/or less expensive (more cost effective) drug has come to market.

Bottom line question - Do you approve the request? Even after buying the drugs, do you have the staff to manage the drug dispensing? The staff to provide the smoking cessation classes? The behavior modification part of the cessation program? Studies have shown that the frequency and the intensity of the interventions for smoking cessation are directly proportional to the number of patients who achieve a long term quit. Things to remember and consider in your decision are:

-       Can you afford to purchase the drug or drugs?
-       Do you have the pharmacy and mental health staff to support the counseling part?
-       Do you have leadership support to do this knowing that you're providing a benefit to these patients that is not covered in the NMOP or retail network?

-       Do you have a mechanism to measure the results of your intervention? Patients started on pharmacotherapy, patients achieving a long term (1 year) quit/cessation, money spent on pharmacotherapy, patients counseled, etc.

-       Does everyone agree with the policies regarding use and duration of therapy with smoking cessation pharmacotherapy?