Journal of the New Zealand Medical Association, 15-July-2005, Vol 118 No 1218
Buproprion, public funding, and smoking cessation
Clearly Holt et al have a different view from that of PHARMAC on whether buproprion should be publicly funded in New Zealand as a smoking cessation adjunct.1,2 What is not clear is why Holt et al conclude that the current PHARMAC position not to fund buproprion “seriously questions the Ministry of Health’s commitment to smoking cessation and the health of disadvantaged groups in New Zealand, particularly Maori.”1
In fact, the Ministry and wider health sector commitment to the health of disadvantaged groups,3 particularly Maori,4 is absolutely clear. This includes making tobacco control a priority and the funding and successful delivery of a range of smoking cessation initiatives. Many of these initiatives are targeted to Maori and disadvantaged groups. Currently, there is around $6.4 million for smoking cessation services targeted to Maori, and $1.5 million for Maori smokefree promotion. Nicotine replacement therapy (NRT) is an integral part of many of these initiatives, in keeping with its identification in the NHC guidelines as the appropriate first-line therapy.5
In its response, PHARMAC cites reasons for its current position not to fund buproprion, including the large difference in cost-effectiveness compared with nortriptyline, an equally effective product according to the current evidence.2 PHARMAC argues that, perversely, funding bupropion would have adversely affected the health of New Zealanders by restricting the availability of other medicines with greater health gains for the same spending.2 To support their position, Holt et al cite three of the eight principles used to determine the actions in the Ministry of Health’s five-year plan for tobacco control; effectiveness, reach, and appropriate use of targeting.6 They overlook the other principles with that also need to be considered. One of these is cost-effectiveness, which is highly germane to this discussion.
In addition, the principle of “appropriate use of targeting” needs clarification. This principle is described as “maximising the benefits of targeted interventions and minimising potential adverse effects.”6 This refers not to minimising the potential adverse effects of therapeutic interventions, but rather to minimising the potential downsides of targeting, described as “ a potential stigmatising effect and for middle-income groups to miss out.”6
Tobacco control is afforded a high priority in New Zealand, not least because there is major potential for improving health and reducing health inequalities.7 Smoking cessation remains an integral part of tobacco control. Within the funding allocated for smoking cessation, it is important to ensure the prudent use of public money by funding interventions that are effective, cost-effective and acceptable. This is, of course, work in progress and the recently-published research by Holt et al8 will help to inform this work. The Ministry looks forward to working with the researchers, PHARMAC and others towards a common objective of further reducing the serious impact of tobacco on health and health inequalities in New Zealand.
Competing interests: Ashley Bloomfield is a full-time Ministry of Health employee and was involved in the development of the 1999 and revised 2002 National Health Committee smoking cessation guidelines.
Public Health, Ministry of Health
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