Availability, Sales, and Affordability of Tobacco Cessation Medicines in Kerala, India

• Type of Material: Article
• Authors: Smitha Sarma, Northwestern University; Sivadasanpillai Harikrishnan, Sree Chitra Tirunal Institute for Medical Sciences and Technology; Abigail S. Baldridge, Northwestern University; Raji Devarajan, Public Health Foundation of India; Aashna Mehta, Public Health Foundation of India; Sakhtivel Selvaraj, Public Health Foundation of India; Mohammed Ali, Emory University; Padinhare P. Mohanan, Westfort Hitech Hospital; Dorairaj Prabhakaran, Public Health Foundation of India; Mark D. Huffman, Northwestern University
• Language: English
• Date: 2017-11-01
• Publisher: American Heart Association
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2017 American Heart Association, Inc.
• Final Published Version (URL): http://dx.doi.org/10.1161/CIRCOUTCOMES.117.004108
• Title of Journal or Parent Work: Circulation: Cardiovascular Quality and Outcomes
• ISSN: 1941-7705
• Volume: 10
• Issue: 11
• Start Page: e004108
• End Page: e004108
• Grant/Funding Information: This work was funded by the Vanderbilt-Emory-Cornell-Duke Fogarty Global Health Fellowship (NIH/Fogarty 5R25TW009337-06).; The microeconomic data collection was funded by NIH/NHLBI R00HL107749, Cardiological Society of India – Kerala chapter, Centre for Chronic Disease Control, the Northwestern Global Health Initiative, and the Northwestern University Clinical and Translation Science Institute (UL1TR001422).
• Keywords: Cardiovascular System & Cardiology; bupropion; Science & Technology; DISEASE; MIDDLE-INCOME; INCOME COUNTRIES; acute coronary syndrome; tobacco; Cardiac & Cardiovascular Systems; varenicline; Life Sciences & Biomedicine; nicotine; SMOKING-CESSATION
• Research Categories: Health Sciences, Public Health

Abstract

Background-India is the world's second largest consumer of tobacco, but tobacco cessation remains uncommon due, at least in part, to underutilization of cessation pharmacotherapy. We evaluated the availability, sales, and affordability of nicotine replacement therapy, bupropion, and varenicline in the South Indian state of Kerala to understand potential reasons for underutilization. Methods and Results-From November 2016 to April 2017, we collected data on availability, inventory, and pricing of cessation medication through a cross-sectional survey of 199 public, semiprivate (Karunya), and private pharmacies across 5 districts in Kerala using World Health Organization/Health Action International methodology. Revenue and sales data were obtained from the latest Pharmatrac medication database. We assessed affordability using individual- and household-level income and expenditure data collected from November 2014 to November 2016 through the Acute Coronary Syndrome Quality Improvement in Kerala randomized trial. Cessation medications were not available in public hospitals (0%, n=58) nor in public specialty centers (0%, n=10) including those designated to provide cessation services. At least 1 cessation medicine was available at 63% of private pharmacies (n=109) and 27% of Karunya (semiprivate) pharmacies (n=22). Among the 75 pharmacies that stocked cessation medications, 96% had nicotine replacement therapy, 28% had bupropion, and 1% had varenicline. No outlets had sufficient inventory for a patient to purchase a 12-week treatment regimen. There were an estimated 253 270 treatment regimens sold throughout India and 14 092 in Kerala in 2013 to 2014. Treatment regimens cost 1.9 to 13.0× the median amount spent on smoked tobacco and between 8% and 52% of nonsubsistence income. Conclusions-Tobacco cessation medications are unavailable in the Kerala public sector and have limited availability in the private and semiprivate sectors. When available, medications are unaffordable for most patients. Addition of tobacco cessation medication onto national and state essential medicines lists may help increase access.