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Author Notes:

Corresponding author: Mark D. Huffman, MD, MPH,, Northwestern University Feinberg School of Medicine, Department of Preventive Medicine, 680 N. Lake Shore Drive, Suite 1400, Chicago, IL 60660, Fax: 312-908-9588, Telephone: 312-503-5513, m-huffman@northwestern.edu

Drs Prabhakaran and Huffman contributed equally to this work as joint senior authors.

We thank Ramakrishna Venkitakrishnan, Kochumoni R, and Manikandan K for assistance with data collection.

We thank Dr Brian Hitsman for his advice on treatment regimens.

Disclosures: Dr Huffman receives grant support from the World Heart Federation to serve as its senior program advisor for the Emerging Leaders program, which is sponsored by Boehringer Ingelheim and Novartis with prior support from BUPA and AstraZeneca. The other authors report no conflicts.


Research Funding:

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).


  • Science & Technology
  • Life Sciences & Biomedicine
  • Cardiac & Cardiovascular Systems
  • Cardiovascular System & Cardiology
  • acute coronary syndrome
  • bupropion
  • nicotine
  • tobacco
  • varenicline

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


Journal Title:

Circulation: Cardiovascular Quality and Outcomes


Volume 10, Number 11


, Pages e004108-e004108

Type of Work:

Article | Post-print: After Peer Review


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.

Copyright information:

© 2017 American Heart Association, Inc.

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