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A drastic decrease in smoking rates would undoubtedly save hundreds of thousands of Canadian lives and reduce associated health care costs. Effective public health strategies for tobacco control must incorporate both population- and individual-level interventions.1 All Canadian provinces have endorsed the former by enacting legislation that prohibits smoking in workplaces and public areas. Why, then, do most provincial governments provide little or no direct funding for smoking cessation?
Smoking cessation treatments, in combination with counselling, increase the likelihood of a successful attempt at quitting initially and of continued abstinence at one year. They are also cost-effective, with the cost per life-year saved typically being less than $5000.2 Indeed, smoking cessation medications appear more cost-effective than many other primary preventive interventions, such as those for hypertension or hypercholesterolemia.3
In 2007, Canada’s Common Drug Review recommended that varenicline, the newest drug for smoking cessation, be added to provincial drug formularies. Yet only Quebec provides public funding for all smoking cessation pharmacotherapies, and only the Yukon and Prince Edward Island reimburse for at least one product.
Positions in other countries contrast starkly. In Australia and the United Kingdom, where drug insurance is provided to all citizens, reimbursement is available without restriction for all smoking cessation products, including prescription medications and over-the-counter nicotine replacement. In the United States, smoking cessation products are reimbursed by Veterans Affairs and Medicare Part D.
Given the major personal and public health consequences of tobacco use, why are most of Canada’s governments lagging behind? Perhaps our policy-makers think we should not be subsidizing poor lifestyle choices. If so, we ought to deny public funding for heart surgery to patients who continue to smoke or stop paying for care of patients with smoking-related cancers. But we have decided to care for patients who suffer because of poor lifestyle choices, whether smoking, poor diet or physical inactivity, recognizing that few of us follow perfect lifestyles.
Perhaps policy-makers subscribe to the naive view that quitting — or failing to quit — is an individual choice and responsibility. For many, if not most, smoking is a powerful addiction, similar to alcoholism and other forms of substance abuse. Provincial health ministries already reimburse the cost of pharmacotherapy for other drug addictions, such as methadone for heroin addiction or naltrexone for alcohol dependence.
Perhaps funding for smoking cessation lacks political and public support because of the social stigma associated with smoking, ironically a deliberate achievement of tobacco prevention campaigns.
Most important, perhaps policy-makers fail to understand how the cost of smoking cessation products acts as an insurmountable barrier or a powerful disincentive for smokers. A 2009 Cochrane review showed that full financial reimbursement of smoking cessation medications significantly improved one-year abstinence rates among all smokers (relative risk 2.45, 95% confidence interval 1.17–5.12).4 When considered with evidence that people who quit smoking long term gain an average of four years of life,5 full coverage of smoking cessation products among the 5.5 million Canadian smokers might be expected to result in 1.9 million life-years gained, at a cost of $220 for every life-year gained — a bargain compared with most other health interventions.
Given the high cost of tobacco addiction and our inability to decrease the rates of smoking in Canada below 19% in recent years, governments should complement population-level public health strategies against tobacco with a marked increase in investment in individual-level smoking cessation programs. As an immediate first step, all provincial drug formularies should begin reimbursing evidence-based smoking cessation therapies. This will provide coverage to smokers receiving social assistance and to those over 65 years of age. To treat the rest of Canada’s smokers, we should follow the lead of other countries and reimburse smoking cessation therapies for everyone. An appropriate source of funding for this is obvious — the substantial tax revenues collected with the sale of every tobacco product.
Competing interests: See www.cmaj.ca/misc/cmaj_staff.dtl for competing interests for CMAJ editors and for members of the editorial advisory team. None declared for Erika Penz and Braden Manns.