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Prescribing of Smoking Cessation Interventions
March 2009
Introduction
The following pages contain data on the prescribing of pharmaceutical interventions for smoking cessation in Scotland for the calendar years 2000 to 2008, inclusive. Statistics shown include prescribing volume, as measured by the number of prescribed items or defined daily dose, and the gross ingredient cost, at both Scotland and NHS board level.
The National Institute of Clinical Excellence (NICE) 
issued recommendations in March 2002 that smoking cessation products should be available on prescription to smokers who have made a commitment to stop on or before a target stop date. Prescriptions subsequent to the initial commencement of treatment should only be issued to the person if they can demonstrate that they are still trying to stop smoking. If the attempt to stop is unsuccessful, NICE recommends that Bupropion or Nictoine Replacement Therapy (NRT) should not be prescribed again within six months, depending on individual circumstances.
Information on prescribing for smoking can be found on the following Internet sites:
ISD is not responsible for the contents of external Internet sites.
Treatment
Drugs licensed for smoking cessation are given the British National Formulary (BNF) section 4.10;
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Bupropion Hydrochloride (also known as Amfebutamone Hydrochloride), (Zyban® )
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Nicotine Replacement Therapy (Nicopass®, Nicopatch®, Nicorette®, Nicotinell®, NiQuitinCQ® )
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Varenicline (Champix® )
Bupropion Hydrochloride became available on prescription in June 2000, and is restricted to adults aged 18 and over. Nicotine Replacement Therapy (NRT) became available on prescription in April 2001 and Varenicline in January 2007. Both NRT and Varenicline are licensed to people aged 12 and over. NRT is also licensed to be prescribed by nurses in May 2001, making it more accessible to patients.
Smoking Ban
On the 26th March 2006, a ban on smoking in public places was introduced as part of the Smoking, Health and Social Care (Scotland) Bill to improve public health.
Public Health Service
On the 29th August 2008, the Public Health Service element of the new Community Pharmacy Contract was introduced in Scotland. This involves a program of up to twelve weeks in which people can visit their local pharmacist and be supported in their attempt to stop smoking, which may include prescribing of NRT. The patient is charged the current prescription charge (£5.00), instead of paying for the products over the counter, which can be more expensive.
Summary
The prescribing of smoking cessation products in Scotland between 2000 and 2008 has been reviewed. A summary of the findings is given below.
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Prescribing of smoking cessation products show seasonal variation.
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The sharp peaks around the months of January, February and March may be due to New Year Resolutions, while the steady decline after March may be due to successfully quitting or else relapsing.
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Prescribing of smoking cessation products rose sharply just before the introduction of the ban in smoking in public places was introduced in Scotland in March 2006.
- Of the prescribable treatments for smoking cessation, NRT is the most prevalent.
Data Source
Practitioner Services , a division of NHS National Services Scotland, processes all NHS prescriptions for payment of pharmacies, dispensing doctors and appliance suppliers. This gives a full record from which trends in prescribing can be investigated at a detailed level. The data includes prescribing by GPs, nurses, dentists, pharmacists and hospitals, where the latter was dispensed in the community. Hospital dispensed prescriptions are NOT included in the figures. The Information Service Division (ISD) cannot say what proportion of the drug dispensedis actually consumed. These data do NOT include smoking cessation products purchased "over the counter". Prescriptions processed internally by Boards for payment purposes are NOT included in these data.
Prescribing Statistics - Scotland
Data behind the graphs are available for download as an
Excel File
. Figure 1 below shows the number of items prescribed in Scotland, in total and for each drug by calendar year 2000 to 2008.
The introduction of Nicotine Replacement Therapy (NRT) in 2001, and the strict restrictions around Bupropion, which can be found on the Scottish Medicines Consortium (SMC), accounts for a drop of 90.0% between 2000 and 2008.
Nicotine is the most commonly prescribed drug between 2001 and 2008; however it varies year on year. The smoking ban and the introduction of Varenicline account for these variations.
The total prescribing of smoking cessation interventions has increased by 23.1% between 2007 and 2008; this is most like due to the introduction of Varenicline.
Figure 1 - Number of prescribed items, by product, for NHS Scotland, 2000 to 2008
Source: Prescribing Information System, ISD Scotland
A method of examining prescribing levels using different formulations of products (for example chewing gum, patches and tablets) is the defined daily dose (DDD) as developed by the World Health Organisation (WHO) . A DDD is defined as:
"....the assumed average maintenance dose per day for a drug used on its main indication in adults"
DDDs are a statistical measure derived from the international use of the substance in question. As British prescribing patterns may differ from the accepted international value, each DDD should be regarded as a technical value, a close approximation of an average of the actually used doses. The DDDs are therefore not necessarily the most frequently prescribed or used doses.
WHO defined daily dose (DDD) values for smoking cessation products available on prescription are shown in the following table:
Table 1 - WHO Defined Daily Dose Valuse
| Drug | Administration Route | Defined Daily Dose |
| Bupropion | Oral | 300mg |
| Nicotine | Chewing Gum | 30mg |
| Nicotine | Inhaled | 60mg |
| Nicotine | Nasal | 30mg |
| Nicotine | Transdermal | 14mg |
| Nicotine | Sublingual | 30mg |
| Varenicline | Oral | 2mg |
Source: World Health Organisation (WHO)
This value offers an explanation of what proportion of the population may receive a certain drug treatment. For example, an estimated drug consumption of 10 DDDs per 1,000 population per day corresponds to a daily use of the drug by 1% of the population. The population used in this review is the mid-year estimates produced by the General Registrar Office for Scotland (GRO), but restricted to individuals aged 12 and over, the most likely group to be prescribed the above drugs.
Figure 2 - DDD's per 1,000 population per day, by product, for NHS Scotland, 2000 to 2008
Source: Prescribing Information System, ISD Scotland
The data presented in figure 2 indicates that the percentage of the 'target' population making daily use of Nicotine et al has risen form 0.09% (3,857 people) in 2000 to 0.03% (14,133 people) by 2008. It must be emphasised that these figures are estimates, the actual patient base in not known.
Figures 3 and 4 below; show the gross ingredient cost and the cost per item, in total and by individual drug for the calendar years 2000 to 2008.
Figure 3 - Gross Ingredient Cost (GIC), by product, for NHS Scotland, 2000 to 2008
Source: Prescribing Information System, ISD Scotland
The prescribing patterns exhibited in figures 1, 2 and 3 are similar. In 2006 all graphs shows a peak, when the smoking ban was introduced. In 2007, Varenicline was introduced which accounts for the drop in NRT. Looking at the cost per item for the drugs involved in smoking cessation, gives a better view on the costing implications on these drugs.
Figure 4 - Cost per item (£), by product, for NHS Scotland, 2000 to 2008
Source: Prescribing Information System, ISD Scotland
Figure 4 above shows that Bupropion was the most costly item from 2000 to 2008, averaging £39.91 per item and Nicotine is the least expensive at an average of £26.16 per item.
Prescribing Statistics - NHS Boards
The Prescribing Information database does not currently hold patient details and therefore it is not possible to provide a direct comparison of how many patients receive smoking cessation interventions in each NHS Board. A proxy can be obtained through the use of the GRO NHS Board mid year estimates for people aged 12 and over.
Figures 5 and 6 show prescribing of smoking cessation interventions by NHS Board in terms of the number of prescribed items per 1000 population and the by the number of DDD's per 1000 population per day, respectively.
NHS Board ciphers are displayed on the figures 5 and 6 for reasons of clarity. Table 2 provides a translation between the cipher and the NHS Board name.
Please note that NHS Argyll and Clyde ceased to exist as a single entity from April 2006. Argyll and Bute was absorbed into NHS Highland and the remainder into NHS Greater Glasgow to become NHS Greater Glasgow and Clyde.
Table 2 - NHS Board Cipher Name
| NHS Board Cipher | NHS Board Name |
| A | Ayrshire and Arran |
| B | Borders |
| F | Fife |
| G | Greater Glasgow and Clyde |
| H | Highland |
| L | Lanarkshire |
| N | Grampian |
| R | Orkney |
| S | Lothian |
| T | Tayside |
| V | Forth Valley |
| W | Western Isles |
| Y | Dumfries and Galloway |
| Z | Shetland |
Figure 5 - Number of prescribed items, per 1,000 population aged 12 and over, 2000 to 2008
Source: Prescribing Information System, ISD Scotland
Considerable variation exists among the fourteen NHS Boards in 2008, shown in figure 5. All NHS Boards show an increase from 2000 to 2008.
Figure 6 - DDD's per 1,000 population aged 12 and over per day, 2000 to 2008
Source: Prescribing Information System, ISD Scotland
Expressing the prescribing data in terms of the number of DDD's per 1,000 population aged 12 and over per day (figure 6) produces an essentially similar pattern to that shown in figure 5. In 2008 the highest recorded rate was in NHS Highland at 4.6 DDD's per 1,000 population per day, equivalent to 0.5% of the 'target' population and NHS Borders the lowest at 0.8 DDD's per 1,000 population per day, equivalent to 0.08% of the 'target' population.
Seasonal Variation in Prescribing for Smoking Cessation
The figures below show the seasonality effect for smoking cessation products by month between 2000 and 2008.
Figure 7 - DDD's by month for all smoking cessation products, 2000 to 2008
Source: Prescribing Information System, ISD Scotland
Figure 7 above, shows peaks in January, this could be due to people opting to stop smoking for a new year's resolution. The high peak in March 2006 occurred at the introduction of the smoking ban.
Figure 8 - DDD's by month, by product, 2000 to 2008
Source: Prescribing Information System, ISD Scotland
DDD's by product as shown in figure 8 shows a similar trend to that of figure 7, with peaks every January and in March 2006. The introduction of NRT in 2001 is mirrored by the decrease of Bupriopion. Varenicline and Nicotine have a correlation, when Nicotine decreases, Varenicline increases and visa versa. This could be due to patients changing their smoking cessation product.
Prescribing
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