Characteristics of first-time varenicline users - A cross-sectional study in Finnish quitters.

BACKGROUND: Varenicline is an efficacious medicine for smoking cessation (SC) but little is known about the characteristics of varenicline users. This study examined the characteristics of first-time (naïve) varenicline users in Finland and compared those who had previously used SC pharmacotherapy to those who were trying SC pharmacotherapy for the first time. METHODS: A cross-sectional survey was conducted in Finnish community pharmacies between February 2014 and January 2015. Pharmacy customers purchasing a varenicline starter package for the first time ever were asked to complete a questionnaire or to participate in a structured interview conducted by the pharmacist (identical questions). The questionnaire included questions about demographic characteristics, smoking habits, previous cessation attempts and factors associated with varenicline use. RESULTS: Altogether 98 people completed the survey. The majority were daily smokers (96%, n = 94), with a history of over 10 years of regular smoking (94%, n = 92), and a strong/very strong nicotine dependence (67%, n = 66). Half of the participants (54%, n = 53) were trying a SC pharmacotherapy for the first time. Demographic characteristics and smoking habits were similar between first-time and previous users of SC medications (p > 0.05). Health centers (42%, n = 41) and occupational health care clinics (37%, n = 36) were the most common sources of varenicline prescriptions. The majority of participants received the prescription for varenicline after mentioning their desire for quitting to a physician (70%, n = 69). CONCLUSIONS: Considering the relatively large proportion of SC naïve medicine users among new users of varenicline, smokers who have previously been reluctant to quit smoking, to use other pharmacological SC interventions, or perhaps unaware of these options may be interested in attempting cessation with varenicline. Most participants made the initiative to discuss their smoking with the physician, which led to varenicline prescribing. This suggests that physicians may not satisfactorily recognize their patients' nicotine dependence and desire to quit, and they should more actively support patients' smoking cessation.

Primary health care utilisation and its costs among middle-aged smokers.

OBJECTIVE: To study and compare the utilisation of primary health care services among 46-year-old current smokers, ex-smokers and never-smokers, and to estimate the corresponding costs. METHODS: This population-based cohort study is based on the Northern Finland Birth Cohort 1966, which is a longitudinal research program in Finland's two northernmost provinces. The study is based on data collected at the 46-year follow-up, during which a total of 4997 individuals completed questionnaires on their primary health care service utilisation. Primary health care covered visits to both occupational and public health care (typically community health centres). RESULTS: Current smokers visited primary health care professionals more often per year than never-smokers, regardless of gender (RR 1.24, 95 % confidence interval 1.10-1.43 for men; RR 1.10, 1.01-1.22 for women). When primary health care services were categorised based on the type of service provided, current smokers of both genders were more likely to visit a dentist (RR 1.56, 1.32-1.84 for men; RR 1.34, 1.15-1.55 for women) or a physician (RR 1.20, 1. 03-1.40 for men; RR 1.15, 1.02-1.30 for women) than their never-smoking counterparts (BMI adjusted for). For men, the total annual costs of primary health care visits were 28 % higher for current smokers versus never-smokers (P < 0.001). For women, the difference was 21 % (P < 0.01). CONCLUSIONS: Smokers visit primary health care professionals more often already at the age of 46, before the expected diagnosis of fatal smoking-related illnesses. This phenomenon not only predicts an elevated incidence of serious illnesses in later life (such as cardiovascular disease), but also causes an economic burden on the health care system.

Re-treatment with varenicline is a cost-effective aid for smoking cessation.

OBJECTIVE: One quit attempt with varenicline has been found to be a cost-effective smoking cessation intervention. The purpose of this study was to analyze varenicline's cost-effectiveness in patients who relapse during or after the first treatment. A comparison was made between re-treatment schema with varenicline and re-treatment schema with bupropion, NRT and unaided cessation, and treatment once with varenicline in a Finnish context. METHODS: The two-quit version of BENESCO Markov model was used to follow a cohort of smokers making up to two quit attempts over a lifetime. The abstinence rates of the interventions were derived from a Cochrane review. Gender- and age-specific data on the incidence and prevalence of five smoking-related diseases were included in the model. Quality-adjusted life-years, total expected costs, and the lifetime cumulative incidence of smoking-related morbidities and mortality were the primary outcomes evaluated. RESULTS: The study cohort comprised 116,533 smokers who were willing to make a quit attempt. In the lifetime simulation, re-treatment with varenicline yielded 6,150-20,250 extra quitters, depending on the comparator. Among these quitters it was possible to prevent 899-2,972 additional cases of smoking-related diseases, and 395-1,307 deaths attributable to smoking. Re-treatment with varenicline resulted in cost savings of up to 54.9 million Euros. Re-treatment with varenicline dominated all the other smoking cessation interventions used in the analysis. Sensitivity analysis supported the robustness of the base case results. LIMITATIONS: The analysis did not consider adverse events, and included only five major smoking-related diseases, which is a conservative approach, and probably leads to under-estimation of cost-effectiveness of cessation interventions. Furthermore, assumptions of constant relative risks for smoking-related diseases for each smoking status and the proxy values used as efficacy estimates of second quit attempts for other interventions than varenicline are limitations. CONCLUSIONS: A second quitting effort with varenicline is economically justifiable.

Cardiovascular disease risk factors in relation to smoking behaviour and history: a population-based cohort study.

OBJECTIVE: To investigate how individual risk factors for cardiovascular disease (CVD) (blood pressure, lipid levels, body mass index, waist and hip circumference, use of antihypertensive or hypolipidemic medication, and diagnosed diabetes) differ in people aged 46 years with different smoking behaviour and history. METHODS: This population-based cohort study is based on longitudinal data from the Northern Finland Birth Cohort 1966 project. Data were collected at the 31-year and 46-year follow-ups, when a total of 5038 and 5974 individuals participated in clinical examinations and questionnaires. Data from both follow-ups were available for 3548 participants. In addition to individual CVD risk factors, Framingham and Systematic Coronary Risk Evaluation (SCORE) algorithms were used to assess the absolute risk of a CVD event within the next decade. RESULTS: The differences in individual risk factors for CVD reached statistical significance for some groups, but the differences were not consistent or clinically significant. There were no clinically significant differences in CVD risk as measured by Framingham or SCORE algorithms between never smokers, recent quitters and former smokers (7.5%, 7.4%, 8.1% for men; 3.3%, 3.0%, 3.2% for women; p<0.001). CONCLUSIONS: The effect of past or present smoking on individual CVD risk parameters such as blood pressure and cholesterol seems to be of clinically minor significance in people aged 46 years. In other words, smoking seems to be above all an independent risk factor for CVD in the working-age population. Quitting smoking in working age may thus reduce calculated CVD risk nearly to the same level with people who have never smoked.

Physicians discuss the risks of smoking with their patients, but seldom offer practical cessation support.

BACKGROUND: Our aim was to study the smoking cessation-related 1) attitudes & experiences and 2) consultation practices of Finnish physicians and to determine if there is a relationship between the two. METHODS: An online survey on smoking cessation was sent to 39 % of all Finnish physicians, with emphasis on physicians working in fields relevant to smoking cessation. A total of 1141 physicians (response rate 15 %) responded to the online survey, 53 % of whom were employed in primary health care. A total of 1066 respondents were eligible for the analysis. The questionnaire included questions on the physician's own smoking status, their attitudes and experiences on smoking cessation, and the implementation of smoking cessation in clinical practice. Two sub-scales concerning smoking-related consultation activities were constructed: one for conversation, and another for practical actions. RESULTS: The most common consultation activities (respondents who reported doing the following actions "nearly always") were asking how much the patient smokes (65 %), marking smoking status in patient records (58 %) and recommending quitting to the patient (55 %). The least common activity was prescribing withdrawal medication (4 %). Primary care physicians were more active than those working in secondary health care in nearly all activities mapped. A positive attitude and experiences on smoking cessation were associated with actively offering withdrawal support. Those who were familiar with the local treatment guidelines for tobacco addiction were 30 % more active in offering practical cessation help to their patient. The respondents were more active in discussing smoking with their patients than in offering practical cessation help. CONCLUSION: Physicians offer their patients practical cessation support relatively infrequently. Practical cessation calls for continuous education of physicians about the nature of tobacco and nicotine addiction, the role of smoking as a risk factor for various diseases, and the practical measures needed for smoking cessation. Secondary care physicians should acknowledge the authority they pose toward smoking patients.

[Tobacco withdrawal in individuals suffering from mental disorders]. / Mielenterveyden häiriöistä kärsivien tupakasta vieroitus.

Smoking is very common in individuals with mental illnesses, but smoking cessation help is inadequately offered to them. Some 54% of Finnish psychiatrists often advise their patients to quit smoking, yet 34% often recommend nicotine replacement therapy, and only 12% of them often prescribe tobacco withdrawal medication. Factors that affect advisement in smoking cessation include the psychiatrists' own attitudes and personal smoking history, barriers within the work settings, and the patient's diagnosis. Because smoking poses detrimental effects on the treatment of psychiatric illnesses, as well as on the health of the patient, tailored and more intensive smoking cessation counseling should be offered to individuals with mental illnesses.

Is nicotine replacement therapy overvalued in smoking cessation? Analysis of smokers' and quitters' communication in social media.

BACKGROUND: Internet discussion forums provide new, albeit less used data sources for exploring personal experiences of illness and treatment strategies. OBJECTIVE: To gain an understanding of how discussion forum participants value nicotine replacement therapy (NRT) in smoking cessation (SC). SETTING: Finnish national Internet-based discussion forum, STUMPPI, supporting SC and consisting of ten free discussion areas, each with a different focus. The analysis was based on STUMPPI forum participants' postings (n = 24 481) in five discussion areas during January 2007-January 2012. DESIGN: Inductive content analysis of the postings concerning NRT use or comparing NRT to other SC methods. RESULTS: Three major themes related to NRT in SC emerged from the discussions. These were as follows: (I) distrust and negative attitude towards NRT; (II) neutral acceptance of NRT as a useful SC method; and (III) trust on the crucial role of NRT and other SC medicines. The negative attitude was related to following perceptions: NRT use maintains tobacco dependence, fear of NRT dependence or experience of not gaining help from NRT use. NRT was perceived to be useful particularly in the initiation of SC attempts and in dealing with physiological dependence. The most highlighted factors of successful quitting were quitters' own psychological empowerment and peer support from the discussion community. CONCLUSIONS: The majority of STUMPPI forum participants had low or balanced expectations towards the role of NRT in SC. More research from the smokers' and quitters' perspective is needed to assess the real value of NRT compared to other methods in SC.

Cost effectiveness of fesoterodine and tolterodine for the treatment of overactive bladder with urge urinary incontinence in Spain and Finland.

BACKGROUND: Overactive bladder is a prevalent condition worldwide that is associated with a considerable burden, both on the patient and on society. OBJECTIVE: Our objective was to assess the economic value of fesoterodine compared with tolterodine extended release (ER) for the treatment of overactive bladder (OAB) with urge urinary incontinence (UUI) in Spain and Finland. METHODS: A decision-tree economic model estimated the 52-week costs and quality-adjusted life-years (QALYs) of OAB/UUI patients initiating treatment with fesoterodine 4 mg/day or tolterodine ER. Individuals were evaluated for treatment response (UUI fewer than one episode/day) and persistence at weeks 4, 12, and 24. Titration from fesoterodine 4 mg/day to 8 mg/day was permitted at week 4. At week 12, non-responders discontinued treatment permanently. Efficacy, discontinuation, and utility data were derived from four clinical trials of fesoterodine. OAB-related costs, including physician visits, laboratory tests, incontinence pads, and comorbidities (fracture, skin infection, urinary tract infections, depression, and nursing home) were also included. RESULTS: A total of 19.5 % and 18.0 % of fesoterodine and tolterodine ER patients remained on treatment until week 52, respectively. QALYs were higher with fesoterodine than tolterodine ER (0.762 vs. 0.760). In Spain, fesoterodine treatment had higher total costs than (generic) tolterodine ER (€6,697 vs. 6,597), resulting in a cost of €15,633/QALY gained. In Finland, fesoterodine was cost saving relative to (non-generic) tolterodine ER (€7,885 vs. 8,024). Sensitivity analysis confirmed that these findings were robust to the expected price decrease for generic tolterodine ER in Finland. CONCLUSION: Fesoterodine is cost effective or cost saving relative to tolterodine ER for the treatment of OAB with UUI in two European countries. Payers and prescribers should consider a broad scope of costs to make informed cost-conscious choices of antimuscarinic treatment.

Community pharmacists' involvement in smoking cessation: familiarity and implementation of the National smoking cessation guideline in Finland.

BACKGROUND: Guidelines on smoking cessation (SC) emphasize healthcare cooperation and community pharmacists' involvement. This study explored the familiarity and implementation of the National SC Guideline in Finnish community pharmacies, factors relating to Guideline familiarity, implementation and provision of SC services. METHODS: A nationwide mail survey was sent to a systematic, sample of community pharmacy owners and staff pharmacists (total n = 2291). Response rate was 54% (n = 1190). Factors related to the SC Guideline familiarity were assessed by bivariate and multivariate analysis. RESULTS: Almost half (47%) of the respondents (n = 1190) were familiar with the SC Guideline and familiarity enhanced Guideline implementation. The familiarity was associated with the respondents' perceptions of their personal SC skills and knowledge (OR 3.8); of customers' value of counseling on nicotine replacement therapy (NRT) (OR 3.3); and regular use of a pocket card supporting SC counseling (OR 3.0). Pharmacists' workplaces' characteristics, such as size and geographical location were not associated with familiarity. In addition to recommending NRT, the pharmacists familiar with the Guideline used more frequently other Guideline-based SC methods, such as recommended non-pharmacological SC aids, compared to unfamiliar respondents. CONCLUSIONS: SC Guideline familiarity and implementation is crucial for community pharmacists' involvement in SC actions in addition to selling NRT products. Pharmacists can constitute a potential public health resource in SC easily accessible throughout the country.

Cost effectiveness of varenicline versus bupropion and unaided cessation for smoking cessation in a cohort of Finnish adult smokers.

OBJECTIVE: To assess the cost effectiveness of varenicline compared with bupropion or unaided cessation for smoking cessation in Finnish adult smokers. RESEARCH DESIGN AND METHODS: The BENESCO (BENEfits of Smoking Cessation on Outcomes) Markov model was used to follow a hypothetical cohort of smokers making a single quit attempt over a lifetime. Gender and age-specific data on the incidence and prevalence of five smoking-related diseases (chronic obstructive pulmonary disease [COPD], lung cancer, coronary heart disease [CHD], stroke and asthma exacerbations) were included in the model. Life-years (LYs), quality-adjusted life-years (QALYs), total treatment costs and the lifetime cumulative incidence of these parameters were the primary outcomes evaluated, and they were compared for varenicline versus bupropion and varenicline versus unaided cessation. The primary data were derived from Finnish publications and databases. Deterministic and probabilistic sensitivity analyses were performed to test the robustness of the base-case model. RESULTS: The treatment cohort comprised 229 301 smokers making a quit attempt. In the lifetime simulation, use of varenicline prevented 1965 and 5057 additional cases of smoking-related disease, and 1184 and 3047 deaths attributable to smoking, when compared with bupropion and unaided cessation, respectively. Compared with bupropion and unaided cessation varenicline treatment yielded 4392 and 11 303 additional LYs (4851 and 12 485 QALYs), respectively. Varenicline resulted in cost savings of 15 million and 43 million euros (euro) compared with bupropion and unaided cessation, respectively. In the 20-year time horizon analysis, varenicline yielded an incremental cost-effectiveness ratio (ICER) of euro8791/QALY and euro7791/QALY gained in comparison to bupropion and unaided cessation, respectively. Sensitivity analyses supported the robustness of the base-case results for varenicline. CONCLUSION: Varenicline dominated over its comparators, i.e. it was more effective and resulted in cost saving compared with bupropion and unaided cessation.

Nicotine replacement therapy practices in Finland one year after deregulation of the product sales--has anything changed from the community pharmacy perspective?

OBJECTIVE: According to the Finnish national Current Care Guideline of smoking cessation (SC), pharmacists' task is to support rational and safe use of NRT products. In 2006, the Medical Act releasing NRT from pharmacy only to general sales was amended. This study assesses the Finnish pharmacy owners' and staff pharmacists' perceptions of NRT products' role and usage patterns about a year after the deregulation. METHODS: A nationwide survey was conducted, targeting every second Finnish pharmacy owner and staff pharmacist (n=2291), working in community pharmacies. Response rate 54% (n=1190). RESULTS: According to respondents, inappropriate usage of NRT, like possible addiction, products' misuse or use in harm reduction purposes, exists in Finland. NRT sales have decreased at pharmacies and clients obtain only the counselling for NRT at pharmacy but buy the products elsewhere. The motivation to counsel NRT customers has diminished among 30% of pharmacy owners and 17% of staff pharmacists. Still the respondents found that it is pharmacists' duty to offer SC counselling and NRT important in SC. CONCLUSIONS: Despite NRT products' sales at pharmacies having decreased and especially pharmacy owners' motivation to counsel NRT usage having diminished, pharmacists still see it as their duty to guide and support SC.

Patients' Preferences for Generic and Branded Over-the-Counter Medicines: An Adaptive Conjoint Analysis Approach.

BACKGROUND: : Despite increased use of generic medicines, little is known about either the attitudes of patients towards them or the decision-making process surrounding them. Young adults use over-the-counter (OTC) analgesics relatively often. OBJECTIVE: : To assess the preferences of patients for generic and branded OTC pain medicines, to identify clusters with different preference structures, and to estimate the price elasticity of a generic alternative among university students. METHODS: : Finnish university students (n = 256; students in courses at the Helsinki School of Economics) responded to an adaptive conjoint analysis (ACA) questionnaire on the choice between branded and generic OTC ibuprofen products. Product attributes of price, brand, onset time of effect, place of purchase and source of information were included in the questionnaire on the basis of the literature, a focus group and a previous pilot study. Several socioeconomic and health behavior descriptors were employed. Individual-level utility functions were estimated, preference clusters were identified, and the price elasticity of the generic medicine was assessed. RESULTS: : Five clusters with characteristic individual-level preferences and price elasticity but few differences in socioeconomic background were detected. Approximately half of the respondents were strongly price sensitive while the others had other preferences such as brand or an opportunity to buy the medicine at a pharmacy or to have a physician or a pharmacist as an information source. CONCLUSION: : The study provided new information on the concomitant effects of brand, price and other essential product attributes on the choice by patients between branded and generic medicines.

Medicine use by Finnish female conscripts during voluntary military service.

OBJECTIVE: The goal was to assess the prevalence of prescribed and nonprescribed medicine use, use predictors, and origin of medicines for Finnish female conscripts during their voluntary military service. METHODS: An anonymous mail survey was conducted in April 1999 among all Finnish female conscripts on duty. RESULTS: Of the respondents (N = 177; response rate, 68%), 61% had used at least one medicine in the 2 weeks preceding the study, 44% prescribed and 31% nonprescribed medicines. Most of the prescribed medicines were provided by Finnish Defence Forces health care, whereas most of the nonprescribed medicines were of civilian origin. The consumption of prescribed and nonprescribed medicines was differently related to respondents' background variables. Common overall medicine use and use of over-the-counter analgesics and stimulants and their association with potentially negative health behaviors may contribute to inappropriate medicine use. CONCLUSION: Finnish female conscripts commonly use prescribed and nonprescribed medicines. The importance of sufficient medication information for female conscripts is emphasized.

Self-medication among Finnish young men in the beginning of common military service.

PURPOSE: Little is known about self-medication in adolescent and young adult males, particularly in ones exposed to increased stress. The objective of this article is to analyze self-medication and its predictors in young Finnish men at entry into common military service. METHODS: The responding men (n = 857) from nine brigades anonymously completed a self-administered questionnaire during the first conscription days before active military training in July 1999. The effect of pre-disposing, need and health behavior variables on self-medication was assessed using Andersen et al. theoretical health care utilization model. RESULTS: In the 2 weeks preceding the survey, 65% of the men reported self-medication. Self-medication for pain or common cold symptoms was reported by 54% while 8% had taken caffeine tablets or other stimulants. Multivariate analysis on overall self-medication showed an association with brigade and using health services before the conscription. Along with pre-disposing variables, need variables were associated with self-medication for pain or common cold symptoms and self-medication with stimulants. Stimulant use was also associated with health behaviors such as trial with illegal drugs during lifetime. CONCLUSIONS: Young men frequently self-medicate at the initial stage of conscription that may pose them at an increased risk for adverse effects of medicines or other medical problems. The military and civilian primary health care providers should discuss the proper use of self-medication with young men.