To the Editor:
In March 2020, the COVID-19 pandemic led to a lockdown throughout most of the United States. In response, the number of outpatient primary and specialty care appointments dropped significantly.1 Tobacco use was determined to be an important and immediately modifiable risk factor associated with COVID-19 transmission and severity.2 During the pandemic, patients fell behind on preventive screening and chronic disease state management, including treatment of nicotine dependence. Although the use of cigarettes seemed to decrease at the start of the pandemic, e-cigarette sales increased1, nicotine pouch sales fell slightly during the first few months of the pandemic and then increased, and smokeless tobacco sales remained consistent.3,4 In general, those who smoke showed more interest in quitting during the pandemic.5, 6, 7 However, overall, those who smoke were 2% less likely to attempt quitting in 2020 vs 2019, with 63.2% and 65.2% attempting cessation, respectively. Although sales of over-the-counter nicotine replacement therapy (NRT) did not hit sales projections in 2020, the prevalence of successful cessation did not change from the previous year.8 Given the importance of smoking as a COVID-19 risk factor and the heightened interest in smoking cessation during the pandemic, we aimed to assess whether the medical community was able to capitalize on this opportunity to improve population health. In a large national cohort of patients in the United States, we evaluated the impact of the pandemic on the prescribing of medications for tobacco and nicotine dependence.
Methods
We evaluated data from January 2018 through December 2020, compiled from a large national pharmacy benefit manager claims database that serves one-third of the US population. The search was limited to patients who had a commercial or Medicaid insurance benefit (commercial: 82.1%, 81.9%, and 76.2%, Medicaid: 5.3%, 5.5%, and 10.9% of the Pharmacy Benefit Management database in 2018, 2019, and 2020, respectively) and a prescription for a medication to treat nicotine dependence. Medications assessed were varenicline, NRT (patches, gum, lozenges, inhaler, nasal spray), and bupropion (sustained release 150 mg only). Patients were classified by their primary insurance type (commercial or Medicaid). Members with dual coverage were excluded. Metrics of utilization (day per members months) and prevalence per 1 million members were created for each month. This report follows the Strengthening the Reporting of Observational Studies in Epidemiology Statement guidelines for cross-sectional studies.
Statistical Methods
An interrupted time series analysis was conducted for each of the three therapies for each insurance type. We used a linear model to evaluate whether any change in use and prevalence occurred for each of the three therapies before and during the pandemic. The preperiod was defined as January 2018 through March 2020 and postperiod was defined as April 2020 through December 2020. Models included variables for an interval for each month throughout the entire study period, an indicator for each month in the postperiod, and an interval for each month in the postperiod.
The study was deemed exempt by the Clinical Investigation Department at Naval Medical Center Portsmouth and the University of Pittsburgh institutional review board because the data for this study were deidentified and in full compliance with the Health Insurance Portability and Accountability Act.
Results
During the study period, among the commercially insured were 18,865,250 members in 2018, 20,730,882 members in 2019, and 22,200,802 members in 2020, of whom 270,684 patients (across 2018, 2019, and 2020) filled 836,213 (varenicline, NRT, bupropion) prescriptions (adjusted to 30-day supplies).
A significant decline in the prevalence of users of and prescriptions for varenicline, NRT, and bupropion was found in the postperiod compared with the preperiod (P < .001 for all) (Table 1). After April 2020, the prevalence of users of and prescriptions for varenicline and NRT showed no significant change. Prevalence of individuals using bupropion and prescriptions showed a small but significant increase over the course of the postperiod (Fig 1, Table 1). Importantly, for both Figures 1 and 2, the left vertical scale pertains to varenicline and NRT, whereas the right vertical scale pertains to bupropion (reflecting significantly lower prevalence of prescriptions relative to varenicline and NRT).
Table 1.
Trends in Use of Medications to Treat Nicotine Dependence Before and During the COVID-19 Pandemic
| Medication | Estimate | Standard Error | P Value |
|---|---|---|---|
| Commercial insurance | |||
| Preperiod | |||
| Varenicline | |||
| Individuals using medication | 0.1 | 0.5 | .7751 |
| Prescriptions | 0.00003 | 0.00002 | .0576 |
| NRT | |||
| Individuals using medication | 2.7 | 0.4 | < .0001a |
| Prescriptions | 0.00007 | 0.00001 | < .0001a |
| Bupropion | |||
| Individuals using medication | 0.3 | 0.1 | .0008a |
| Prescriptions | 0.00002 | 0.000003 | < .0001a |
| Level change between preperiod and postperiod | |||
| Varenicline | |||
| Individuals using medication | –135.6 | 16.9 | < .0001a |
| Prescriptions | –0.00481 | 0.00060 | < .0001a |
| NRT | |||
| Individuals using medication | –68.5 | 13.7 | < .0001a |
| Prescriptions | –0.00198 | 0.00045 | .0001a |
| Bupropion | |||
| Individuals using medication | –16.5 | 2.3 | < .0001a |
| Prescriptions | –0.00065 | 0.00010 | < .0001a |
| Postperiod Change | |||
| Varenicline | |||
| Individuals using medication | –3.8 | 2.7 | .1713 |
| Prescriptions | –0.00012 | 0.00010 | .2344 |
| NRT | |||
| Individuals using medication | –1.0 | 2.2 | .6399 |
| Prescriptions | –0.00001 | 0.00007 | .8877 |
| Bupropion | |||
| Individuals using medication | 1.6 | 0.4 | .0001a |
| Prescriptions | 0.00006 | 0.00002 | .0008a |
| Medicaid insurance | |||
| Preperiod | |||
| Varenicline | |||
| Individuals using medication | 6.5 | 1.9 | .0015a |
| Prescriptions | 0.00023 | 0.00006 | .001a |
| NRT | |||
| Individuals using medication | 5.6 | 4.2 | .1998 |
| Prescriptions | 0.00011 | 0.00012 | .3686 |
| Bupropion | |||
| Individuals using medication | –1.1 | 0.3 | .001a |
| Prescriptions | –0.00003 | 0.00001 | .005a |
| Level change between preperiod and postperiod | |||
| Varenicline | |||
| Individuals using medication | –101.5 | 61.8 | .1104 |
| Prescriptions | –0.00323 | 0.00210 | .1327 |
| NRT | |||
| Individuals using medication | –561.0 | 140.3 | .0004a |
| Prescriptions | –0.01470 | 0.00404 | .0009a |
| Bupropion | |||
| Individuals using medication | –28.1 | 9.7 | .0067a |
| Prescriptions | –0.00096 | 0.00036 | .0117a |
| Postperiod change | |||
| Varenicline | |||
| Individuals using medication | –3.1 | 9.9 | .7606 |
| Prescriptions | –0.00008 | 0.00034 | .8112 |
| NRT | |||
| Individuals using medication | 0.6 | 22.6 | .9774 |
| Prescriptions | 0.00014 | 0.00065 | .8367 |
| Bupropion | |||
| Individuals using medication | 1.7 | 1.6 | .2915 |
| Prescriptions | 0.00007 | 0.00006 | .2272 |
Values are absolute; user prevalence and prescriptions per member per month are presented. Positive values indicate a positive trend, negative values indicate a negative trend. NRT = nicotine replacement therapy.
Statistically significant at P < .05.
Figure 1.
Line graph showing use of medications to treat nicotine dependence among commercially insured patients, January 2018 through December 2020.
Figure 2.
Line graph showing use of medications to treat nicotine dependence among Medicaid-insured patients, January 2018 through December 2020.
Among the Medicaid insured were 1,220,680 patients in 2018, 1,382,922 patients in 2019, and 3,165,063 patients in 2020, of whom 51,589 patients filled 171,608 prescriptions. A decline in the prevalence of individuals using varenicline and prescriptions occurred in the postperiod compared with the average level in the preperiod, but this was not statistically significant. However, for NRT and bupropion, a decline in prevalence of individuals using the medications and prescriptions was found in the postperiod compared with the preperiod (P < .001) (Table 1). After April 2020, the prevalence of individuals using the medication and prescriptions for varenicline, NRT, and bupropion showed no significant change (Fig 2, Table 1). Both commercially and Medicaid insured populations showed preperiod trend changes in medications, but all were in the positive direction (Table 1).
Discussion
Despite recognition of the importance of smoking as a risk factor for adverse outcomes associated with COVID-19, we found a negative association with the pandemic and prescribing pharmacotherapy for the treatment of nicotine dependence. Bandi et al8 reported from a nationally representative survey of 788,008 people who smoke that fewer attempted smoking cessation in 2020 compared with 2019, and self-reported successful cessation was unchanged. Notably, we found that the overall prepandemic prevalences of varenicline—the most effective agent to treatment nicotine dependence—as well as of NRT were not regained throughout the study period. Bupropion did show a small but significant increase in the postperiod that may be attributable to increased rates of co-occurring pandemic-related depression. Although calls stressing the importance of treatment and cessation were made during the pandemic, and a framework for the implementation of a telehealth-based, pandemic-adapted tobacco dependence treatment campaign was created early on,2 our findings suggest that the US medical system was unable to meet the corresponding need.
Our study has several limitations. Most importantly, we were unable to determine use of over-the-counter NRT. However, our findings are consistent with a report of national sales of NRT in 2019 and 2020, which documented that sales for patches (–6.4%) and gum (–1.2%) were lower than expected.8 Finally, in light of the Chantix recall that significantly affected overall prescribing of pharmacotherapy in 2021, results after 2020 were not assessed given the difficulty in determining a true trend.9
Given higher rates of interest in cessation in 2020,5, 6, 7 the pandemic may have given individuals who use nicotine products added motivation to obtain pharmacotherapy to assist in an attempt to quit. The lack of increased prescribing of pharmacotherapy for nicotine dependence to meet that need represents a lost opportunity to take advantage of a situation where individuals were motivated to quit. This likely has resulted in both immediate and long-term adverse effects on the health of individuals who use tobacco and other nicotine products.
Financial/Nonfinancial Disclosures
The authors have reported to CHEST the following: A. E. L. previously owned stock in Walmart, Target, and Johnson and Johnson within the past 36 months. None declared (T. L., M. E., U. P., C. B. G.).
Footnotes
DISCLAIMER: The views expressed in this publication are those of the author and do not necessarily reflect the official policy of the Department of Defense, Department of the Army, US Army Medical Department, Defense Health Agency or the US government.
References
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