Make Nicotine Gum, Patches Available Over The Counter

In Malaysia, nicotine replacement therapy products can only be dispensed by a medical practitioner or pharmacist, unlike New Zealand that provides such items without prescription.

KUALA LUMPUR, Feb 9 – An expert has urged the government to make nicotine replacement therapy (NRT) products, like nicotine patches, gum, or lozenges, available over-the-counter to better enable smokers to quit .

According to the National Health and Morbidity Survey (NHMS) 2019, an estimated 4.9 million Malaysians aged 15 years and older currently smoke tobacco.

The Ministry of Health’s (MOH) 2016 clinical practice guidelines (CPG) on the treatment of tobacco use disorder noted that NRT products do not need a doctor’s prescription as they fall under Group C medications in the Poisons Act 1952.

However, the same Act states that Group C medications can only be dispensed by a registered medical practitioner or a licensed pharmacist.

Galen Centre for Health and Social Policy chief executive Azrul Mohd Khalib said access to NRT products needs to be improved if Malaysia is serious about helping smokers to quit.

“You know you go to the pharmacy, you have to sign in a book, you have to write your name, put an IC number, and in some places, you’ve got to get a prescription — it’s equivalent to trying to get a contraceptive pill for women. 

“So, if you imagine trying to go to the pharmacy just to get a gum or a nicotine patch, you might give up before you even walk to the pharmacy,” Azrul said in a recent BFM podcast on the country’s smoking cessation strategies.

There are two NRT products currently available in Malaysia, namely the patch and gum. In general, NRT helps to reduce urges to smoke and withdrawal symptoms associated with smoking cessation by replacing the nicotine from cigarettes. Common NRTs are gum, patch, lozenges, and inhalator.

NRT products help deliver nicotine to the brain, but less rapidly than from smoking cigarettes. The CPG noted that people should use NRT for at least eight to 12 weeks and that using two NRT products (such as patches and gum) is more effective than using one.

NRTs have been around for over 40 years and have a strong safety profile and are effective in smoking cessation. The World Health Organization (WHO), as well as the Malaysian government, have listed NRTs as part of essential medicines for smoking cessation.

In New Zealand, where the country in December last year announced a ban on smoking for those aged 14 and below in a bid to outlaw the habit by 2050, NRT products are available for purchase over-the-counter. 

NRT products like inhalers and mouth spray can be bought at supermarkets or pharmacies without any prescription, while patches, gum, and lozenges are subsidised so they can be obtained cheaply or for free at community pharmacies, according to New Zealand’s Ministry of Health.

“It’s the enabling environment that make it possible for smokers to actually see a future where they can quit smoking and I think New Zealand is now embarking on an ambitious experiment to actually make that a reality, not just for people born up to a certain age, but pretty much for everyone,” Azrul said.

Prof Dr Mohamad Haniki Nik Mohamad, who is chief coordinator of the Certified Smoking Cessation Service Provider (CSCSP) at the Kulliyyah of Pharmacy, International Islamic University Malaysia, said a combination of behaviour and pharmacological interventions would yield the best results to help people quit smoking.

Dr Mohamad Haniki, who has been providing smoking cessation services for almost 20 years, said other than physical dependence to nicotine, the environment can also create challenges that prevent smokers from being successful in quitting.

He said the month of Ramadan, for example, creates an enabling environment for smokers to quit or at least abstain for certain hours.

“Firstly, it creates a total 180 degrees’ environment where the majority of Muslims are not smoking — at least during the daytime — and then there’s no food, there’s no eating, and there’s no drinking.

“We know that eating and drinking are strong triggers for smoking because they reinforce smoking. For example, if they drink coffee or tea, they would smoke. If they eat, they would smoke to double or triple their pleasure,” Dr Mohamad Haniki told BFM.

“So, when there is no drinking or eating, and the environment is more conducive in the sense that you don’t see people smoking and you don’t smell the cigarette,” he said, adding that making NRT products readily available also contributes to an enabling environment to quit smoking.

In a separate interview on Astro Awani’s Consider This, Pantai Hospital Kuala Lumpur consultant respiratory physician Dr Helmy Haja Mydin mentioned that 50 per cent of smokers want to quit.

“It’s usually a combination of physiological, but also social issues, economic issues that drive people to continue smoking. So, it’s a very complex system which is not going to be determined or solved by just one intervention,” Dr Helmy said.

Azrul pointed out that the reality of quitting smoking is hard for many and that some estimates suggest that it would take at least 30 attempts and relapses before they succeed.

“What we need to do if we want to really help smokers to quit, is we really need to improve access to these sort of proven methods of smoking cessation,” he said.

Separately, Dr Mohamad Haniki told CodeBlue when contacted that there is high‐certainty evidence that using a combination of NRT products versus a single‐form NRT can increase the chances of helping smokers quit successfully.

He also cited a study published in the Cochrane Database of Systematic Reviews 2019 on the varying efficacy of different doses of NRT products for smoking cessation.

The research noted that 21mg patches resulted in higher quit rates than 14mg patches (24-hour), and using 25mg patches resulted in higher quit rates than using 15mg (16‐hour) patches. There was no clear evidence of superiority for 42/44 mg over 21/22 mg (24‐hour) patches. 

The study found that using a fast‐acting form of NRT, such as gum or lozenge, resulted in similar quit rates to nicotine patches. 

There is moderate‐certainty evidence that using NRT prior to quitting may improve quit rates versus using it from quit date only. However, further research is needed to ensure the robustness of this finding, it stated.

Dr Mohamad Haniki said smoking cessation medications, including NRT products and varenicline, are generally available in most community pharmacies and private clinics in Malaysia. Supplies are also available at MOH health clinics and hospitals with quit-smoking clinics or services.

“Community pharmacists are more accessible to most Malaysians and we have certified more than 5,000 pharmacists under the CSCSP programme which started since 2002 by the Malaysian Pharmacists Society (MPS) and Malaysian Academy of Pharmacy (MAP), in collaboration with the MOH and pharmaceutical industry. 

“More health care professionals are added to the list after having successfully completed level 2 of the CSCSP, currently under the public-private partnership, like the mQuit programme,” he said.

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