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Drug and Alcohol Dependence In 2009, the FDA required a black box warning (BBW) on bupropion and varenicline, the two commonly prescribed smoking cessation agents due to reports of adverse neuropsychiatric events. We investigated if there was a decline in use of bupropion and varenicline after the BBW by comparing the percent using these medications before and after BBW. We conducted a retrospective observational study using data from the Medical Expenditure Panel Survey from 2007 to 2014. The study sample consisted of adult smokers, who were advised by their physicians to quit smoking. We divided the time period into “pre-warning”, “post-warning: immediate”, and “post-warning: late.” Unadjusted analysis using chi-square tests and adjusted analyses using logistic regressions were conducted to evaluate the change in bupropion and varenicline use before and after the BBW. Secondary analyses using piecewise regression were also conducted. On an average, 49.04% of smokers were advised by their physicians to quit smoking. We observed a statistically significant decline in varenicline use from 22.1% in year 2007 to 9.23% in 2014 (p value < 0.001). In the logistic (Adjusted Odds Ratio = 0.36, 95% CI = 0.22–0.58) and piecewise regressions (Odds Ratio = 0.64, 95% CI = 0.41–0.99) smokers who were advised to quit smoking by their physicians were less likely to use varenicline in the immediate post-BBW period as compared to pre-BBW period. While the use of varenicline continued to be significantly low in the late post-BBW period (AOR = 0.45, 95% CI = 0.31–0.64) as compared to the pre-BBW period, the trend in use as seen in piecewise regression remained stable (OR = 0.90, 95% CI = 0.75–1.06).

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Using cigarette tax hike as a solution has failed to work Price hikes intensified around the year 2014, and there was a sharp decline of 12% in legalised sale of cigarettes. During the most recent tax hike, prices for a pack of 20 cigarettes rose from RM17 (US$4.02) to RM21.50 (US$5.08). Illicit cigarette trade filled up the gap left by legal sales. Its penetration rate increased from 36.3% in 2011 to 51% in 2016. This resulted in an estimated loss of RM4.4 billion (US$1.06 billion) in government revenue last year. From the year 2011 to 2015, average cigarette prices went up by more than 30% . If the price hikes do deter consumers, there should have been a corresponding decrease in total cigarette consumption. The Malaysian government needs to relook at its future strategies Attempts to minimise the prevalence of smoking failed due to the absence of policies to restrict black market activities. The government had oversimplified the problem by assuming price hikes would decrease the cigarette consumption in lower income families.

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