Presentation by Hayden McRobbie, M.B., Ch.B., Ph.D., Auckland University of Technology, New Zealand, at the Global Bridges Preconference at the 15th World Conference on Tobacco OR Health in Singapore.
Challenges to Tobacco Dependence Treatment in Europe -- Hayden McRobbie, M.B., Ch.B., Ph.D.
1. Europe
Tobacco Dependence Treatment
Hayden McRobbie MB ChB PhD
Wolfson Institute of Preventive Medicine, Queen Mary University of London
Faculty of Health & Environmental Sciences, Auckland University of Technology
Inspiring Limited
2. Male smoking prevalence
World Health Organization. The Tobacco Atlas. http://www.who.int/tobacco/statistics/tobacco_atlas/en
4. Treatment to help dependent
smokers stop
Item Score /10
Recording of smoking status in medical notes
Legal or financial incentive to record smoking status in all medical notes or patient files 1
Brief advice in primary care
Family doctors reimbursed for providing brief advice 1
Quitline
National quitline or quitlines in all major regions of country 1
ADDITIONAL POINT FOR
Quitline counselors answering at least 30 hours a week (not recorded messages) 1
Network of smoking cessation support and its reimbursement
Cessation support network covering whole country; free 4
Cessation support network but only in selected areas; free 3
Cessation support network covering whole country; partially or not free 3
Cessation support network but only in selected areas; partially or not free 2
Reimbursement of medications
Medications totally reimbursed or free to users or 2
Medications partially reimbursed 1
5. Tobacco Treatment Scores
Country Treatment Score Country Treatment Score
UK 9 Italy 5
Denmark 7 Portugal 5
Romania 7 Hungary 5
Poland 7 Finland 4
Luxembourg 7 Spain 4
Ireland 6 Cyprus 4
France 6 Germany 4
Malta 6 Czech Republic 4
Sweden 6 Austria 4
Belgium 6 Turkey 3
Switzerland 6 Lithuania 3
Netherlands 6 Greece 3
Slovenia 6 Iceland 2
Estonia 6 Bulgaria 2
Slovakia 6 Latvia 0
Norway 5
6. Challenges
Lack of routine brief interventions
Lack of systems to help HCPs to
deliver brief interventions and
referral
Lack of reimbursement
8. Belgium
~350 "tobaccologists" trained for at least 1 year in smoking cessation
• Majority of them work within CAF (Centre d'Aide Aux Fumeurs)
• Staffed by at least one MD and one tobaccologist
• The majority of CAF are situated in hospital facilities.
Pharmacotherapy
• NRT is not reimbursed, but mutual funds give 50 € for help in smoking cessation
• Varenicline is reimbursed after the first 15 days of treatment which are paid by the
smokers
• Bupropion is reimbursed in patients with COPD
8 consultations for smoking cessation (over a maximum of 2 years) are
reimbursed for any MD, or a psychologist-tobaccologist.
A minority of GP received a short training in smoking cessation provided by their
professional scientific association.
With thanks to Dr. Pierre Bartsch, professor of lung medicine at the University of Liege in Belgium
9. France
Train ‘Tobaccologists’ (Smoking Cessation Specialist) in post-graduate courses at 5
medical schools
• 100 hours of classes, 20 hours of clinical practice, written exam, 20-30 page thesis
• Physicians can put this after their name (although not recognized as a medical
specialty), and midwives can use the title “Smoking Cessation Specialist Midwife”
SCS can have a
• dedicated state paid position in hospitals and/or private practice
• Approximately 600 smoking cessation clinics/practices across France
Society: http://www.societe-francaise-de-tabacologie.com/
Treatments
• All forms of NRT (except Nasal Spray) available on prescription and OTC
• Varenicline and bupropion are prescription drugs
• Counseling is mandatory with prescription medicines
• All but varenicline is reimbursed (50 euros/year/person)
• Pregnant women: NRT reimbursed up to 150 euros/pregnancy
With thanks to Professor Ivan Berlin
10. Spain
Three regions (Madrid, Navarra and La Rioja) have well designed smoking cessation
programmes
• Clinics in primary and secondary care facilities
• Staffed by part-time specialists
• Medications are reimbursed in some cases
• E.g. Smokers with COPD, CVD, asthma, diabetes, cancer, pregnant women and
those with psychiatric illness
In regions where no good smoking cessation programmes exist
• A few clinics, most in hospitals
• Treatments not reimbursed
Treatments
• NRT – gum lozenges and patch (OTC)
• Bupropion and varenicline on prescription
Training is provided by medical societies and some universities in post-graduate courses
The US Tobacco Dependence Treatment Guidelines have been translated into Spanish
With thanks to Professor Carlos Jimenez-Ruiz
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11. Germany
Smoking cessation services vary across Germany, especially in the new Federal states
In the new Federal states, the supply of smoking cessation services is insufficient
• Smoking cessation providers lack the specialised skills needed for smoking
cessation counselling and treatment
The barriers against engagement most commonly reported included:
• lack of adequate reimbursement
• lack of training in smoking cessation promotion
• lack of demonstration materials.
Most German health insurance funds provide reimbursement for cognitive-behavioural
group-based courses for smoking cessation
• However, the reimbursement for non-pharmacological interventions which is around
€75-100 is insufficient to cover the staff costs for providing these services
• Although physicians, hospital departments and insurance companies may provide
smoking cessation services, smokers have to pay for any pharmacotherapies they
receive
With thanks to Dr Tobias Raupach
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12. United Kingdom
Behavioural support and pharmacotherapy fully subsidized
Services reaching high needs areas
In 2010/11 the English services
• Saw over 700,000 people
• About 384,000 people reported successfully quitting
at the 4 week follow-up
1
13. Treatment format
∗ Brose L, West R, McDermott M, Fidler J, Croghan E, McEwen A (2011) What makes for an
effective stop-smoking service? Thorax.
1
14. Medication options used
Brose L, West R, McDermott M, Fidler J, Croghan E, McEwen A (2011) What makes for
an effective stop-smoking service? Thorax.
1
15. United Kingdom
Behavioural support and pharmacotherapy fully subsidized
Services reaching high needs areas
In 2010/11 the English services
• Saw over 700,000 people
• About 384,000 people reported successfully quitting
at the 4 week follow-up
However more basic levels of brief intervention are not
routinely occurring in secondary care, and primary care
could do more
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16. Addressing the Basics
My Intervention :: Page1-Opening http://ncsct-training.co.uk/player/play/VBA
Very Brief Advice on Smoking
Introduction
A training module developed by the National Centre
for Smoking Cessation and Training (NCSCT) on
how to deliver very brief advice to smokers
This training module should take you less than 30
minutes to complete
To begin click the 'Continue' button below
Continue
http://ncsct-training.co.uk/player/play/VBA?thiz=Page1-Opening
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18. The Western Pacific
Large geographical
area
Many different
cultures and
languages
Vastly different
levels of tobacco
control
1
19. Barriers to smoking cessation
Economic factors
Lack of awareness by policy makers of the health
consequences and costs of tobacco
Low perception of risks among the public
Lack of policies that promote cessation
Smoking behaviour of service providers and their own lack
of knowledge or awareness
Poor healthcare systems
Lack of infrastructure
Industry action
Abdullah & Husten Thorax 2004;59:623–630
1
20. Pacific Smoking Prevalence
Males Females
Rasanathan &TukuitongaJournal of the New Zealand Medical Association, 12-October-2007, Vol 120 No 1263
2
21. Tobacco Control in the Pacific
All independent Pacific countries are parties to the FCTC
Willingness to adopt strong solutions
• Smokefree villages
• In 2007 Premier of Niue has suggested the novel
approach of financial payments of up to NZ$1700 to
each of Niue’s estimated 200 smokers to quit smoking
as a means of reducing the greater cost to the
Government of treating smoking-related illnesses
Extensive provision of smoking cessation support which
could include face-to-face services at community meetings,
village events, and sports clubs as well as personalised
services via quitlines.
Wilson et al (2007) Journal of the New Zealand Medical
Association, 30-November-2007, Vol 120 No 1266
2
22. A smokefree Fijian village
1986 – a group of HCPs (Surfers Medical
Association) started a small scale treatment
and health promotion programme in the
Fijian village of Nabila
1990 – ‘stocktake’
• 238 ethnic Fijians in Nabila
• 147 > 16 years of age
• 31% smokers
Groth-Marnat et al (1996) Soc. Sci. Med 43(4) 473-477
2
23. A pledge to become smokefree
If all of the smokers in the
village abstained, then the
medical team promised to
match whatever money was
raised for building a
community centre
3 months later the medical
team received a letter to
say that Nabila was now a
smokefree village
Groth-Marnat et al (1996) Soc. Sci. Med 43(4) 473-477
2
24. Becoming smokefree
Village aversive smoking
Followed by a ceremony where all remaining
cigarettes were destroyed
Kava ceremony
Tabu established
Village wide commitment
Further kava ceremonies to reinforce
commitment
Groth-Marnat et al (1996) Soc. Sci. Med 43(4) 473-477
2
25. Relapse did happen
In 4 people – with consequences
• The 1st tripped after smoking and lacerated his
scalp
• The 2nd was attacked by a dog
• The 3rd developed testicular swelling
• The 4th collapsed unconscious immediately
after smoking, whilst drinking kava
All sought forgiveness from the elders and
got back on track
Groth-Marnat et al (1996) Soc. Sci. Med 43(4) 473-477
2
26. Australian GP Guidelines
Recommend that HCPs
should
• Give brief advice to stop
smoking
• Make an assessment of the
smoker’s interest in quitting
• Make an offer of
pharmacotherapy and
counselling where
appropriate
• Provide self help material
• Refer to more intensive
support such as Quitline and
other local programs that
may be available in each
state.
2
27. Guidelines aim to address barriers
Belief Evidence
Assistance with smoking Most patients think smoking cessation
cessation is not part of my role assistance is part of your clinical role
I have counselled all my smokers Only 45–71% of smokers are counselled
Smokers aren’t interested in Nearly all smokers are interested in quitting and more
quitting than 40% of smokers make quit attempts each year
and more think about it
I routinely refer patients for Referrals to Quitline are low (10–25%)
smoking cessation assistance
I’m not effective Clinicians can achieve substantial quit rates over 6–12
months, 12–25% abstinence, which have important
public health benefits
Smokers will be offended by Visit satisfaction is higher when smoking is addressed
enquiry appropriately
I don’t have time to counsel Effective counselling can take as little as a minute
smokers
The RACGP, Supporting smoking cessation: a guide for health professionals
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29. The ABCs
A - ask whether a
person smokes
B - give brief advice
to quit to all people
who smoke and
C – make and offer
of and refer to
cessation treatment
2
30. The Health Target
95% of hospitalised
smokers will be provided
with advice and help to
quit by July 2012
90% of enrolled patients
who smoke and are seen
in General Practice, will
be provided with advice
and help to quit by July
2012. 3
32. The case in Malaysia
Have TDT guidelines
Lack of training for HCPs to
undertake brief interventions
Over 300 Quit Clinics in almost every
district
• Not well utilized
Access to most pharmacotherapies
• NRT is expensive
• Pharmacists can supply
3
33. Are TDTs Cost-effective?
Agreed that TDTs are extremely cost-effective – but it depends upon the
definition
World Health Organization thresholds of being ‘cost-effective’ if less
than three times gross domestic product (GDP) per capita and ‘very
cost-effective’ if less than GDP per capita
Vietnam example: GDP per capita VND 11 500 000 ($US1160)
Intervention VND per DALY averted
Physician brief advice 1,742,000
Nicotine patch 287,684,000
Bupropion 172,582,000
Varenicline 108,412,000
Higashi & Barendregt (2011) Addiction, 107, 658–670
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High income, relatively low smoking prevalence 15.1% of people in Australia, aged 14 years or older, were daily smokers Quitline - www.quitbecauseyoucan.org.au Some face-to-face services Medicines - Pharmaceuticals benefits scheme (PBS) Patches – 12 weeks/year (2 courses for Aboriginal or Torres Strait Islander) – An authority prescription is required and the support program being used needs to be specified. Varenicline - can be prescribed for up to 24 weeks of continuous Bupropion one course per year
Big challenge ahead – requires a big approach. Smoking cessation treatment is a significant part of New Zealand’s multi-pronged, comprehensive strategy for getting to a smokefree 2025. The two main thrusts of our smoking cessation strategy are firstly to motivate more quit attempts, and secondly to ensure that those quit attempts are well supported with cessation treatments and lead to good smokefree outcomes.
New Zealand’s comprehensive approach, which includes this range of options for cessation treatment is set out in the ABC programme. The ABCs highlight the important but different roles played by health care workers and cessation service providers to provide good help for smokers to quit. The ABCs are about addressing smoking with every patient, and ensuring that they get joined up with cessation treatment that works for them. ABC is about Asking every patient if they smoke, providing brief advice to quit, and providing smoking cessation medications and or referring on to more intensive cessation support services. And then, of course, the role of cessation services in the ABC is to provide the C in a high quality, evidence based way.
The Government recognises the value of the ABC approach. And while cessation support services have been doing their part for years, it took a health target to get the healthcare sector on board. The health target is that: 95% of hospitalised smokers will be provided with advice and help to quit by July 2012. And in primary care that: 90% of enrolled patients who smoke and are seen in General Practice , will be provided with advice and help to quit by July 2012.
This shows that the target has seen great success. When it first started smoking was sometimes recorded in the patient notes as part of someone's social history but was not consistently screened for, nor addressed in health care settings In Q4 of 2010-11, 85% of hospitalised patients that smoke were offered brief advice to quit smoking so nearly everyone that smokes was offered help to quit in hospitals. Last year 105,000 smokers were identified and 80,000 smokers received brief advice to quit. And the percentages continue to increase. The coverage achieved through the health target is unprecedented for a smoking cessation treatment and extending the health target to Primary care will extend the reach of the intervention tremendously - Indeed we know that aout 94% of patients are enrolled with a GP and about 85% of these will see their GP each year. So the vast majority of the NZ population are likely to be screened for smoking and provided brief advice and help to quit this year, if we achieve the target!