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Smoking Cessation Programs In Primary Health Care – An Approach For Reducing Health-Related Behavioral Risk Factors
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Smoking Cessation Programs In Primary Health Care – An Approach For Reducing Health-Related Behavioral Risk Factors

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GRF 2nd One Health S, National Center of Public Health and Analyses, Bulgaria & Michgan State Univeristy

GRF 2nd One Health S, National Center of Public Health and Analyses, Bulgaria & Michgan State Univeristy

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  • This is from the 40 year follow up of a cohort of British doctors. It illustrates an average loss of life of about 7.5 years and shows that any given age survival rates for smokers are considerably lower. The use of doctors eliminates any social class or income bias.

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  • 1. Smoking Cessation Programs In Primary Health Care – An Approach For Reducing Health-Related Behavioral Risk Factors Plamen Dimitrov - National Center of Public Health and Analyses, Bulgaria and Michigan State University, USA Antoaneta Manolova - National Center of Public Health and Analyses, Bulgaria Galia Tsolova - National Center of Public Health and Analyses, Bulgaria 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 2. The global tobacco epidemic • • • • According to the WHO, the total number of smokers in the world is about 1.2 billion, or about 1/3 of the total population aged 15 years and older (47.0% of men and 12.0% of women). Each year, over 5.4 million people worldwide die of a tobacco-related diseases. By 2030, their number is expected to reach 10 million and smoking to become the LEADING single cause of death. Tobacco kills up to half of all users 100 million deaths were caused by tobacco in the 20th century. If current trends continue, there will be up to one billion deaths in the 21st century. 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 3. Tobacco is a risk factor for six of the eight leading causes of deaths in the world Ischemic Cerebrovascular heart disease disease Tuberculosis Trachea Tobacco Chronic Lower HIV/AIDS Diarrhoeal disease bronchus use respiratory obstructive lung infections pulmonary cancers disease http://www.who.int/nmh/publications/fact_sheet_tobacco_en.pdf 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 4. Health risks associated with smoking    Tobacco is proven or probable causal factor in about 25 diseases and its impact on global health is great, though not fully appreciated. Cigarette smoking is one of the main factors of chronic non-communicable diseases. Cigarette smoking formed 12.2% of the global disease burden in the WHO European Region (from 3.0% to 26.8% for different countries) and is responsible for 2.3% to 20.9% of all deaths. For Bulgaria, these indicators are 13.5% and 12.4%. 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 5. Overall risk in smokers and non-smokers Never smokers % Alive and in good health 100 80% 80 Smokers 60 59% 7.5 years 40 33% 20 12% 0 40 55 70 85 100 Age (years) Doll et al. BMJ 1994 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 6. Smoking in Bulgaria      Bulgaria is among the countries with high smoking prevalence in Europe. Smoking is a major factor for current high incidence and mortality rates from non-communicable diseases. The indicators will continue to deteriorate if necessary measures will not be taken. Urgent actions are needed in order to reduce smoking prevalence in Bulgaria. It is recommended tobacco control, including prevention, quitting smoking, and therapeutic measures to be integrated into primary health care. 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 7. Smoking among adults in Europe OECD, “Smoking among adults”, in Health at a Glance: Europe 2012, OECD Publishing. 2012. http://dx.doi. org/10.1787/9789264183896-24-en 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 8. Tobacco attributable mortality among Bulgarian male population by age groups and causes of deaths 100 90 80 70 60 35-44 45-64 >65 50 40 30 20 10 0 Lung cancer All cancers CVD All causes HEM – Closing the Gap EU Project, Partly funded by the European Commission http://www.hem.waw.pl/index.php?idm=87,108,116&cmd=1 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 9. Non-communicable diseases epidemic    Of the 57 million global deaths in 2008, 36 million, or 63%, were due to NCDs, principally cardiovascular diseases, diabetes, cancers and chronic respiratory diseases. As the impact of NCDs increases, and as populations age, annual NCD deaths are projected to continue to rise worldwide, and the greatest increase is expected to be seen in low- and middle-income regions. A large percentage of NCDs are preventable through the reduction of their four main behavioural risk factors: tobacco use, physical inactivity, harmful use of alcohol and unhealthy diet. 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 10. WHO-NCD “best-buys” interventions     Cost-effective Feasible Low cost Appropriate to implement within the constrains of the local health system 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 11. WHO-NCD “best-buys” interventions           Protecting people from tobacco smoke and banning smoking in public places; Warning about the dangers of tobacco use; Enforcing bans on tobacco advertising, promotion and sponsorship; Raising taxes on tobacco; Restricting access to retailed alcohol; Enforcing bans on alcohol advertising; Raising taxes on alcohol; Reduce salt intake and salt content of food; Replacing trans-fat in food with polyunsaturated fat; Promoting public awareness about diet and physical activity, including through mass media. http://www.who.int/nmh/publications/ncd_report_summary_en.pdf 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 12. Health Act - banning smoking in public places 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 13. Ban on tobacco advertising, promotion and sponsorship 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 14. http://ec.europa.eu/taxation_customs/taxation/excise_duties/tobacco_products/rates/index_en.htm 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 15. Tobacco cessation • • • Tobacco cessation includes (singly or in combination) behavioral and pharmacological interventions such as brief advice and counseling, intensive support, and administration of pharmaceuticals. Quitting tobacco is not easy as tobacco dependence is a cluster of behavioural, cognitive and physiological phenomena. But the evidence is strong that it can be done. From quit lines to counselling to prescription medicines, there are numerous effective ways to quit. 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 16. Summary of effectiveness data for smoking cessation interventions (abstinence at least six months) Intervention (source) Comparator Odds ratio (95% confidence interval) Increased chances of quitting successfully Self-help interventions No intervention 1.24(1.07-1.45) 24% Brief advice vs. no advice 1.66(1.42-1.94) 66% Intensive advice vs. no advice 1.84(1.60-2.13) 84% Intensive vs. minimal 1.37(1.20 to 1.56) 37% Nursing intervention Usual care 1.28(1.18 to 1.38) 28% Individual behavioural counselling Minimal behavioural intervention 1.39(1.24 to 1.57) 39% Group behaviour therapy Self-help programme 1.98(1.60-2.46) 98% Without telephone counselling 1.41(1.27-1.57) 41% Less intensive vs. no 1.33(1.21-1.47) 33% Physician advice Telephone counselling Source: http://www.who.int/tobacco/quitting/summary_data/en/index.html 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 17. The situation in Bulgaria     The development and implementation of effective prevention of tobacco-related diseases are needed; combined policy measures as well as individual and population strategies have to be implemented. Development and optimization of integrated approaches to solving the problem is particularly important in terms of reforming the healthcare services in the country. Crucial role in the fight against smoking play medical professionals from primary care GPs do not develop sufficient activity and are not prepared enough in this area. They neither systematically assess the tobacco smoking nor control it as a risk factor. 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 18. Guide to good practice for healthcare professionals on the evaluation and control of the risk in smokers • • Prepared with the support of Operational Program “Human Resources Development” financed by the Europe Social Fund of the EU, issued in Bulgaria in 2013, presents the needed actions for smoking cessation programs in the health care settings and will serve as a tool in that direction. The guide aims to assist medical professionals in their activities focused both on preventing smoking among the population and to effective interventions for its cessation among smokers. 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 19. 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 20. Types of interventions, implementation in healthcare systems    Brief interventions by health professionals in the context of their routine activities; Intensive support provided by professionals directly involved in the treatment of tobacco dependence in specialized laboratories for quitting; Pharmacological support of the change. 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 21. Steps in the approach to smoking cessation     Step 1: Health education and general information to enhance motivation for quitting. Major effect on light smokers. Step 2: Brief advice from a health professional to quit smoking. Major effect on light smokers. Step 3: Advice, nicotine replacement, follow-up by a specialist. Suitable for moderately motivated and medium dependence smokers. Step 4: Specialized counseling rooms and agencies working with group sessions. Provide assistance to high-dependent smokers. 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 22. Algorithm of the organization of medical care for patients-smokers smoking yes no passive Primary Health Care – General practitioners, Specialized health care yes NCD risk assessment no brief intervention strategy- 5 A Desire for quitting no Not sure Specialized rooms for smoking cessation yes Intensive counseling Treatment programs Motivational counseling 5 R Monitoring and surveillance 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 23. Brief intervention strategy At this stage, the health care professional advises and informs the patient about the dangers of smoking on health – “quick consultation” or “brief intervention strategy” 5 A – Ask, Advise, Assess, Assist, and Arrange. This method is used as a guide for the physician and the duration is for no more than 5 minutes. 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 24. Individual behavioral counseling     These are more intensive interventions by medical professionals who take more than 10 minutes. The choice of tactics in therapy depends on the type of behavior of the patient and the mode of his/her psychological readiness and level of motivation for smoking cessation. Most patients go through different stages in the process of quitting. In each of them smokers have their individual characteristics and needs that must be considered by the medical specialist in the choice of strategy. For those who are not yet ready to make their experience, the physician should direct its efforts towards motivating. 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 25. Motivational interview    Many patients do not feel ready to quit smoking. The reason for this behavior is the lack of awareness about the harmful effects of tobacco smoke on the body, the fear from the consequences of quitting smoking - stress, weight gain, withdrawal symptoms, failed previous attempts and others. Motivational counseling is a set of questions that medical specialist discusses with the patient to improve his knowledge about the effects of smoking on health and readiness to quit smoking – the system of 5 R - Relevance, Risks, Rewards, Roadblocks, and Repetition. 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 26. Conclusions   The problem with smoking prevention and diseases that arise from it is an important task of primary healthcare. Early detection, prevention and treatment of tobacco smoking and dependence needs to be part of the programs for the prevention of chronic non-communicable diseases (NCD), and to be integrated into primary health care in the healthcare system. 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 27. Conclusions     Smoking cessation programs require long and systematic intervention and control. Support and assistance to patients to quit smoking is related to how physicians perceive their role in this process. They must not only possess the necessary knowledge and skills for intervention, but also to apply skills for advice and support in their clinical practice and for this to be routinely included in the scope of primary care. Health care professionals needs training for consultation and support to smokers and help overcome smoking 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland
  • 28. Conclusions   The guidance “Guide to good practice for healthcare professionals on the evaluation and control of the risk in smokers” will be used in primary health care settings for the purposes of smoking cessation programs. The effectiveness of the implemented approaches and methods of quitting will be evaluated on regular basis. The guide will be useful not only for a better understanding of the problem, but with the proposed schemes and solutions successfully used in many countries of the world, will help reduce smoking among the Bulgarian population in the future. 2nd GRF One Health Summit 2013 17-20 November, Davos, Switzerland