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Challenges to Tobacco Dependence Treatment in Europe -- Hayden McRobbie, M.B., Ch.B., Ph.D.
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Challenges to Tobacco Dependence Treatment in Europe -- Hayden McRobbie, M.B., Ch.B., Ph.D.

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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.

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.

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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!

Challenges to Tobacco Dependence Treatment in Europe -- Hayden McRobbie, M.B., Ch.B., Ph.D. Challenges to Tobacco Dependence Treatment in Europe -- Hayden McRobbie, M.B., Ch.B., Ph.D. Presentation Transcript

  • Europe Tobacco Dependence Treatment Hayden McRobbie MB ChB PhD Wolfson Institute of Preventive Medicine, Queen Mary University of LondonFaculty of Health & Environmental Sciences, Auckland University of Technology Inspiring Limited
  • Male smoking prevalence World Health Organization. The Tobacco Atlas. http://www.who.int/tobacco/statistics/tobacco_atlas/en
  • Europe on the Tobacco Control Scale
  • Treatment to help dependent smokers stop Item Score /10 Recording of smoking status in medical notesLegal 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
  • Tobacco Treatment ScoresCountry Treatment Score Country Treatment ScoreUK 9 Italy 5Denmark 7 Portugal 5Romania 7 Hungary 5Poland 7 Finland 4Luxembourg 7 Spain 4Ireland 6 Cyprus 4France 6 Germany 4Malta 6 Czech Republic 4Sweden 6 Austria 4Belgium 6 Turkey 3Switzerland 6 Lithuania 3Netherlands 6 Greece 3Slovenia 6 Iceland 2Estonia 6 Bulgaria 2Slovakia 6 Latvia 0Norway 5
  • Challenges Lack of routine brief interventions Lack of systems to help HCPs to deliver brief interventions and referral Lack of reimbursement
  • CASE STUDIES
  • Belgium ~350 "tobaccologists" trained for at least 1 year in smoking cessation • Majority of them work within CAF (Centre dAide 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
  • 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/pregnancyWith thanks to Professor Ivan Berlin
  • 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 SpanishWith thanks to Professor Carlos Jimenez-Ruiz 1
  • 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 receiveWith thanks to Dr Tobias Raupach 1
  • 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
  • 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
  • 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
  • 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 1
  • Addressing the BasicsMy 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 1
  • Western PacificTobacco Dependence Treatment 1
  • The Western Pacific Large geographical area Many different cultures and languages Vastly different levels of tobacco control 1
  • 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 actionAbdullah & Husten Thorax 2004;59:623–630 1
  • Pacific Smoking Prevalence Males FemalesRasanathan &TukuitongaJournal of the New Zealand Medical Association, 12-October-2007, Vol 120 No 1263 2
  • 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
  • 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% smokersGroth-Marnat et al (1996) Soc. Sci. Med 43(4) 473-477 2
  • 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 villageGroth-Marnat et al (1996) Soc. Sci. Med 43(4) 473-477 2
  • 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 commitmentGroth-Marnat et al (1996) Soc. Sci. Med 43(4) 473-477 2
  • 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 trackGroth-Marnat et al (1996) Soc. Sci. Med 43(4) 473-477 2
  • 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
  • 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 smokersThe RACGP, Supporting smoking cessation: a guide for health professionals 2
  • Smokefree Aotearoa 2025 2
  • 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
  • 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
  • 3
  • 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
  • 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 3
  • WAYS FORWARD?Email me hayden.mcrobbie@inspiringlimited.com 3