Which countries have tobacco dependence treatment guidelines

A survey of tobacco dependence treatment guidelines and systems in 45 countries Martin Raw 1, 2 and Catherine Slevin 2 1 Freelance consultant; Special Lecturer; Manage2 Division of Epidemiology and Public Health, University of Nottingham, England Sao Paulo and Nottingham Friday 7 December 2007 Contents
1 Key messages.3
2 Introduction.5
3 Methods.74 Results of guidelines survey.95 Results of treatment survey.186 Summary of results.307 Discussion and conclusions.358 Recommendations.379 Acknowledgements.3810 References.3911 Appendices.40 Appendix 1. Copies of original national guidelines.41Appendix 2 The guidelines questionnaire.42Appendix 3 The questionnaire for countries without guidelines.44Appendix 4 The treatment questionnaire.45 1 Key messages
This report presents the results of two surveys, in 45 countries in all, of tobacco dependence
treatment guidelines, and of treatment for dependent smokers. The overall conclusion of the
study is that treatment is not a high priority in many countries and that most smokers,
probably a large majority in most countries, do not have easy access to smoking
cessation support or medications. It further revealed the need for technical support: many
countries need help to develop treatment guidelines and systems.
Article 14 of the Framework Convention on Tobacco Control states that ‘each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence.' We summarise here the key messages from the results of these surveys, which show that Article 14 is very far away indeed from being implemented in many countries. The key findings are followed by our recommendations.
The good news / positive findings
• All the guidelines surveyed seem to be broadly evidence based • Almost all used the Cochrane database as a source • Over half are based on another country's guidelines, especially those from the US and • Most guidelines are for the whole healthcare system, are national, have broad support from medical and professional societies, and three quarters are formally supported by government • Two thirds of countries have quitlines with national coverage • Almost all quitlines (over 90%) have people answering (as opposed to mainly recorded messages), but only 42% offer multiple sessions with call back counselling, the approach for which the scientific evidence is strongest • The commonly available medications are nicotine gum, nicotine patch, bupropion, and • Most countries allow the sale of nicotine gum and patches through pharmacies The not so good news / opportunities for improvement
• Most of the countries that do not have guidelines expressed a need for technical expertise and/or financial support • Only half of countries have an official written policy on treatment or a government official responsible for treatment • Very few countries have a treatment system with national coverage • Only a quarter of countries say help is easily available in general practice • Almost no countries say help is easily available in work places or community based • No countries report help being easily available in schools and prisons.
• Very few countries permit stop smoking medications on general sale • In most countries only bupropion and varenicline are available on a doctor's • Few countries fully reimburse any of the medications • Fewer than half of countries reimburse brief advice/support and fewer than one third intensive specialist support • Taken together, the vast majority of GPs, primary care nurses and pharmacists are neither reimbursed for helping smokers stop, nor is it within their normal work contract.
1. Appoint an official lead on tobacco dependence treatment.
2. Develop a national policy on treatment.
3. Develop comprehensive, national, evidence based treatment guidelines endorsed by prestigious national health professional organizations.
4. Fund a national quitline answered by trained counsellors, with multiple sessions of 5. As soon as possible develop an intensive, specialised treatment service as part of the national healthcare system.
6. Make all stop smoking medications as widely available as possible, and make them as cheap as possible to tobacco users.
To the Conference of the Parties:
7. Develop guidelines to help countries interpret "adequate treatment for tobacco dependence treatment." 8. Develop a template to show countries what would be ideal treatment provision and what measures they might prioritize if they have limited resources.
9. Provide technical support for countries to help them develop evidence based guidelines and develop and implement effective treatment policies.
The FCTC recognizes the addictive nature of tobacco use as well as the role of smoking cessation and tobacco dependence treatment: " - - - - cigarettes and some other products containing tobacco are highly engineered so as to create and maintain dependence - - - - - many of the compounds they contain and the smoke they produce are pharmacologically active - - - - - tobacco dependence is separately classified as a disorder in major international classifications of diseases" (1).
Article 14 of the FCTC states that countries shall develop evidence based treatment guidelines and take effective measures to promote adequate treatment for tobacco dependence. (1) Article 14
Demand reduction measures concerning tobacco dependence and cessation
1) Each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence. 2) Towards this end, each Party shall endeavour to: a) design and implement effective programmes aimed at promoting the cessation of tobacco use, in such locations as educational institutions, health care facilities, workplaces and sporting environments;b) include diagnosis and treatment of tobacco dependence and counselling services on cessation of tobacco use in national health and education programmes, plans and strategies, with the participation of health workers, community workers and social workers as appropriate; c) establish in health care facilities and rehabilitation centres programmes for diagnosing, counselling, preventing and treating tobacco dependence; and d) collaborate with other Parties to facilitate accessibility and affordability for treatment of tobacco dependence including pharmaceutical products pursuant to Article 22. Such products and their constituents may include medicines, products used to administer medicines and diagnostics when appropriate.
Although most tobacco control measures, including smoke-free environments, tax and price increases, advertising bans, large warning labels, and information campaigns increase the number of smokers wanting to stop, and trying to stop, only a small proportion of smokers manage to stop smoking unaided (2), and tobacco use is recognized as an addiction by both the World Health Organization and the American Psychiatric Association (2). Tobacco dependence treatment to help smokers to quit, including increased access to medications, has been identified as one of six effective tobacco control interventions by the World Bank, and is strongly supported by scientific evidence (3,4). The spontaneous cessation rate is reported in the Royal College of Physicians of London report to be between about 1% and 3%, but abstinence rates among smokers who receive treatment reach around 20% for intensive support plus medications (2). Treating dependent smokers is also one of the most cost effective medical interventions in producing population health gain (5).
This report presents the results of two surveys. In the first survey we sent a questionnaire to countries which told us they have tobacco dependence treatment guidelines, to learn more about the guidelines: how they came about, their content, impact, and so on. In the second survey we sent a second questionnaire to these countries plus several others asking about their tobacco dependence treatment systems. As our original enquiries identified a few countries that do not have guidelines but are planning them, we sent a short, supplementary questionnaire to them asking about their plans.
The purpose of this study is to establish the state of treatment in these countries, and by doing so get an idea of progress in implementing Article 14. We hope to continue these surveys at regular intervals, to monitor development of tobacco dependence treatment and assess needs - what do countries need in order to be able to progress in introducing evidence based treatment? A note on terminology
Because there is potential confusion over use of the terms smoking cessation and tobacco dependence treatment, this chapter uses the definition of treatment from the World Health Organization's European guidelines: "Tobacco dependence treatment includes (singly or in combination) behavioural and pharmacological interventions such as brief advice and counselling, intensive support, and administration of pharmaceuticals, that contribute to reducing or overcoming tobacco dependence in individuals and in the population as a whole" (6). The term smoking cessation includes all cessation, whether it occurs as a result of broader tobacco control measures or individual support of dependent smokers through treatment. Tobacco dependence treatment is the narrower activity of helping and supporting tobacco users overcome their dependence on nicotine. For the sake of brevity, the term smoking, where used, should be taken to include all tobacco use.
3 Methods
In October 2005 MR conducted an informal survey through the SRNT and Globalink listserves asking to hear from countries with tobacco dependence treatment guidelines. Countries were later added to this list from the 2007 FCA Monitor survey, conducted in early 2007 with 27 of the 41 countries that first ratified the FCTC. The first 41 countries that ratified the Framework Convention were: Armenia, Australia, Bangladesh, Bhutan, Brunei Darussalam, Canada, Cook Islands, Fiji, France, Ghana, Hungary, Iceland, India, Japan, Jordan, Kenya, Madagascar, Maldives, Malta, Mauritius, Mexico, Mongolia, Myanmar, Nauru, New Zealand, Norway, Pakistan, Palau, Panama, Peru, Qatar, San Marino, Seychelles, Singapore, Slovakia, Solomon Islands, Sri Lanka, Syrian Arab Republic, Trinidad & Tobago, Thailand, Uruguay. Twenty seven of these 41 countries participated in the 2007 FCA Monitor survey (7), and these are listed in Table 1.
Table 1. The 27 countries of the FCA Monitor survey
01
Armenia (Europe, LMI) 15 Mexico (Americas, UMI) Australia (Western Pacific, HI) 16 Mongolia (Western Pacific, LI) Bangladesh (South East Asia, LI) 17 New Zealand (Western Pacific, HI) Canada (Americas, HI) 18 Norway (Europe, HI) Fiji (Western Pacific, LMI) Pakistan (Eastern Mediterranean, LI) Ghana (Africa, LI) Palau (Western Pacific, UMI) Hungary (Europe, UMI) Panama (Americas, UMI) Iceland (Europe, HI) 22 India (South East Asia, LI) 23 Slovakia (Europe, UMI) Japan (Western Pacific, HI) 24 Sri Lanka (South East Asia, LMI) Jordan (Eastern Mediterranean, LMI) 25 Thailand (South East Asia, LMI) Kenya (Africa, LI) Trinidad & Tobago (Americas, UMI) Madagascar (Africa, LI) 27 Uruguay (Americas, UMI) Mauritius (Africa, UMI) In brackets: the country's WHO region and World Bank income level: LI = low-income economy, LMI = lower-middle-income, UMI = upper-middle-income, HI = high-income (7).
The 2005 informal listserve enquiry was repeated in June 2007. Through these enquiries we compiled a total sample of 31 countries which informants told us have treatment guidelines, and which returned our guidelines questionnaire (Table 2). The people who filled in the questionnaires were those who responded to the listserve enquiries, or people recommended by them, and contacts identified from the FCA Monitor survey. Most contacts work outside government, a few inside. In July 2007 the 31 countries with guidelines were sent a questionnaire about their treatment systems. We received replies from 29. The listserve enquiries and FCA Monitor sample revealed 14 countries that do not have treatment guidelines and so we sent a short, supplementary questionnaire to these 14 countries asking if they had any plans to produce guidelines (Table 3). Finally, this informal contact with non-guidelines countries resulted in 7 also filling in our treatment questionnaire. Thus data on treatment services were collected from 36 countries in all (Table 4), with formal data collection ending in early October 2007. It is important to understand that this is not a representative sample. This is a qualitative study which had as its starting point informal listserve enquiries, and then added to that sample a sample of the 41 countries that originally ratified the FCTC. It is also important to remember that our results are depend on the contacts, who kindly helped us by filling in the questionnaires. Some are treatment specialists, some are not, some work in government, most do not. It is of course possible that there could be plans or developments in their country that they were not told about or for some other reason were unaware of. We did not have the resources in this study to explore and clarify the data further, in partnership with our contacts, something we would like to do in the future. If any readers discover information in this report that is out-of-date, or know of new developments, we ask them to get in touch and tell us Table 2. Responses from countries with guidelines (31)
Argentina
Russian Federation Table 3. Responses from countries without guidelines (14)
Armenia (no) Ghana (yes) Mauritius (yes) Romania (yes)
Bangladesh (no) India (no) Pakistan (yes) Uruguay (yes)
Canada (yes) Jordan (yes) Palau (no)
Fiji (yes) Kenya (yes) Peru (yes)
Note: we have indicated if the country is planning guidelines Table 4. Countries which returned the treatment services questionnaire (36)
Argentina
Russian Federation In summary, the two main samples are 31 for the guidelines survey and 36 for the treatment services survey. In presenting the results, and to keep the tables as simple and clear as possible, if a country did not answer a particular question, or we were unable to understand the answer, we simply left it out of that table. The results are presented in two mains sections: the guidelines results (section 3) then the treatment results (section 4), each section presenting questionnaire responses question by question. The questionnaires are in the Appendices.
4 Results of guidelines survey
Do the guidelines recommend evidence based interventions?
Question 1. Do the guidelines recommend these three evidence based interventions? Brief Interventions? Intensive behavioural support? Medications? All 31 countries reported that their guidelines recommend brief interventions, intensive behavioural support and medications.
Medications recommended by guidelines
Question 2. Which medications do the guidelines recommend? All guidelines recommend NRT (mostly unspecified but some specified gum and patch only, some all NRTs), and almost all bupropion. Many of these guidelines were written before varenicline came onto the market, which is why varenicline does not feature in many of the guidelines. This can be seen from the treatment survey results, which show varenicline to be much more widely available now.
Table 5. Medications recommended by guidelines
Country
First line NRT, bupropion, second line nortriptyline, clonidine NRT, bupropion, nortriptyline, Fluoxetin, Venflaxin, Moclobemid, Doxepin NRT, bupropion, nortryptiline, clonidine NRT patch, NRT gum, bupropion All NRTs, bupropion NRT, Bupropion, varenicline, nortriptyline All NRTs, bupropion, clonidine, nortriptyline NRT, bupropion, varenicline NRTgum, NRT patch NRT gum, patch, sublingual tablet, inhaler, nasal spray NRT, bupropion, nortriptyline All NRTs, bupropion, varenicline, nortriptyline NRT, bupropion, varenicline Russian Fed.
NRT, bupropion, varenicline NRT, bupropion, varenicline NRT gum, NRT patch, bupropion NRT, bupropion.
NRT, bupropion, varenicline All NRTs, bupropion first line, nortriptyline, clonidine second line.
Other interventions recommended by the guidelines
Question 3. If the guidelines recommend any other interventions (e.g. hypnosis, acupuncture, laser therapy, etc) please list them.
The other interventions most frequently mentioned were quitlines, self-help booklets and
books. Some countries said that their guidelines mention interventions not proved to be
effectice, including hypnosis, acupuncture, laser therapy, electro-stimulation, herbal and
homoeopathic products. One country stated: "The guidelines mention acupuncture,
hypnotherapy and aversive therapy as possible alternatives, but state that further scientific
evidence is needed to prove their effectiveness in smoking cessation." No country in this
survey actually recommends an intervention not supported by the evidence, although the
above reference to acupuncture and hypnotherapy seems potentially quite confusing.
Sources the guidelines drew on
Question 5. Do the guidelines explicitly refer to or reference the Cochrane database?Question 6. Are the guidelines based on another country's guidelines? If so which country? Of the 30 countries that answered these two questions, 25 reference or explicitly refer to the Cochrane database.
Of the 17 countries who said that their guidelines are based on those of another country, 7 are based the US guidelines, 1 on the English guidelines and 4 on the US and English guidelines. The others were: France – US, English, Australian, New Zealand and European; Kyrgyzstan – Russian; Malaysia – US and New Zealand; Russian Federation – England, US and others; Italy – various. Thus more than half of the countries used guidelines from another country as a starting point.
Are the guidelines for the whole healthcare system?
Question 4. Are the guidelines for the whole healthcare system and for all professionals? Twenty countries out of 28 that answered the first part of this question said that they are for the whole healthcare system, 5 said they are for primary healthcare and hospitals only, 2 for primary care only and 1 for hospitals only. Twenty two countries of the 28 that answered the second part of this question said that they are for all health professionals. The other answers were: GPs only 2; doctors and GPs 2; GPs and nurses 1; doctors, GPs, pharmacists and dentists 1.
Are the guidelines national or more local?
Question 7. Are the guidelines national? regional? more local?Question 8. If you guidelines are national can you define national (for example, produced or funded by the national government or government agency, written for the whole healthcare system and for the entire country, endorsed by prestigious national professional bodies) All 31 respondents said that their guidelines are national, not regional or more local. This question was followed by a question asking them to define ‘national'. The answers are presented in Table 6.
Table 6. Definition of "national"
Country
Government agency and endorsed by more than 20 medical associations Funded by the Commonwealth Government; endorsed by a number of national and state-based bodies Written as consensus by the Austrian Society of Pneumology Written and funded by national agency, written for the entire public health system, endorsed by professionals who work with tobacco addiction Funded by the Chilean Health Ministry 19 medical associations Funded solely by the Health Education Authority, a national government agency, endorsed by all the key national professional associations, launched by the health minister.
All National guidelines are made by the Finnsih Medical Society, Duodecim, with financial support from the Ministry of Social Affairs and Health.
Produced or funded by the national government or government agency, written for the whole healthcare system and for the entire country, endorsed by recognized health authorities and national professional bodies Approved by Association of the Scientific Medical Societies, funded by a number of medical societies.
Published by the Ministry of Health, endorsed by professional organisations.
They were produced by the national government, written for specialists, endorsed by prestigious national professional esperts.
Funded by the national government for the entire country.
National in this case means that the guidelines have been compiled by the international project experts (Kyrgyz-Finnish Lung Health Programme), reviewed by the Ministry of Health, recommended by this agency for the countrywide use by target professionals and they are being used for the countrywide training of family doctors and nurses.
Produced or funded by the national government or government agency, written for the whole healthcare system and for the entire country, endorsed by prestigious national professional bodies. All of these.
They were written by professionals from the Mexican National Institutes of Health.
Developed and approved government organization and implemented by the State organizations Funded by the ministry of health through funding the partnership on smoking cessation project (a platform of 25 organisations in health care (public and private) concerned with smoking and cessation). Produced under supervision of the Dutch Institute for Healthcare Improvement. They invited 20 research and medical scientific organisations to develop the guideline. Written for the whole healthcare system. Endorsed by all participating organisations.
Funded by the NZ Ministry of Health for the whole country and healthcare system and endorsed by more than 20 professional bodies.
The guidelines are produced and funded by the government agency, the Directorate for Health and Social Affairs.
Produced by prestigious national professional bodies and national government institution (Caja de Seguro Social) 1. written and endorsed by prestigious national professional individuals and bodies, 2. referred to the whole healthcare system, 3. published as a special edition of medical journal distributed all over the country Designed by academic centre to distribute through the entire healthcare system.
Russian Fed.
Written for the whole healthcare system and for the entire country Written for the whole healthcare system and for the entire country, endorsed by prestigious national professional bodies Written for the whole healthcare system and for the entire country, endorsed by prestigious national professional bodies Endorsed by prestigious national professional bodies.
Funded by the government and for the whole health care system US Public Health Service Are the guidelines formally endorsed by national government?
Question 9. Are they formally endorsed or supported by national government? If yes what form does this endorsement/support take? Of the 30 countries that answered this question 22 (73%) reported that the guidelines are formally endorsed or supported by national government and 8 that they are not.
Were the guidelines peer reviewed?
Question 10. Did the guidelines go through any kind of peer review process? If so please briefly describe process.
Twenty eight countries answered this question of which 27 described a revew process and only one said the guidelines were not peer reviewed at all. Many guidelines went through a fairly rigorous and demanding multi-stage review process, and many involved medical and health organisations in this process. However the nature of the review process varied quite a lot. The comments presented in Table 7 give an indication of the processes.
Table 7. Selected comments on the review processes the guidelines underwent
Nineteen medical associations sent comments
The guidelines were reviewed by experts in the field and revised in the light of their
feedback, then reviewed by the professional organisations who endorsed them and
revised in the light of their feedback, then reviewed by Thorax reviewers and revised
in the light of their feedback, and then the summary version published in the BMJ
went through its own peer review.
Professional organisations (chest physicians', cardiologists' organisations),
professional colleges and public health professionals at the Semmelweis Medical
University reviewed the document.
Written by a pool of specialists, and revised by selected experts.
This review is done by two external reviewers that the Ministry assigns.
They are published in a peer reviewed journal.
The 21 participating organisations were divided into 3 working groups (one on brief
interventions, one on pharmacology, one on intensive interventions) who each wrote a
part of the guideline. The total group agreed in a meeting upon the complete
guideline. This concept version was publicly published on the site of the CBO, were
anyone could comment on it (incl. pharma companies): the consultation round. Some
participating scientific organisations discussed the guideline in a committee or annual
meeting. All organisations formally endorsed the guideline
The guideline was reviewed by leading medical associations.
It was reviewed by teachers from Faculty of Medicine
Reviewed by the modified Delphi Method
Funding and publication
Question 11. Who funded the guidelines?Question 12. Where are the guidelines published? Twenty eight countries answered the first question, just over half (57%) reporting government funding. The results are summarised in Table 8. Guidelines are published in a variety of places including peer review scientific journals (including special supplements), on websites, including government websites, in official government journals and in booklets. One country reported that their guidelines were funded by the pharmaceutical industry.
Table 8. Sources of funding
Government bodies
Medical and academic societies or programmes 5Private publishing house Pharmaceutical industry Question 13. Was any one individual, group of individuals, or organisation, primarily responsible for leading the process that led to your guidelines? The edited responses of the countries who answered are presented in Table 9.
Table 9. People and organisations responsible for the guidelines process
Argentina
Two coordinators and a panel of 20 experts from different health care organizations.
Professor Nick Zwar, School of Public Health and Community Medicine, University of New South Wales; Professor Robyn Richmond, School of Public Health and Community Medicine, University of New South Wales; Dr Ron Borland, VicHealth Centre for Tobacco Control, The Cancer Council Victoria; Suzanne Stillman, Quit Victoria, The Cancer Council Victoria; Margaret Cunningham, General Practice Education Australia; Dr John Litt, Department of General Practice, Flinders University.
Alfred Lichtenschopf was chair of the working party 'Tobacco Prevention and Restriction' by the Austrian Society of Pneumology Inca - Instituto Nacional do Câncer.
Marisol Acuña, Tobacco Control Assesor for the Chilean Health Ministry Working Group for Prevention and Treatment of Tob Dependence Martin Raw was commissioned by the HEA; the project was then led by Martin Raw, managed by Ann McNeill, and the scientific evidence review led by Robert West, so it had three leaders, all very experienced. The review group included world experts on treatment, and a key department of health official was involved in ‘incorporating' the guidelines into the government White Paper, being written at the time.
Medical Society Duodecim since 1994 Process of guidelines started with first French guidelines in 1998 – Société de tabacologie – scientific organisation on smoking cessation/ few individuals/ Paris Hospital - Hospital and medical accreditation authority. Several other guidelines for different public and collected reviews by INSERM have been conducted ( pregnant women hopitalized patients, university students).
Batra, Lindinger and Schütz and the societies named in funding answer.
Professional College of Chest Physicians, Dr Gábor Kovács and Dr Imre Vadász.
Professor Hisayoshi Fujiwara ( Cardiologist Director, Japanese Society of Circulation, Director, Japanese Society for Tobacco Control) was one individual who is responsible for the guideline.
The staff of the following organizations were in charge: Kyrgyz-Russian Slavic University, Department of Internal Diseases; Kyrgyz-Finnish Lung Health Programme; Public Association "Lung Health" (former Kyrgyz Asthma Centre).
Initiative of the Tobacco Control Unit, MOH Malaysia, where team members were then identified, consisting of psychiatrist, physicians, pharmacists, paediatrician, gynaecologist, epidemiologists & experts in areas of clinical, public health & research. They represent relevant sections within the MOH & other government agencies, selected academic institutions and professional NGOs.
They made a "consensus" among "the majority" of the National Institutes of Health and "other institutions" like the National Social Security Institute, the Youth Integration Centers, and "some private institutions" like Lomas Altas Clinic.
Officer in charge of medical technology and standardization and officer in charge of mental health issues.
The guideline is written by representations of the 21 scientific and research organisations. There was a chairperson in each working group, including one advisor from the CBO in each working group. Overall a professor in GP was chair of the whole process.
Clinical Trials Research Unit, University of Auckland led a consortium of agencies (National Heart Foundation, National Addiction Centre, Auckland Tobacco Control Research Centre).
Directorate for Health and Social Affairs, Department Tobacco Control The mental health program Prof. Witold Zatonski, Cancer Centre and Institute of Oncology.
NHS Health Scotland (formally Health Education Board for Scotland) and ASH Scotland In years 2002, 2004, 2005 Dr Kavcova with group of co-authors. In 2006 Dr Kavcova and Dr. Ondrejka. In 2007 Dr Ochaba, Dr. Kavcova and a group of collaborators Institute of Public Health of Slovenia, CINDI Slovenia Spanish Respiratory Society, Spanish GP Societies, and Spanish Specialists on Smoking Working group: Dr Jacques Cornuz, Dr Jean-Paul Humair and Dr Jean-Pierre Zellweger Task force appointed by DHHS Did the guidelines include cost effectiveness evidence?
Question 14. Do your guidelines include evidence on cost efectiveness? All 31 countries answered this question, of which 15 (48%) said they included cost effectiveness evidence and 16 did not.
Professional endorsement and impact of guidelines on policy
Question 15. Can you please list the professional organisations that have formally endorsed the guidelines?Question 16. Please give any information you can about the impact your guidelines have had on treatment policy in your country? We asked informants to list the professional organisations that formally endorsed the guidelines. We will not list here what would be an enormously long list of organisations. We asked for this information to get an impression of how extensive the endorsement process was, our hypothesis being that formal endorsement by prestigious professional organisations, especially medical and health organisations, will give the guidelines credibility and authority, which would in turn make them much more likely to influence policy. Unfortunately there is no way of confirming this hypothesis just from this survey, but it is clear from the lists of endorsers, that in many countries the guideline authors made a great effort to ensure broad support for the guidelines. Establishing the relationship between this support and the impact of the guidelines would be a worthwhile project. We asked for informal impressions of the impact the guidelines have had on policy and present in Table 10 selected, edited comments on this impact. Broadly speaking, the comments suggest that in many countries guidelines have had a significant impact on policy.
Table 10. Impact of guidelines on policy
Argentina
Guidelines impact has not been measured but there is plenty of evidence that support their value. Eg. Tobacco educational agenda has been included in most of the national scientific societies meetings and national guidelines are referred guide. A national educational meeting provided a recommendation on tobacco related issues based on the national guidelines. Guidelines had been included in most in medical curriculum of medical schools in Argentina. Smoking cessation training programmes are available in different cities and supported by government, university and scientific societies. Smoking cessation programmes have been developed in many social security health care systems and guidelines are reported as the standard of care. Smoking cessation programmes are available in many public hospitals although most do not provide free of charge medication.
Increase in fax referrals to Quitline. No other information available at this time They led fairly directly, working with a key government official as described above, to the creation of a national treatment service for smokers. The political climate at the time was supportive of this and highly relevant to what happened.
Difficult to be precise on impact of guidelines, but they serve as a basis to reinforce the cessation infrastructure already relatively well developed in France (at least one cessation clinic for each ‘department', hospitals offering cessation and free NRT to hospitalized patients, good access to OTC medications, although steps to reimbursement still needed This guidelines are being followed during the training of health professionals on smoking cessation.
Poor impact to date.
Distributed in hardcopy format to all State Health Departments for use in the MOH's Quit Clinics. Other clinical/ professional bodies in Malaysia are also encouraged to use this CPG None, we don't have any changes in the policies due to the guidelines publication.
Health care organisations work according to the guideline; some scientific health care organisations translated the guideline into protocols or standards for their own profession; Stivoro, the national tobacco control institute, developed interventions and provides telephone support according to the guideline. The guideline helps to convince the necessity of working with effective interventions in stead of not yet proven effective interventions. The ministry of health works according to the guidelines and effective interventions.
Significant impact on subsidised treatments, training content regarding evidence based treatments, and related competencies developed from guidelines The guideline has not been implemented well enough, so it is difficult to say whether it has influenced practice.
At this moment they have not yet been implemented The guideline was published in May 2007, so we cannot give any details about results so far.
Russian Fed.
The program envisages two main stages. At first stage a one-hour educational session will be provided for health professionals in clinics of Moscow and the Moscow region. This session aims to educate and motivate medical staff of clinics concerning smoking health hazards and tobacco control activities, and to outline the rationale for physician based smoking cessation assistance. At the second stage a one-day smoking cessation training course will be provided for physicians who want it. The purpose of the course is to teach and to train physicians for skilled professional work with patients and groups of patients concerning tobacco education, motivation to quit, smoking cessation assistance and tobacco dependence treatment GPs and nurses in PHC teams were educated and provide treatment in Primary Health Care centres all around the country 5 Results of treatment survey
Official written policy on treatment
Question 1. Does your country have an official written policy on tobacco dependence treatment? Yes, a written government stand-alone policy on treatment. Yes, a written government policy on treatment but which is part of an overall tobacco control policy. No. Question 2. If yes, what does the official government policy on tobacco dependence treatment include? Thirty five countries answered the first question, of whom 7 have a stand-alone policy on treatment (20%), 10 (29%) a policy which is part of a broader tobacco control policy, and 19 (54%) said they do not have an official policy (Table 11). Those that do have an official policy were asked what it includes (Table 12). Table 11. Official written policy on treatment
Country (n = 35)
Stand alone
Part of tob.
Russian Fed.
Table 12. Content of official policy
Country
A national funded A strategy to research strategy interventions by specialised Table 12 continued A policy on promoting Telephone quitlines Mandatory recording of patients' smoking pharmaceutical products status in medical notes Government official responsible for treatment services
Question 3. Is there an officially identified person in government (or contracted by the government) who oversees or manages tobacco dependence treatment services? Of 35 respondents 17 (49%) said that there is a person in charge of treatment services.
Question 4. Does your country have a telephone quitline (with a person answering, not just automated/recorded messages)? Yes, a well funded national quitline in all major regions of the country. Yes, but only a patchwork of small local lines. No, but we are planning one. No.
Twenty three out of 35 respondents (66%) said their quitline has national coverage while six countries (17%) do not have quitlines at all.
Table 13. Which countries have telephone quitlines
Country
National
Patchwork
planning one
Russian Fed.
If a country responded that they have a quitline they were asked if the quitline has or provides: a person answering (always or almost always); mostly recorded messages; a line toll free to callers; multiple sessions of counselling with active support (counsellors call back to offer ongoing support); referrals to local specialist treatment services; medications to help smokers stop. The results are presented in Table 14.
Table 14. Characteristics of quitlines (n = 26)
If yes, does the quitline have/provide:
A person answering (always or almost always) Mostly recorded messages A line toll free to callers Multiple support sessions, counsellors calling back to offer support Referrals to local specialist treatment services Medications to help callers stop Specialised treatment system
Question 6. Does your country have a specialised treatment system (experts or units/clinics)
offering individual or group support devlivered by trained professionals? Four answers: A
network of treatment support covering the whole country (ie. all smokers have access), A
network of treatment support but only in selected areas (for example cities), Limited treatment
support, not a national system, just a few centres, No network.
If there is a treatment system, please describe it.
Table 15. Characteristics of specialised treatment system (n = 33)
Network covering whole country
Only in selected areas Just a few centres Of the 33 respondents, few (21%) claim a genuinely national treatment system in which all smokers can get help, with most saying they have a network of support but only in selected areas. Only one country said they had no treatment support at all. We asked for a description of the treatment system and present the responses (minimally edited for style) in Table 16.
Table 16. Further descriptions of treatment systems
Brazil
Treatment centers that are part of the NHS are growing in numbers but still largely insufficient. There are complaints about lack of medication. During a recent meeting, some staff complained about political interference with provision of medication (medication provided to states controlled by political allies but not to adversaries of central government).
340 tobacco treatment units are located in hospitals, prevention departments and dependence services of national health care system. A 2005 survey by the Società Italiana di Tabaccologia (SITAB) in through 139 participating units showed remarkable differences in clinical approach and evaluations of smoker patients in many of them.
There is a network of family physicians and nurses trained on treatment of tobacco dependence, but mainly brief interventions, and a bit expanded interventions, as part of PAL training. About 3000 specialists were trained as one-day training in 5-days training course on PAL in 2004-2006 with Kyrgyz-Finnish Lung Health Programme.
The only treatments proposed are ‘Plan de Cinq Jours', a group therapy, and Tabac-Stop Center that are private initiatives. Some doctors can also help smokers who want to quit, but they do not advertise. There are some doctors that also use acupuncture to help quitters.
There are private Smoking Cessation Centres, and centres funded by the Ministry of Health, but there is no a specialised treatment system.
Out patient department of National Center for Mental Health, MOH provides treatment for smokers, but in the community we do not have any quit service None of the above actually describe the current system, which will probably be revamped somewhat in the next year. We have a network of Maori providers called Aukati Kai Paipa, but not in every centre. The quality is patchy. We have poor data on the activity of other trained providers and they are not well connected.
We are in the process of getting two nurses trained in nicotine cessation. We have a few counsellors who have had limited specific training in nicotine cessation. We are trying to build a reliable system for nicotine cessation delivery service.
Some public hospitals and PHC centres have specific treatment for nicotine dependence that is delivered by trained heath professionals. There is a long waiting list to be seen by these specialists. At hospital level pharmacological support is free.
There is a network of about 50 health professionals trained in smoking cessation and who offer treatment support. Beginning in September 2007 some of them are included in a pilot project of the Ministry of Health through which they offer free treatment to smokers and are also paid for consultation. Depending on the results, the system will be generalized.
It consists of the network of Regional Public Health Offices. These health workers cannot prescribe medications like Zyban and Champix. Prescription of these drugs are allowed only by MDs.
Ease with which smokers can get help
Question 10. Can smokers easily get help to stop smoking in the following settings?Settings: General/family practice, Hospital clinics, Work places, Pharmacists, Specialist clinics, Addiction services, Community based clinics, Dentists, Schools, Prisons, Telephone quitlines, Country/regional internet sites.
Table 17. Can smokers get help in these settings
Setting (n)
Not easily
General/family practice (35) Hospital clinics (33) Specialist clinics (32) Addiction services (33) Community based clinics (29) Telephone quitlines (34) Internet sites (32) Medications and reimbursement of treatment and health professionals' time
The final three questions in the treatment survey asked about the availability and licensing of medications, about reimbursement of tobacco dependence treatment, including behavioural support and medications, and about reimbursement of health professionals' time.
Question 7. Are the following medications: available in your country? how are they licensed? (general sale (eg. supermarkets), from pharmacies (over the counter), doctor's prescription) can they be advertised on television? Table 18 shows the number of countries that say that the listed medications are or are not available in that country. The only really commonly available medications are nicotine replacement therapy (NRT), in particular the gum and patch, bupropion and varenicline. Varenicline has become available quite quickly since its launch in the USA in 2006, however it is still quite recent so that in many countries it is unavailable not because it has been refused permission but because the application process is still underway. Just eight countries mentioned "other" medications (Table 19). The results on how the medications are licensed and if they can be advertised on television are presented in Table 20.
Table 18. Availability of medications
NRT (sublingual tablet) NRT (nasal spray) Table 19. Other medications
Country
Not in practice used for cessation Probably used in services when bupropion unavailable Amitryptiline, sertraline for depressant phase of withdrawal For anxiety phase of withdrawal Available from pharmacies and can be advertised on television Can be advertised on television. Not available from pharmacies or on doctor's prescription but no details given on how it is available.
Available on prescription by pharmacies, but not registered for smoking cessation in the Netherlands Available on doctor's prescription and can be advertised on television Russian Fed.
Available from pharmacies Table 20. Licensing of medications
NRT (sublingual tablet) NRT (nasal spray) Very few countries permit stop smoking medications on general sale (ie. available in any shop, for example supermarkets) and the few that do typically permit mainly nicotine gum and patches. A majority of countries allow the sale of nicotine gum and patches through pharmacies (called "over-the-counter" sales in some countries) but relatively few countries allow the sale of any of the other medications through pharmacies yet. Only bupropion and varenicline are available on a doctor's prescription in a majority of countries. Very few other medications available on prescription in many countries. Finally, only nicotine gum and patches can be advertised on television in a significant number of countries.
Question 8. Are the following interventions free of charge or fully reimbursed to users by the health care system or other third party payers (for example insurance comopanies)? Yes totally, Yes partially, No.
Table 21. Reimbursement of treatment
NRT (sublingual tablet) NRT (nasal spray) Brief advice and support Intensive specialist support Note: intensive specialist support was defined as only including support based on scientificevidence of effectiveness. Most countries in the survey do not reimburse any of the medications at all. Thus the general picture on reimbursement reflects the broader picture on implementation of adequate treatment provision: it is not available in most countries. In Table 22 we present edited comments people made about reimbursement.
Table 22. Further comments about reimbursement
Country
Varenicline is awaiting the announcement of a decision as to whether it will be partially covered by the Pharmaceutical Benefits Scheme in Australia. There are indicators that it will get such approval.
In Brazil, all treatment provided through public health system is free of charge.
Intensive specialist support is free for patients, but they have to pay for all medication. Some health insurance companies are starting to contribute a little bit.
People pay a fixed prescription charge but this is waived for those on low income; in effect, more that half of prescriptions in England are free.
The national insurance reimburses up to 50 euros/year/person cost of NRT and varenicline. More and more complementary insurance groups pick up the full cost of cessation treatment but this is not universal. Hospitalized patients have access to treatment free of charge while hospitalised.
Those who have medical insurance can claim but very few have it.
Behavioural support is given by specialized doctors and psychologist with group therapy in three steps (preparation, full immersion and maintenance), with 8-10 sessions. The access to open groups is optional.
The ‘Plan de Cinq Jours' organisers offer their service for free but there can be voluntary contributions from the quitters.
Advice from the GP or specialist is reimbursed, additional treatment is not always covered/reimbursed GPs will usually charge for brief advice but as part of a general consultation. Practice nurses are unlikely to charge for giving brief advice as a separate item of service. A few GPs and practice nurses have specialist cessation skills and charge for intensive support. Brief advice or intensive support in public hospitals is free of charge. Outside of the publicly funded health system, users generally pay.
If a person accesses a counsellor through the hospital, there will be a small charge. However, if a person accesses a counsellor through the tobacco program office or addiction facility, there is no charge.
Intensive specialist support is free of charge only in some regions and some clinics which have a contract with National Health Fund.
Russian Fed.
Intensive specialist support including motivation and behavioural support provided only in unitary services as usually for some expences Psychiatrists are paid by health insurance. Advice and treatment are free of charge for smokers. Smokers must pay for bupropion and varenicline and for NRT.
Medications are rarely reimbursed. A few insurance companies partially reimburse. It is difficult to give a simple answer about all of these. In general OTC medications are not covered by insurance companies (though with some exceptions). My sense is that spray and inhaler are generally not covered, but that varenicline has made progress in getting decent coverage (though usually with high co-pays) from insurers. The Medicare program does cover brief advice as well as the medications.
Question 9. Are the following health care providers reimbursed for smoking cessation support, or is smoking cessation support within their terms of services (contract) and part of their normal salary? Two answers: Reimbursed for providing cessation support, Yes/No or Cessation support within terms of service and part of normal salary, Yes/No.
Table 23. Reimbursement of health professionals' time
Profession
Within normal
General practitioners Nurses in general practice Addiction specialists Table 24. Further comments about reimbursement of health professionals' time
Country
Professionals in Brazilian public health system receive a fixed (and very low) salary. So if one gives any kind of treatment to smokers, it is considered part of the job. Private health insurance covers little of smoking treatment, coverage depending on the specific insurance contract. In the case private health insurance provides coverage for smoking cessation treatment, such treatment would be delivered by medical doctors. A few insurance plans may provide some discount on medication cost.
Of course this response depends partly on your definition of ‘support'. GPs are reimbursed for brief advice for ‘at risk' smokers. Some (a very small number) of GPs and practice nurses spend a small amount of their time providing cessation support for their patients and are reimbursed for this. The guidelines recommend that ALL health professionals opportunistically advise smokers to stop.
The 2004 public health law provides that GPs and possibly other health professionals deliver prevention consultations/acts . This is currently under discussion. With recent change of government, too early to say what will happen.
Nobody is specifically reimbursed. All is part of one's normal salary It is expected of any good health professional to advise their patient not to use tobacco.
No other professionals reimbursed for treating smokers.
Reimbursement is difficult: GPs receive €9 for a 10 minute consultation, in which they could give smoking cessation treatment. GPs however ask for a special tariff for smoking cessation as they need to see their patients more frequently than one consultation. Nurse practitioners in GP practice exist, but not 100% over the country, and the funding for these nurses to provide smoking cessation treatment is limited. So the answer is yes and no, but the situation we are in is not optimal. The same counts for some doctors and nurses in hospitals.
There is no specific funding for the provision of cessation support but there is an increasingly explicit expectation that this is part of good practice for all medical, dental, and nursing staff. Most pharmacists are community based, self-employed and not salaried.
Not all the above professionals are trained to deliver tobacco cessation services thus it is difficult to respond to the question. If they do have cessation skills, they would provide brief intervention and would not get extra reimbursement for it.
Reimbursement for providing cessation support for general practitioners is only provided in some regions where a contract with National Health Fund is available.
Providing cessation is part of the normal salary but there is no real indication from the MOH to provide such services. It is more up to individual motivation from clinicians to do it.
Many physicians are providing tobacco dependence treatment free of charge. Public health professionals provide consultation and NRT as part their salary.
Countries that do not have treatment guidelines
We mentioned in the introduction and methods that we conducted a supplementary survey of 14 countries we discovered do not have treatment guidelines. Included among the questions were: why they don't have guidelines, if they have any plans for guidelines, if they would be based on another country's guidelines and if they would find help useful. Ten of these countries are planning treatment guidelines and 4 are not. Of those not planning guidelines, lack of expertise and money were cited as reasons, while one simply stated that it was not a priority. Some of the countries planning guidelines also said they need financial support and expertise.
Apart from money, the kind of help asked for includes: "a comparative review of the existing national guidelines would be very useful, or participating in the international meeting on this issue"; "samples of treatment guidelines elsewhere"; "sharing of best practices so that implementation of the guidelines is successful"; "technical support"; "templates would be useful which we could review/adapt to meet our needs; treatment guideline samples would help us to know the essential elements of guidelines"; "some examples of how others countries developed their guides, do we need guidelines or a national consensus – these questions are delaying further advance." Finally, on the use of other countries' guidelines as a starting point most of these countries mentioned neighbour countries. Of these 14 countries, one is high income (according to the World Bank classification), 4 upper-middle income, and the remaining 9 lower-middle or low income. 6 Summary of results
Summary of guidelines results
Do the guidelines recommend evidence based interventions? Do any recommend
interventions that are not evidence based? Do the guidelines include cost effectiveness
evidence?
All reported that their guidelines recommend brief interventions, intensive behavioural support and medications. All recommend NRT and almost all bupropion (many of these guidelines were written before varenicline was available). No guidelines actually recommend an intervention not supported by the evidence, although one country said: "The guidelines mention acupuncture, hypnotherapy and aversive therapy as possible alternatives, but state that further scientific evidence is needed to prove their effectiveness in smoking cessation." Half include cost effectiveness evidence and half do not.
Sources the guidelines drew on
The vast majority (over 80%) reference or refer to the Cochrane database, and 57% said that their guidelines are based on those of another country. These source guidelines were mainly from the US and England although some used more ‘local' sources, for example Kyrgyzstan used the Russian guidelines and Malaysia used the New Zealand guidelines. The Russian Federation said that their guidelines draw on the English and US guidelines. Thus more than half of the countries used guidelines from another country as a starting point.
Are the guidelines for the whole healthcare system, national, and formally endoresed by
government?
The majority reported that their guidelines are for the whole healthcare system, and all health professionals, although a significant minority, about a quarter, said that they are not. All 31 respondents said their guidelines are national (as opposed to regional or more local), and three quarters said they are formally endorsed or supported by government (and a quarter that they are not).
Were the guidelines peer reviewed?
Twenty seven out 28 countries described a review process (only one said the guidelines were not peer reviewed at all) and many guidelines went through quite a rigorous and demanding review process, and many involved medical and health organisations in this process.
Funding and publication
Just over half reported government funding, and the guidelines are published in a variety of places including peer review scientific journals, on websites, in official government journals, and in booklets. One country reported that their guidelines were funded by the pharmaceutical industry.
Leadership, professional endorsement and impact
We asked who led the process of writing the guidelines, as well as for a list of the professional organisations that formally endorsed them, and comments on the impact the guidellines have had on policy. We asked for this information to get an impression of how important leadership was in the process, and how extensive the endorsement process was. We hypothesised that formal endorsement by prestigious professional organisations, especially medical and health organisations, would give the guidelines credibility and authority, which would in turn make them much more likely to influence policy. Although we cannot confirm the hypothesis just from this survey, it is clear that in many countries the guideline authors made a great effort to ensure broad support for the guidelines, especially from medical and professional societies, and our contacts' comments suggest that in many countries guidelines have had a significant impact on policy. It does also seem clear that in many cases key individuals or groups were responsible for leading the guidelines process, although establishing the relationship between these two key factors – leadership and professional endorsement – and policy impact, would require further investigation.
Summary of treatment results
Does country have an official treatment policy and a government official responsible for
treatment
Seventeen countries (49%) have an official written policy on treatment, 19 do not, and 17 (49%) said that there is a person officially in charge of treatment services.
Contents of official policy
Of the 7 policy components (a strategy on training, a funded national research strategy for cessation, a strategy to support interventions by primary care professionals, intensive support in specialised treatment facilities, a policy on promoting the use of pharmaceutical products, telephone quit lines, and mandatory recording of patients' smoking status in medical notes) no country has all components. Half (50%) have a training strategy, 44% a funded research strategy, 56% a primary care strategy, just 44% specialised treatment facilities, 56% a policy to promote medications, 75% have quitlines, and only 31% the mandatory recording of smoking status in medical notes. Twenty three out of 35 respondents (66%) said their quitline has national coverage while six
countries (17%) do not have quitlines at all. Thus of the 29 countries with quitlines 23 or 79%
are national or have national coverage. It is also interesting to note that although 75% of
countries in the survey have quitlines in their official written policy, 83% actually have
quitlines. We asked countries with quitlines if the quitline has or provides: a person answering
(always or almost always); mostly recorded messages; a line toll free to callers; multiple
sessions of counselling with active support (counsellors call back to offer ongoing support);
referrals to local specialist treatment services; medications to help smokers stop. The research
evidence suggests that quitlines offering multiple sessions with call back counselling are
effective (8). Almost all (92%) quitlines have a person answering (as opposed to mainly
recorded messages) but only 42% offer multiple sessions with call back counselling. Exactly
half offer a toll free line and 65% refer callers to local treatment services.
Specialised treatment system
Only one fifth of the countries have a national treatment system in which all smokers can get help, just 7 out of 33 or 21%, with most saying they have a network of support but only in selected areas. One country has no treatment support at all.
Accessibility of help
Article 14 emphasises accessiblity of help and the previous finding emphasises how very few countries so far have widespread treament services. We approached this issue from the smokers' perspective, by asking our informants how easily smokers can get help in various settings: general/family practice, hospital clinics, work places, pharmacists, specialist clinics, addiction services, community based clinics, dentists, schools, prisons, quitlines, country/regional internet sites. By far the highest scores were for quitlines (62% of countries said smokers can easily get help from quitlines) and the internet (47% of countries). Only 26% said help is easily available in general practice, 28% in specialised treatment clinics, 23% in pharmacists, 21% in hospital clinics and 18% in addiction services.
Almost no countries said help is easily available in work places or community based clinics, and none said help is easily available in schools and prisons.
Availability, licensing and advertising of medications
The final three questions in the treatment survey asked about the availability and licensing of medications, about reimbursement of tobacco dependence treatment, including behavioural support and medications, and about reimbursement of health professionals' time.
The only really commonly available medications are nicotine gum, nicotine patch, bupropion and varenicline. Varenicline has become available quite quickly since its launch in the USA in 2006. Nortryptiline is mentioned as available by 4 countries, cytisine by 5 and rimonabant by one (Mexico).
Very few countries permit stop smoking medications on general sale (ie. available in any shop, for example supermarkets) and the few that do typically permit mainly nicotine gum and patches. A majority of countries allow the sale of nicotine gum and patches through pharmacies (called "over-the-counter" sales in some countries) but relatively few countries allow the sale of other medications through pharmacies yet. Only bupropion and varenicline are available on a doctor's prescription in a majority of countries (they are not yet available on prescription in 8 countries).
Only nicotine gum and patches can be advertised on television in a significant number of countries.
Reimbursement of treatment
Most countries do not fully reimburse any of the medications. In almost half (43%) brief advice or support is free or fully reimbursed by the healthcare system but this is true for intensive specialised support in only 31% of countries. The general picture on reimbursement reflects the broader picture on implementation of adequate treatment provision: it is not available in most countries.
Reimbursement of health professionals
Finally we asked if health professionals are reimbursed for providing smoking cessation support, or if it considered a normal part of their job. In terms of accessibility the key professions are probably pharmacists, general practitioners and nurses in general practice. Just one country said that pharmacists are reimbursed and 8 that cessation support is considered a normal part of their job. For GPs the numbers are 7 and 13 and for primary care nurses 2 and 11. Although interpretation of these figures is complicated – for example putting smoking cessation support within the terms of a professional's contract does not necessarily mean it gets done – the figures are nevertheless disappointingly low. They show that taken together the vast majority of GPs, primary care nurses and pharmacists are neither reimbursed for helping smokers stop, nor is it within their normal work contract. These figures, even more than the figures on specialist treatment facilities, emphasise that for most smokers, probably a large majority in most countries, smoking cessation support and medications are quite inaccessible.
Key points from the results
The good news / positive findings
• All the guidelines seem to be broadly evidence based • Almost all used the Cochrane database as a source • Over half are based on another country's guidelines, especially those from the US and • Most guidelines are for the whole healthcare system, are national, have broad support from medical and professional societies, and three quarters are formally supported by government • Two thirds of countries have quitlines with national coverage • Almost all quitlines (over 90%) have people answering (as opposed to mainly recorded messages but only 42% offer multiple sessions with call back counselling, the approach for which the scientific evidence is strongest • The commonly available medications are nicotine gum, nicotine patch, bupropion, and • Most countries allow the sale of nicotine gum and patches through pharmacies The not so good news / opportunities for improvement
• Most of the countries that do not have guidelines expressed a need for technical expertise and/or financial support • Only half of countries have an official written policy on treatment or a government official responsible for treatment • Very few countries have a treatment system with national coverage • Only a quarter of countries say help is easily available in general practice • Almost no countries say help is easily available in work places or community based • No countries report help being easily available in schools and prisons.
• Very few countries permit stop smoking medications on general sale • In most countries only bupropion and varenicline are available on a doctor's • Few countries fully reimburse any of the medications • Fewer than half of countries reimburse brief advice/support and fewer than one third intensive specialist support • Taken together, the vast majority of GPs, primary care nurses and pharmacists are neither reimbursed for helping smokers stop, nor is it within their normal work contract.
7 Discussion and conclusions
It is encouraging that the guidelines surveyed seem to be broadly evidence based and interesting that almost all used the Cochrane database as a source, a strong endorsement both of the value of the Cochrane Centre tobacco reviews and of their reputation and influence. The fact that over half of the surveyed countries based their guidelines on those of another country is not entirely surprising, but it does show the value of shared experience, and it is notable that some of the countries that do not have guidelines highlighted their need of technical expertise and of examples of other guidelines to work from.
It is also encouraging that two thirds of countries surveyed have quitlines with national
coverage, however there is room for improvement here too, as only 42% offer multiple
sessions with call back counselling, the approach for which the evidence is strongest.
Obviously such an approach will cost more but even so quitlines are likely to be a relatively
cheap way of offering support, albeit minimal, to smokers. Because of the popular uptake of
mobile phones, quitlines will enable us to reach many people in low income countries that
have little access to face-to-face treatment services. One country in the survey has a quitline
with mainly recorded messages, for which there is no strong evidence of effectiveness. We
believe that scarce resources should not be spent on interventions for which there is no strong
evidence of effectiveness.
Only half of countries in our survey have an official written policy on treatment or a government official responsible for treatment, which reinforces the broad impression from this work that treatment is not yet a high priority in many countries. This conclusion is supported by many of our findings: very few countries have a treatment system with national coverage, only a quarter of countries say help is easily available in general practice, almost no countries say help is easily available in work places or community based clinics, no countries report help being easily available in schools and prisons, few countries permit stop smoking medications on general sale, in most countries only bupropion and varenicline are available on a doctor's prescription, few countries fully reimburse any of the medications, fewer than half of countries reimburse brief advice/support and fewer than one third intensive specialist support, and taken together, the vast majority of GPs, primary care nurses and pharmacists are neither reimbursed for helping smokers stop, nor is it within their normal work contract.
On the positive side nicotine gum, nicotine patch (but not the other NRTs), bupropion, and varenicline are widely available, and most countries allow the sale of nicotine gum and patches through pharmacies. However since few countries fully reimburse any of the medications of health professionals' time for giving smoking cessation support the real picture is that for most smokers in most countries, treatment is inaccessible.
It seems likely that treatment is a low priority at least partly because of its cost or perceived cost. This is especially likely to be true of the medications, but it is disappointing that brief advice and support is reimbursed in so few countries. Brief advice is an extremely cost effective intervention in producing population health gain (5) and is also an extremely cheap intervention. It ought to be part of routine health care in every country.
Leaving aside cost considerations for the moment, certain treatment provisions might be considered worthwhile.
Ideally a country should have: • A national telephone quitline with a person answering, providing call-back counselling, and mutiple support sessions; • All relevant health professionals trained and reimbursed to raise the issue, give brief advice when appropriate, and refer to specialist treatment services; • Mandatory recording of smoking status routinely in all medical notes; • A specialist treatment service which is part of the country's national healthcare system, in the same way as any other secondary treatment service is (for those with alcohol and drug problems for example); • The provision of all effective medications through doctor's prescription; • The provision of NRT through broader channels like general sale.
In terms of robust scientific evidence, most of the medications are of similar effectiveness (4) and so ideally all should be available, which would allow tobacco users a choice. Reimbursement is also fundamentally important because stop smoking medications (and behavioural support if they have to pay) are typically more expensive than cigarettes for many smokers , and are simply beyond their ability to pay.
Based on our findings we make the following recommendations.
1. Appoint an official lead on tobacco dependence treatment.
2. Develop a national policy on treatment.
3. Develop comprehensive, national, evidence based treatment guidelines endorsed by prestigious national health professional organizations.
4. Fund a national quitline answered by trained counsellors, with multiple sessions of 5. As soon as possible develop an intensive, specialised treatment service as part of the national healthcare system.
6. Make all stop smoking medications as widely available as possible, and make them as cheap as possible to tobacco users.
To the Conference of the Parties: 7. Develop guidelines to help countries interpret "adequate treatment for tobacco dependence treatment." 8. Develop a template to show countries what would be ideal treatment provision and what measures they might prioritize if they have limited resources.
9. Provide technical support for countries to help them develop evidence based guidelines and develop and implement effective treatment policies.
People too numerous to mention helped in so many ways in this survey. We are sure to omit some from this list, apologise in advance if that is the case, and ask you to let us know. Many people answered the original listserve emails telling us about guidelines, far too numerous to mention individually, many helped us try to find contacts within countries who might help us by filling in our questionnaires, and many people gave some feedback during the process of designing the questionnaires, and we warmly thank all of these for their help. We want to thank Peter Anderson and Luk Joossens, whose questionnaires we drew on in designing ours, and Natasha Jategaonkar, who helped enormously in finding contacts to fill in the questionnaires from the FCA survey, and the following people who helped with various aspects of the research, including, questionnaire design: Rick Botelho, Joe Gitchell, John Hughes, David Graham, Paul Hooper, Ken Wassum, Peter Selby, Karen Slama, Heather Wipfli, Fran Stillman, Yumiko Mochizukiy, Linda Bailey, Hana Ross, Mira Aghi, Robert West, and Hayden Robbie. Doreen McIntyre and Joanne Wourms gave steadfast support from the Global Treatment Partnership, which funded this project. Last but not least we are greatly indebted to our partners in these surveys, the country contacts who patiently filled in the questionnaires, and without whom this report would not exist: Gustavo Zabert, Narine Movsisyan, Suzanne Stillman, Ian Ferretter, Kurt Aigner, Manfred Neuberger, Debra Efroymson, Saifuddin Ahmed, Montezuma Ferreira, Janet Nevala, Diane Fournier, Maria Paz Corvalan, Eva Kralikova, Andy McEwen, Luseyane Ligabalavu, Kristina Patja, Sylviane Ratte, Jacques le Houezec, Anil Batra, Akwasi Osei, Imre Vadasz, Tibor Szilagyi, Raj Kumar, Giacomo Mangiaracina, Elizabeth Tamang, Manabu Sakuta, Jun Sono, Ziyad Alawneh, Ahmed Ogwell, Denis Vinnikov, Mohamad Hankini Nik Mohamed, Véronique Le Clezio, Nuria Lanzagorta, Karen García, Gombodorj Tsetsegdary, Fleur van Bladeren, Chris Bullen, Hege Wang, Javaid Khan, Annabel Lyman, Reina Roa, Carlos Farias, Witold Zatonski, Antonio Vaz Carneiro, Luis Rebelo, Magda Cionbanu, Vladimir Levshin, Julia Hurst, Elena Kavcova, Tomas Caks, Carlos Jimenez Ruiz, Karl Fagerstrom, Jacques Cornuz, Adriana Menendez, Richard Hurt, Joe Gitchell.
1. World Health Organization, Framework Convention on Tobacco Control, Article 142. Royal College of Physicians Tobacco Advisory Group. Nicotine addiction in Britain. London: Royal College of Physicians, 2000. 3. Joossens L, & Raw M. The tobacco control scale: a new scale to measure country activity. Tobacco Control 2006;15:247-253. 4. West R, McNeill A, Raw M. Smoking cessation guidelines for health professionals: an update. Thorax 2000;55:987-999. 5. Parrott S, Godfrey C, Raw M, West R, McNeill A. Guidance for commissioners on the cost-effectiveness of smoking cessation interventions. Thorax 1998; 53, Supplement 5 Part 2: 1-35. 6. Raw M, Anderson P, Dubois G, et al. WHO evidence based recommendations on the treatment of tobacco dependence. Tobacco Control 2002;11:44-46. 7. Jategaonkar N (Ed). Civil Society monitoring of the Framework Convention on Tobacco Control: 2007 status report of the Framework Convention Alliance. Geneva, Framework Convention Alliance, 2007.
8. Stead LF, Perera R, Lancaster T. Telephone counselling for smoking cessation. Cochrane Database of Systematic Reviews 2001, Issue 2. Art. No.: CD002850. DOI: 10.1002/14651858.CD002850.pub2. (Date of last subtantive update: April 11. 2006) 1. Copies of national guidelines received2. The guidelines questionnaire3. The questionnaire for countries without guidelines4. The treatment questionnaire Appendix 1. Copies of original national guidelines
During this survey we have received copies of the following national guidelines (most,
but not all, in their native language):
1. Argentina2. Czech Republic 20053. England 1998 (cost effectiveness guidance)4. England 20005. Finland 20036. Kyrgyzstan 20047. Malaysia 20038. Mexico 20059. Netherlands 200610. New Zealand 200711. Poland 200612. Portugal 200213. Scotland 200414. Slovenia 200415. USA 200016. WHO Europe 2002 Other guidance and guidelines received:
1. Brasil, respiratory guidelines, 20042. Northern Ireland, training framework for smoking cessation, 20033. Ontario, integrating cessation into nursing, 20074. Panama, guide to implement cessation clinics, 2005?5. Slovakia, GPs, 2006 Appendix 2 The guidelines questionnaire
Tobacco dependence treatment guidelines in your country
Please reply to Catherine Slevind Martin Raw Division of Epidemiology and Public Health, University of Nottingham, England. Thank you very much.
If it is easier to give extra detail in an email or extra document please feel free to do so.
Country: Informant's name: Email: Telephone number: Do the guidelines recommend these three evidence based interventions? Brief interventions? Intensive behavioural support? Which medications do the guidelines recommend? If the guidelines recommend any other interventions (eg. quitlines, self-help books/resources, hypnosis, acupunture, laser therapy, etc) please list them: Are the guidelines for the whole healthcare system and all professionals? If not are they just for: Primary healthcare Hospitals Other (please specify): Doctors GPs Nurses Pharmacists Dentists Other (please specify): Do the guidelines explicitly refer to or reference the Cochrane database? Are the guidelines based on another country's guidelines?If so which country? Are the guidelines: National? Regional? More local? We have a regional/federal structure and regions have their own If your guidelines are national, can you define national (for example, produced or funded by the national government or government agency, written for the whole healthcare system and for the entire country, endorsed by prestigious national professional bodies): Are they formally endorsed or supported by national government?If yes what form does this endorsement/support takes: Did the guidelines go through any kind of peer review process? If so please briefly describe process: Who funded the guidelines? Where are the guidelines published? Was any one individual, group of individuals, or organisation, primarily responsible for leading the process that led to your guidelines?If yes please give any details you can: Do your guidelines include evidence on cost effectiveness? Can you please list the professional organisations that have formally endorsed the guidelines? Please give any information you can about the impact your guidelines have had on treatment policy in your country.
Please give any further details you can about how your guidelines came about. We are interested in understanding the process – who led it, how did they get funding, how did they get professions to give support, was it difficult, and so on.
Appendix 3 The questionnaire for countries without guidelines
Plans for tobacco dependence treatment guidelines in your country
In this short questionnaire we ask about any plans you have in your country to publish
national treatment guidelines
Please reply to Catherine Slevind Martin Raw Division of Epidemiology and Public Health, University of Nottingham, England. Thank you very much.
If it is easier to give extra detail in an email or extra document please feel free to do so.
Country: Informant's name: Email: Telephone number: Are there any plans to develop guidelines in the near future?
If not is it possible to say why not (eg. lack of money, insufficient
expertise, insufficient resources of another kind, not a priority, we use
another country's guidelines so don't need our own, wouldn't be able to
deliver the services anyway, etc)?
Would it be useful to have help to produce guidelines?If so what kind of support? If yes can you give a few details by answering the following questions
Who will be writing the guidelines? What organisation will own them/publish them? Who is funding the work? Will they be formally endorsed/supported by your national government? Will they be formally endorsed by prestigious national professions?If so which ones will be asked to endorse them? Will they be based on another country or organisation's guidelines?If so, which country/organisation? Will they be peer reviewed or go through any other process of review and revision? Please give details if possible.
Please give any further details you think may be helpful, for example about the process of developing the guidelines, what approaches they will recommend, whether they will be for the entire healthcare system or only for some settings or professions, whether they will be national, regional or more local, and so on. Appendix 4 The treatment questionnaire
Treatment services for tobacco dependence survey
September 2007
Please reply to Catherine Slevinnd Martin Raw niversity of Nottingham, England. Thank you very much.
If it is easier to give extra detail in an email or another document please feel free to do so.
Country: Your name: Your email: Your telephone number: 1) Does your country have an official written government policy on tobacco dependence
treatment?
(please mark all that apply)
Yes, a written government stand-alone policy on tobacco dependence treatment
Yes, a written government policy on tobacco dependence treatment,
but which is part of an overall tobacco control policy
Please add any further detail here, and if possible give details (and URL) of the document: 2) If yes, does the official government policy on tobacco dependence treatment include:
A strategy on training for health professionals A national funded research strategy for smoking cessation A strategy to support interventions by primary care professionals Yes Intensive support in specialised treatment facilities A policy on promoting the use of pharmaceutical products Telephone quit lines Mandatory recording of patients' smoking status in medical notes Yes Please add any further detail or comments here: -----------------------------------------------------------------------------------------------------------------
3) Is there an officially identified person in government (or contracted by the
government) who oversees or manages tobacco dependence treatment services?
If yes please give any details you can, including this person's contact details: 4) Does your country have a telephone quitline (with a person answering, not just
automated/recorded messages)?
Yes, a well funded national quitline or quitlines in all major regions of the country Yes, but only a patch work of small local quitlines No, but we are planning one If yes does the quit line have/provide:
A person answering (always or almost always) Mostly recorded messages A line toll – free to callers Multiple sessions of counselling with active support (Counsellors call back to offer ongoing support) Referrals to local specialist treatment services Medications to help smokers stop Please give any further information or details you can: 6) Does your country have a specialised treatment system (experts or units/clinics)
offering individual or group support delivered by trained professionals?
A network of treatment support covering the whole country
(ie. all smokers have access)
A network of treatment support but only in selected areas (for example cities) Limited treatment support, not a national system, just a few centres If there is treatment system, please describe it: 7) Are the following medications: available in your country? how are they licensed? can
they be advertised on television?
(over the counter) NRT gumNRT patchNRT sublingual tabletNRT lozengeNRT inhalerNRT nasal sprayCystisineBupropionVareniclineOther medication* Please give any further details or comments you can: 8) Are the following interventions free of charge or fully reimbursed to users by the
health care system or other third party payers (for example insurance companies)?
NRT gumNRT patchNRT sublingual tabletNRT lozengeNRT inhalerNRT nasal sprayBupropionVareniclineOther medications(please specify)Brief advice and supportIntensive specialist support Note: "Intensive specialist support" only includes support based on scientific evidence of effectiveness.
If it is difficult to give a simple answer about the behavioural support, please describe the support health professionals give and how it is charged: 9) Are the following health care providers reimbursed for smoking cessation support, or
is smoking cessation support within their terms of service (contract) and part of their
normal salary?
Cessation support within terms of service and part cessation support of normal salaryYes General practitionersNurses in general practiceHospital doctorsHospital nursesPharmacistsDentistsAddiction specialists Please give any further details you can, including any other professionals reimbursed for treating smokers: 10) Can smokers easily get help to stop smoking in the following settings?
Yes, easily Not really widely General/family practiceHospital clinicsWork placesPharmacistsSpecialist clinicsAddiction servicesCommunity based clinicsDentistsSchools PrisonsTelephone quit-linesCountry/regional internet sites Please add any further details you can, including any evidence you have to support any "yes" answers. We are less interested in whether the help is officially available, more if it is genuinely available in reality.
If you have any doubts, or would like to discuss this survey, please do not hesitate to contact us.
Thank you again for your help.

Source: http://www.treatobacco.net/en/uploads/documents/Publications/Raw%20&%20Slevin%202007%20survey%20on%20treatment%20guidelines%20and%20services%20in%2045%20countries.pdf