Could international human rights obligations motivate countries to implement tobacco cessation support?

BACKGROUND AND AIMS

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) seeks to realize the right to health through national tobacco control policies. However, few states have met their obligations under Article 14 of the FCTC to develop evidence-based policies to support tobacco cessation. This article examines how human rights obligations could provide a legal and moral basis for states to implement greater support for individuals to overcome their addiction to tobacco.

ANALYSIS

The United Nations (UN) has a well-established legal framework for promoting human rights, looking to the right to health to realize health autonomy. Where addiction undermines autonomy, it is widely acknowledged that addiction presents a significant barrier to cessation for individuals who use tobacco, undermining the right to health. The UN human rights system could, therefore, provide a complementary basis for monitoring state obligations under Article 14 of the FCTC, identifying challenges to FCTC implementation and motivating states to support tobacco cessation.

CONCLUSIONS

The United Nations' human rights system offers a mechanism that could be used to monitor Framework Convention on Tobacco Control implementation in national policy, facilitating accountability for the progressive realization of cessation support.

The impact of COVID-19 on the WHO FCTC, cessation, and tobacco policy

'In the absence of the COVID-19 pandemic, many people in tobacco control worldwide would have been at the Hague, Netherlands, from 9-14 November for the 9th Conference of the Parties (COP9) of the WHO Framework Convention on Tobacco Control (WHO FCTC), advocating for even stronger policies against the tobacco epidemic. The COP has been postponed to 2021, but the pandemic did not stop the global civil society from "virtually" gathering to talk about the WHO FCTC, where it is and where it is going.'

Challenges to implementing the WHO Framework Convention on Tobacco Control guidelines on tobacco cessation treatment: a qualitative analysis

AIM

To identify barriers to implementing the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) Article 14 guidelines on tobacco dependence treatment (TDT).

DESIGN

Cross-sectional survey conducted from December 2014 to July 2015 to assess implementation of Article 14 recommendations.

SETTING AND PARTICIPANTS

Survey respondents (n = 127 countries) who completed an open-ended question on the 26-item survey.

MEASUREMENTS

The open-ended question asked the following: 'In your opinion, what are the main barriers or challenges to developing further tobacco dependence treatment in your country?'. We conducted thematic analysis of the responses.

FINDINGS

The most frequently reported barriers included a lack of health-care system infrastructure (n = 86) (e.g. treatment not integrated into primary care, lack of health-care worker training), low political priority (n = 66) and lack of funding (n = 51). The absence of strategic plans and national guidelines for Article 14 implementation emerged as subthemes of political priority. Also described as barriers were negative provider attitudes towards offering offer TDT (n = 11), policymakers' lack of awareness about the effectiveness and affordability of TDT (n = 5), public norms supporting tobacco use (n = 11), a lack of health-care leadership and expertise in the area of TDT (n = 6) and a lack of grassroots and multi-sector networks supporting policy implementation (n = 8). The analysis captured patterns of co-occurring themes that linked, for example, low levels of political support with a lack of funding necessary to develop health-care infrastructure and capacity to implement Article 14.

CONCLUSION

Important barriers to implementing the Framework Convention on Tobacco Control Article 14 guidelines include lack of a health-care system infrastructure, low political priority and lack of funding.

Prevalence of tobacco use in healthcare workers: A systematic review and meta-analysis

Objectives

To estimate tobacco use prevalence in healthcare workers (HCW) by country income level, occupation and sex, and compare the estimates with the prevalence in the general population.

Methods

We systematically searched five databases; Medline, EMBASE, CINHAL Plus, CAB Abstracts, and LILACS for original studies published between 2000 and March 2016 without language restriction. All primary studies that reported tobacco use in any category of HCW were included. Study extraction and quality assessment were conducted independently by three reviewers, using a standardised data extraction and quality appraisal form. We performed random effect meta-analyses to obtain prevalence estimates by World Bank (WB) country income level, sex, and occupation. Data on prevalence of tobacco use in the general population were obtained from the World Health Organisation (WHO) Global Health Observatory website. The review protocol registration number on PROSPERO is CRD42016041231.

Results

229 studies met our inclusion criteria, representing 457,415 HCW and 63 countries: 29 high-income countries (HIC), 21 upper-middle-income countries (UMIC), and 13 lower-middle-and-low-income countries (LMLIC). The overall pooled prevalence of tobacco use in HCW was 21%, 31% in males and 17% in females. Highest estimates were in male doctors in UMIC and LMLIC, 35% and 45%, and female nurses in HIC and UMIC, 21% and 25%. Heterogeneity was high (I² > 90%). Country level comparison suggest that in HIC male HCW tend to have lower prevalence compared with males in the general population while in females the estimates were similar. Male and female HCW in UMIC and LMLIC tend to have similar or higher prevalence rates relative to their counterparts in the general population.

Conclusions

HCW continue to use tobacco at high rates. Tackling HCW tobacco use requires urgent action as they are at the front line for tackling tobacco use in their patients.

Evaluating clinical stop-smoking services globally: towards a minimum data set

BACKGROUND AND AIMS

Behavioural and pharmacological support for smoking cessation improves the chances of success and represents a highly cost-effective way of preventing chronic disease and premature death. There is a large number of clinical stop-smoking services throughout the world. These could be connected into a global network to provide data to assess what treatment components are most effective, for what populations and in what settings. To enable this, a minimum data set (MDS) is required to standardize the data captured from smoking cessation services globally.

METHODS

We describe some of the key steps involved in developing a global MDS for smoking cessation services and methodologies to be considered for their implementation, including approaches for reaching consensus on data items to include in a MDS and for its robust validation. We use informal approximations of these methods to produce an example global MDS for smoking cessation. Our aim with this is to stimulate further discussion around the development of a global MDS for smoking cessation services.

RESULTS

Our example MDS comprises three sections. The first is a set of data items characterizing treatments offered by a service. The second is a small core set of data items describing clients' characteristics, engagement with the service and outcomes. The third is an extended set of client data items to be captured in addition to the core data items wherever resources permit.

CONCLUSIONS

There would be benefit in establishing a minimum data set (MDS) to standardize data captured for smoking cessation services globally. Once implemented, a formal MDS could provide a basis for meaningful evaluations of different smoking cessation treatments in different populations in a variety of settings across many countries.

A survey of tobacco dependence treatment guidelines content in 61 countries

AIMS

To assess tobacco dependence treatment guidelines content in accordance with Article 14 of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) and its guidelines, and association between content and country income level.

DESIGN

Cross-sectional study.

SETTING

On-line survey from March to July 2016.

PARTICIPANTS

Contacts in 77 countries, including 68 FCTC Parties, six Signatories and three non-Parties which had indicated having guidelines in previous surveys, or had not been surveyed before.

MEASUREMENTS

A nine-item questionnaire on guidelines content, key recommendations, writing and dissemination.

FINDINGS

We received responses from contacts in 63 countries (82%); 61 had guidelines. The majority are for doctors (93%), primary care (92%) and nurses (75%). All recommend brief advice, 82% recording tobacco use in medical notes, 98% nicotine replacement therapy (NRT), 61% quitlines, 31% text messaging and 87% intensive specialist support, and 54% stress the importance of health-care workers not using tobacco. Only 57% have a dissemination strategy, and 62% have not been updated for 5 or more years. Compared with high-income countries, quitlines are less likely to be recommended in upper middle-income countries guidelines [odds ratio (OR) = 0.15, 95% confidence interval (CI) = 0.04-0.61] and intensive specialist support in lower middle-income countries guidelines (OR = 0.01, 95% CI = 0.00-0.20). Guidelines updating is associated positively with country income level (P = 0.027).

CONCLUSIONS

Although most tobacco dependence treatment guidelines in the 61 countries assessed in 2016 follow the World Health Organization's Framework Convention on Tobacco Control Article 14 recommendations and do not differ significantly by income level, improvements are needed in keeping guidelines up-to-date, applying good writing practices and developing a dissemination strategy.

Progress in implementation of WHO FCTC Article 14 and its guidelines: a survey of tobacco dependence treatment provision in 142 countries

AIMS

To (1) estimate the number of Parties to the Framework Convention on Tobacco Control (FCTC) providing tobacco dependence treatment in accordance with the recommendations of Article 14 and its guidelines; (2) assess association between provision and countries' income level; and (3) assess progress over time.

DESIGN

Cross-sectional study.

SETTING

Online survey from December 2014 to July 2015.

PARTICIPANTS

Contacts in 172 countries were surveyed, representing 169 of the 180 FCTC Parties at the time of the survey.

MEASUREMENTS

A 26-item questionnaire based on the Article 14 recommendations including tobacco treatment infrastructure and cessation support systems. Progress over time was assessed for those countries that also participated in our 2012 survey and did not change country income level classification.

FINDINGS

We received responses from contacts in 142 countries, an 83% response rate. Overall, 54% of respondents reported that their country had an officially identified person responsible for tobacco dependence treatment, 32% an official national treatment strategy, 40% official national treatment guidelines, 25% a clearly identified budget for treatment, 17% text messaging, 23% free national quitlines and 26% specialized treatment services. Most measures were associated positively and significantly with countries' income level (P < 0.001). Measures not associated significantly with income level included mandatory recording of tobacco use (30% of countries), offering help to health-care workers (HCW) to stop using tobacco (44%), brief advice integrated into existing services (44%), and training HCW to give brief advice (81%). Reporting having an officially identified person responsible for tobacco cessation was the only measure with a statistically significant improvement over time (P = 0.0351).

CONCLUSION

Fewer than half of countries that are Parties to the Framework Convention on Tobacco Control have implemented the recommendations of Article 14 and its guidelines, and for most measures, provision was greater the higher the country's income. There was little improvement in treatment provision between 2012 and 2015 in all countries.

Health-care interventions to promote and assist tobacco cessation: a review of efficacy, effectiveness and affordability for use in national guideline development

AIMS

This paper provides a concise review of the efficacy, effectiveness and affordability of health-care interventions to promote and assist tobacco cessation, in order to inform national guideline development and assist countries in planning their provision of tobacco cessation support.

METHODS

Cochrane reviews of randomized controlled trials (RCTs) of major health-care tobacco cessation interventions were used to derive efficacy estimates in terms of percentage-point increases relative to comparison conditions in 6-12-month continuous abstinence rates. This was combined with analysis and evidence from 'real world' studies to form a judgement on the probable effectiveness of each intervention in different settings. The affordability of each intervention was assessed for exemplar countries in each World Bank income category (low, lower middle, upper middle, high). Based on World Health Organization (WHO) criteria, an intervention was judged as affordable for a given income category if the estimated extra cost of saving a life-year was less than or equal to the per-capita gross domestic product for that category of country.

RESULTS

Brief advice from a health-care worker given opportunistically to smokers attending health-care services can promote smoking cessation, and is affordable for countries in all World Bank income categories (i.e. globally). Proactive telephone support, automated text messaging programmes and printed self-help materials can assist smokers wanting help with a quit attempt and are affordable globally. Multi-session, face-to-face behavioural support can increase quit success for cigarettes and smokeless tobacco and is affordable in middle- and high-income countries. Nicotine replacement therapy, bupropion, nortriptyline, varenicline and cytisine can all aid quitting smoking when given with at least some behavioural support; of these, cytisine and nortriptyline are affordable globally.

CONCLUSIONS

Brief advice from a health-care worker, telephone helplines, automated text messaging, printed self-help materials, cytisine and nortriptyline are globally affordable health-care interventions to promote and assist smoking cessation. Evidence on smokeless tobacco cessation suggests that face-to-face behavioural support and varenicline can promote cessation.

Tobacco Dependence Treatment Training Programs: An International Survey

INTRODUCTION

In line with Article 14 guidelines for the WHO Framework Convention on Tobacco Control, we aimed to assess the progress in training individuals to deliver tobacco cessation treatment.

METHODS

Cross-sectional web-based survey in May-September 2013 among 122 experts in tobacco control and training from 84 countries (73% response rate among 115 countries surveyed). We measured training program prevalence, participants, and challenges faced.

RESULTS

Overall, 21% (n = 18/84) of countries, mostly low and middle-income countries (LMICs; P = .002), reported no training program. Among 66 countries reporting at least one training program, most (84%) trained healthcare professionals but 54% also trained other individuals including community health workers, teachers, and religious leaders. Most programs (54%) cited funding challenges, although stability of funding varied by income level. Government funding was more commonly reported in higher income countries (high 56%, upper middle 50%, lower middle 27%, low 25%; P = .03) while programs in LMICs relied more on nongovernmental organizations (high 11%, upper middle 37%, lower middle 27%, low 38%; P = .02).

CONCLUSIONS

One in five countries reported having no tobacco treatment training program representing little progress in terms of training individuals to deliver tobacco treatment in LMICs. Without more trained tobacco treatment providers, one of the tenets of Article 14 is not yet being met and health inequalities are likely to widen. More effort and resources are needed to ensure that healthcare worker educational programs include training to assess tobacco use and deliver brief advice and that training is available for individuals outside the healthcare system in areas with limited healthcare access.

How smokers may react to cigarette taxes and price increases in Brazil: data from a national survey

BACKGROUND

Despite being the third largest tobacco producer in the world, Brazil has developed a comprehensive tobacco control policy that includes a broad restriction on both advertising and smoking in indoor public places, compulsory pictorial warning labels, and a menthol cigarette ban. However, tax and pricing policies have been developed slowly and only very recently were stronger measures implemented. This study investigated the expected responses of smokers to hypothetical price increases in Brazil.

METHODS

We analyzed smokers' responses to hypothetical future price increases according to sociodemographic characteristics and smoking conditions in a multistage sample of Brazilian current cigarette smokers aged≥14 years (n=500). Logistic regression analysis was used to examine the relationship between possible responses and different predictors.

RESULTS

In most subgroups investigated, smokers most frequently said they would react to a hypothetical price increase by taking up alternatives that might have a positive impact on health, i.e., they would "try to stop smoking" (52.3%) or "smoke fewer cigarettes" (46.8%). However, a considerable percentage responded that they would use alternatives that would reduce the effect of price increases, such as the same brand with lower cost (48.1%). After controlling for sex age group (14-19, 20-39, 40-59, and ≥60 years), schooling level (≥9 versus ≤9 years), number of cigarettes per day (>20 versus ≤20), and stage of change for smoking cessation (precontemplation, contemplation, and preparation), lower levels of dependence were positively associated with the response "I would try to stop smoking" (odds ratio [OR], 2.19). Young age was associated with "I would decrease the number of cigarettes" (OR, 3.44). A low schooling level was strongly associated with all responses.

CONCLUSIONS

Taxes and prices increases have great potential to stimulate cessation or reduction of cigarette consumption further among two important vulnerable populations of smokers in Brazil: young smokers and those of low educational level. The results from the present study also suggest that seeking illegal products may reduce the impact of increased taxes, but does not eliminate it.

A survey of tobacco dependence treatment guidelines in 121 countries

AIMS

To report progress among Parties to the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in developing national tobacco treatment guidelines in accordance with FCTC Article 14 guideline recommendations.

DESIGN

Cross-sectional study.

SETTING

Electronic survey from December 2011 to August 2012; participants were asked to complete either an online or attached Microsoft Word questionnaire.

PARTICIPANTS

One hundred and sixty-three of the 173 Parties to the FCTC at the time of our survey.

MEASUREMENTS

The 51-item questionnaire contained 30 items specifically on guidelines. Questions covered the areas of guidelines writing process, content, key recommendations and other characteristics.

FINDINGS

One hundred and twenty-one countries (73%) responded. Fifty-three countries (44%) had guidelines, ranging from 75% among high-income countries to 11% among low-income countries. Nearly all guidelines recommended brief advice (93%), intensive specialist support (93%) and medications (96%), while 66% recommended quitlines. Fifty-seven percent had a dissemination strategy, 76% stated funding source and 68% had professional endorsement.

CONCLUSION

Fewer than half of the Parties to the WHO FCTC have developed national tobacco treatment guidelines, but, where guidelines exist, they broadly follow FCTC Article 14 guideline recommendations.

A survey of tobacco dependence treatment services in 121 countries

AIMS

To report progress among Parties to the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) in developing tobacco dependence treatment systems in accordance with FCTC Article 14 and the Article 14 guidelines recommendations.

DESIGN

Cross-sectional study.

SETTING

Electronic survey from December 2011 to August 2012.

PARTICIPANTS

One hundred and sixty-three of the 174 Parties to the FCTC at the time of our survey.

MEASUREMENTS

The 51-item questionnaire contained 21 items specifically on treatment systems. Questions covered the availability of basic treatment infrastructure and national cessation support systems.

FINDINGS

We received responses from 121 (73%) of the 166 countries surveyed. Fewer than half of the countries had national treatment guidelines (n = 53, 44%), a government official responsible for tobacco dependence treatment (n = 49, 41%), an official national treatment strategy (n = 53, 44%) or provided tobacco cessation support for health workers (n = 55, 46%). More than half encouraged brief advice in existing health care services (n = 68, 56%), while only 44 (36%) had quitlines and only 20 (17%) had a network of treatment support covering the whole country. Low- and middle-income countries had less tobacco dependence treatment provision than high-income countries.

CONCLUSION

Most countries, especially low- and middle-income countries, have not yet implemented the recommendations of FCTC Article 14 or the FCTC Article 14 guidelines.

Research priorities for Article 14--demand reduction measures concerning tobacco dependence and cessation

INTRODUCTION

Tobacco dependence treatment (TDT) interventions are often seen as expensive with little impact on the prevalence of tobacco use. However, activities that promote the cessation of tobacco use and support abstinence have an important role in any comprehensive tobacco control program and as such are recognized within Article 14 (A14) of the Framework Convention on Tobacco Control.

OBJECTIVES

To review current evidence for TDT and recommend research priorities that will contribute to more people being helped to stop tobacco use.

METHODS

We used the recommendations within the A14 guidelines to guide a review of current evidence and best practice for promotion of tobacco cessation and TDT, identify gaps, and propose research priorities.

RESULTS

We identified nine areas for future research (a) understanding current tobacco use and the effect of policy on behavior, (b) promoting cessation of tobacco use, (c) implementation of TDT guidelines, (d) increasing training capacity, (e) enhancing population-based TDT interventions, (f) treatment for different types of tobacco use, (g) supply of low-cost pharmaceutical devices/ products, (h) investigation use of nonpharmaceutical devices/ products, and (i) refinement of current TDTs. Specific research topics are suggested within each of these areas and recognize the differences needed between high- and low-/middle-income countries.

CONCLUSIONS

Research should be prioritized toward examining interventions that (a) promote cessation of tobacco use, (b) assist health care workers provide better help to smokers (e.g., through implementation of guidelines and training), (c) enhance population-based TDT interventions, and (d) assist people to cease the use of other tobacco products.

From cigarette smuggling to illicit tobacco trade

BACKGROUND

Tax policy is considered the most effective strategy to reduce tobacco consumption and prevalence. Tax avoidance and tax evasion therefore undermine the effectiveness of tax policies and result in less revenue for governments, cheaper prices for smokers and increased tobacco use. Tobacco smuggling and illicit tobacco trade have probably always existed, since tobacco's introduction as a valuable product from the New World, but the nature of the trade has changed.

METHODS

This article clarifies definitions, reviews the key issues related to illicit trade, describes the different ways taxes are circumvented and looks at the size of the problem, its changing nature and its causes. The difficulties of data collection and research are discussed. Finally, we look at the policy options to combat illicit trade and the negotiations for a WHO Framework Convention on Tobacco Control (FCTC) protocol on illicit tobacco trade.

RESULTS

Twenty years ago the main type of illicit trade was large-scale cigarette smuggling of well known cigarette brands. A change occurred as some major international tobacco companies in Europe and the Americas reviewed their export practices due to tax regulations, investigations and lawsuits by the authorities. Other types of illicit trade emerged such as illegal manufacturing, including counterfeiting and the emergence of new cigarette brands, produced in a rather open manner at well known locations, which are only or mainly intended for the illegal market of another country.

CONCLUSIONS

The global scope and multifaceted nature of the illicit tobacco trade requires a coordinated international response, so a strong protocol to the FCTC is essential. The illicit tobacco trade is a global problem which needs a global solution.

A comparison of four international surveys of tobacco dependence treatment provision: implications for monitoring the Framework Convention on Tobacco Control

AIMS

Article 14 of the Framework Convention on Tobacco Control (FCTC) requires countries to implement systems to provide tobacco dependence treatment. We report on global efforts to monitor the implementation of Article 14, and compare the surveys used in this effort.

DESIGN

Cross-sectional comparison of agreement (concordance and discordance) among the four main surveys used to monitor tobacco dependence treatment provision.

SETTING

Four global surveys of tobacco treatment provision.

PARTICIPANTS

The four surveys were Raw et al. (2009), the Framework Convention Alliance (FCA) Monitor, World Health Organization (WHO) MPOWER survey and the FCTC Party Reports.

MEASUREMENTS

Concordance as measured by percentage providing the same answers, as well as kappa statistic of inter-rater agreement.

FINDINGS

The four surveys used to monitor Article 14 implementation vary widely in countries sampled, questions asked, respondent characteristics and survey design. The four surveys generally show a moderate to high concordance (kappa > 0.60) with each other across most survey pairs and most domains, except for the MPOWER and FCTC Party governmental surveys (63% overall concordance, kappa =0.26). This concordance was lower than any other survey pair examined. Government respondents to the WHO MPOWER and FCTC Party Report surveys provided answers to the same question domains with relatively poorer concordance than those from surveys of non-governmental or mixed governmental/non-governmental sources.

CONCLUSIONS

Current surveys of tobacco dependence treatment provision are in general agreement with each other except for the two official government surveys that rely on governmental respondents. We believe that this points to the continued need for independent non-governmental monitoring of FCTC protocol implementation.

Case studies of tobacco dependence treatment in Brazil, England, India, South Africa and Uruguay

AIMS

The aims of this study are to describe the tobacco dependence treatment systems in five countries at different stages of development of their systems, and from different income levels and regions of the world, and to draw some lessons from their experiences that might be useful to other countries. METHODS AND DATA SOURSES: Data were drawn from an earlier survey of treatment services led by M.R. and A.M., from Party reports to the Secretariat of the Framework Convention on Tobacco Control, and from correspondents in the five countries. These data were entered onto a standard template by the authors, discussed with the correspondents to ensure they were accurate and to help us interpret them, and then the templates were used as a basis to write prose descriptions of the countries' treatment systems, with additional summary data presented in tables.

RESULTS

Two of the middle-income countries have based their treatment on specialist support and both consequently have very low population coverage for treatment. Two countries have integrated broad-reach approaches, such as brief advice with intensive specialist support; these countries are focusing currently upon monitoring performance and guaranteeing quality. Cost is a significant barrier to improving treatment coverage and highlights the importance of using existing infrastucture as much as possible.

CONCLUSIONS

Perhaps not surprisingly the greatest challenges appear to be faced by large, lower-income countries that have prioritized more intensive but low-reach approaches to treatment, rather than developing basic infrastructure, including brief advice in primary care and quitlines.

The impact of eliminating the global illicit cigarette trade on health and revenue

AIMS

The purpose of this study was to update global estimates of the illicit cigarette trade, based on recent data, and estimate how many lives could be saved by eliminating it and how much revenue governments would gain.

DATA SOURCES AND METHODS

Our estimates of illicit market share are based on formal and informal sources. Our method for estimating the effect of eliminating the illicit trade on tobacco related deaths is based on West et al. with some minor modifications, and involves calculating the size of the illicit cigarette trade; the effect of eliminating it on the price of cigarettes and thus on consumption; the revenue governments are losing because of it; and the number of tobacco-related premature deaths that would be avoided if this illicit trade were eliminated.

RESULTS

According to available estimates, the size of the illicit trade varies between countries from 1% to about 40-50% of the market, 11.6% globally, 16.8% in low-income and 9.8% in high-income countries. The total lost revenue is about $40.5 billion a year. If this illicit trade were eliminated governments would gain at least $31.3 billion a year, and from 2030 onwards more than 164,000 premature deaths a year would be avoided, the vast majority in middle- and low-income countries.

CONCLUSIONS

The burden of deaths and lost revenue caused by the illicit cigarette trade falls disproportionately on low- and middle-income countries. Eliminating this trade would avoid millions of premature deaths, and recover billions of dollars for governments.

A survey of tobacco dependence treatment guidelines in 31 countries

AIMS

The Framework Convention on Tobacco Control (FCTC) asks countries to develop and disseminate comprehensive evidence-based guidelines and promote adequate treatment for tobacco dependence, yet to date no summary of the content of existing guidelines exists. This paper describes the national tobacco dependence treatment guidelines of 31 countries.

DESIGN, SETTING, PARTICIPANTS

A questionnaire on tobacco dependence treatment guidelines was sent by e-mail to a convenience sample of contacts working in tobacco control in 31 countries in 2007. Completed questionnaires were received from respondents in all 31 countries. During the course of these enquiries we also made contact with people in 14 countries that did not have treatment guidelines and sent them a short questionnaire asking about their plans to produce guidelines.

MEASUREMENTS

The survey instrument was a 17-item questionnaire asking the following key questions: do the guidelines recommend brief interventions, intensive behavioural support, medications; which medications; do the guidelines apply to the whole health-care system and all professionals; do they refer explicitly to the Cochrane database; are they based on another country's guidelines; are they national or more local; are they endorsed formally by government; did they undergo peer review; who funded them; where were they published; do they include evidence on cost effectiveness of treatment?

FINDINGS

According to respondents, all their countries' guidelines recommended brief advice, intensive behavioural support and nicotine replacement therapy (NRT); 84% recommended bupropion; 19% recommended varenicline; and 35% recommended telephone quitlines. Nearly half (48%) included cost-effectiveness evidence. Seventy-one per cent were supported formally by their government and 65% were supported financially by the government. Most (84%) used the Cochrane reviews as a source of evidence, 84% underwent a peer review process and 55% were based on the guidelines of other countries, most often the United States and England.

CONCLUSION

Overall, the guidelines reviewed followed the evidence base closely, recommending brief interventions, intensive behavioural support and NRT, and most recommended bupropion. Varenicline was not on the market in most of the countries in this survey when their guidelines were written, illustrating the need for guidelines to be updated periodically. None recommended interventions not proven to be effective, and some recommended explicitly against specific interventions (for lack of evidence). Most were peer-reviewed, many through lengthy and rigorous procedures, and most were endorsed or supported formally by their governments. Some countries that did not have guidelines expressed a need for technical support, emphasizing the need for countries to share experience, something the FCTC process is well placed to support.

A survey of tobacco dependence treatment services in 36 countries

AIMS

This paper reports the results of a survey of national tobacco dependence treatment services in 36 countries. The objective was to describe the services and discuss the results in the context of Article 14 of the Framework Convention on Tobacco Control, which asks countries to promote adequate treatment for tobacco dependence.

DESIGN, SETTING AND PARTICIPANTS

A questionnaire on tobacco dependence treatment services was e-mailed to a convenience sample of contacts in 2007. Completed questionnaires were received from contacts in 36 countries.

MEASUREMENTS

The survey instrument was a 10-item questionnaire asking about treatment policy and practice, including medications.

FINDINGS

According to our informants, fewer than half the countries in our survey had an official written policy on (44%), or a government official responsible for (49%), treatment. Only 19% had a specialized national treatment system and only 24% said help was easily available in general practice. Most countries (94%) allowed the sale of nicotine replacement therapy (NRT), bupropion (75%) and varenicline (69%) but only 40% permitted NRT on 'general sale'. Very few countries responding to the question fully reimbursed any of the medications. Fewer than half (45%) fully reimbursed brief advice and only 29% fully reimbursed intensive specialist support. Only 31% of countries said that their official treatment policy included the mandatory recording of patients' smoking status in medical notes.

CONCLUSION

Taken together, our findings show that few countries have well-developed tobacco dependence treatment services and that, at a national level, treatment is not yet a priority in most countries.

An international survey of training programs for treating tobacco dependence

AIMS

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) requires countries to implement tobacco dependence treatment programs. To provide treatment effectively, a country needs trained individuals to deliver these services. We report on the global status of programs that train individuals to provide tobacco dependence treatment.

DESIGN

Cross-sectional web-based survey of tobacco treatment training programs in a stratified convenience sample of countries chosen to vary by WHO geographic region and World Bank income level.

PARTICIPANTS

Key informants in 48 countries; 70% of 69 countries who were sent surveys responded.

MEASUREMENTS

Program prevalence, frequency, duration and size; background of trainees; content (adherence to pre-defined core competencies); funding sources; challenges.

FINDINGS

We identified 61 current tobacco treatment training programs in 37 (77%) of 48 countries responding to the survey. Three-quarters of them began in 2000 or later, and 40% began after 2003, when the FCTC was adopted. Programs estimated training 14,194 individuals in 2007. Training was offered to a variety of professionals and paraprofessionals, but most often to physicians and nurses. Median program duration was 16 hours, but programs' duration, intensity and size varied widely. Most programs used evidence-based guidelines and reported adherence to core tobacco treatment competencies. Training programs were less frequent in low-income countries and in Africa. Securing funding was the major challenge for most programs; current funding sources were government (58%), non-government organizations (23%), pharmaceutical companies (17%) and, in one case, the tobacco industry.

CONCLUSION

Training programs for tobacco treatment providers are diverse and growing. Most upper- and middle-income countries have programs, and most programs appear to be evidence-based. However, funding is a major challenge. In particular, more programs are needed for non-physicians and for low-income countries.

Progress in combating cigarette smuggling: controlling the supply chain

BACKGROUND

The illicit tobacco trade results in huge losses of revenue to governments, estimated at $US40-50 billion in 2006, and in increased consumption and thus health problems because it makes tobacco available more cheaply. On 20 October 2008 the second meeting of the International Negotiating Body (INB2) on the illicit trade protocol of WHO's Framework Convention on Tobacco Control (FCTC) will discuss measures to tackle the illicit trade in tobacco products.

METHODS

This paper presents the experience over the last decade of three countries, Italy, Spain and the United Kingdom, which shows that tobacco smuggling can be successfully tackled.

CONCLUSION

The evidence strongly suggests that the key to controlling smuggling is controlling the supply chain, and that the supply chain is controlled to a great extent by the tobacco industry.

The effect of restricting opening hours on alcohol-related violence

OBJECTIVE

We investigated whether limiting the hours of alcoholic beverage sales in bars had an effect on homicides and violence against women in the Brazilian city of Diadema. The policy to restrict alcohol sales was introduced in July 2002 and prohibited on-premises alcohol sales after 11 pm.

METHODS

We analyzed data on homicides (1995 to 2005) and violence against women (2000 to 2005) from the Diadema (population 360,000) police archives using log-linear regression analyses.

RESULTS

The new restriction on drinking hours led to a decrease of almost 9 murders a month. Assaults against women also decreased, but this effect was not significant in models in which we controlled for underlying trends.

CONCLUSIONS

Introducing restrictions on opening hours resulted in a significant decrease in murders, which confirmed what we know from the literature: restricting access to alcohol can reduce alcohol-related problems. Our results give no support to the converse view, that increasing availability will somehow reduce problems.

The Tobacco Control Scale: a new scale to measure country activity

OBJECTIVES

To quantify the implementation of tobacco control policies at country level using a new Tobacco Control Scale and to report initial results using the scale.

METHOD

A questionnaire sent to correspondents in 30 European countries, using a scoring system designed with the help of a panel of international tobacco control experts.

RESULTS

The 30 countries are ranked by their total score on the scale out of a maximum possible score of 100. Only four countries (Ireland, United Kingdom, Norway, Iceland) scored 70 or more, with an eight point gap (most differences in scores are small) to the fifth country, Malta, on 62. Only 13 countries scored above 50, 11 of them from the European Union (EU), and the second largest points gap occurs between Denmark on 45 and Portugal on 39, splitting the table into three groups: 70 and above, 45 to 62, 39 and below. Ireland had the highest overall score, 74 out of 100, and Luxembourg was bottom with 26 points. However even Ireland, much praised for their ban on smoking in public places, did not increase tobacco taxes in 2005, for the first time since 1995.

CONCLUSIONS

Although the Tobacco Control Scale has limitations, this is the first time such a scale has been developed and applied to so many countries. We hope it will be useful in encouraging countries to strengthen currently weak areas of their tobacco control policy.

Postoperative pain, nausea and vomiting following paediatric day-case tonsillectomy

More than 30% of all surgical activity for children in England and Wales is accounted for by routine ENT operations. There is known to be a high incidence of postoperative pain, nausea and vomiting following paediatric tonsillectomy with or without adenoidectomy. This prospective study examined the incidence of these complications in 100 children admitted for routine, elective day-case tonsillectomy, with or without adenoidectomy. The children were anaesthetised in accordance with our standard paediatric day-case protocol. The incidence of vomiting on the day of surgery was significantly less in the group anaesthetised in accordance with the protocol, compared to those in previously published studies. Postoperative pain was well controlled, with 88% of the children having minimal pain on the day of surgery, and reporting a pain score of 0-2. Modifying the anaesthetic care to a protocol designed to reduce postoperative pain, nausea and vomiting achieved measurable improvements in the recovery of this group following surgery. It has enabled us to evolve from a 100% inpatient stay for these operations to 98% day-case discharge rate, with minimal post anaesthetic or surgical morbidity. We describe the protocol and discuss the implications of implementing such a protocol for children undergoing these common operations.

General practitioners' views on and referral to NHS smoking cessation services

OBJECTIVES

Increasing the rate of smoking cessation remains a major public health goal. To help achieve this in the UK, National Health Service (NHS) smoking cessation services have been established to provide treatment for smokers wanting help with stopping. Referrals from general practitioners (GPs) are crucial to the success of these clinics. This study aimed to assess English GPs' self-reported interactions with, and attitudes towards, their local smoking cessation services.

STUDY DESIGN

Postal survey assessing the attitudes of GPs in England towards, and formal interactions with, NHS smoking cessation services.

METHODS

A questionnaire was posted to a random sample of 544 GPs in England (response rate 63%). GPs' self-reported interactions with smoking cessation services and their attitudes towards these clinics were assessed. GPs were also asked what factors determined whether they prescribed nicotine-replacement therapy (NRT) and Buproprion (Zyban), and what was the extent and nature of their smoking cessation interventions with their patients.

RESULTS

Most GPs (94%) reported that they were aware of the specialist smoking cessation service in their area. Seventy percent of GPs supported the continuation of current funding for specialist smoking cessation services. Seventy percent reported that they referred patients to these services, and 55% had staff within their practices trained as community smoking cessation advisors. Most GPs (79%) reported 'clinical need' as a determinant of whether they prescribed NRT/Zyban, and a few GPs cited 'budgetary constraints' as a factor (15%). Ninety-eight percent of GPs reported that they record smoking status when new patients join their practice, and they advise smokers to stop 'at least every now and then'.

CONCLUSIONS

GPs support the existence and continuation of specialist smoking cessation services, and most reported that they refer patients to them. Virtually every GP reported that they record smoking status when new patients join their practice, and they advise smokers to stop 'at least every now and then'.

Lessons from the English smoking treatment services

This paper summarizes and discusses the key findings of the evaluation of the English smoking treatment services, which were established in 1999 as part of the English National Health Service. Within 4 years these services existed throughout the country and were working at full capacity, a total of pound 76 million having been spent on them over this period, excluding medication costs. In the fourth year almost 235,000 people attended treatment and set a quit date, and the total budget, including medications, was approximately pound 50 million. At the end of the fourth year the government allocated pound 138 million for the services for the period April 2003-March 2006. The CO-validated 4-week abstinence rate was 53%, the validated 52-week abstinence rate was 15%, and the relapse rate from 4 to 52 weeks was 75%. There was no sex difference in cessation rates at long-term follow-up. The cessation results and relapse rate from weeks 4 to 52 are consistent with results from published studies, including clinical trials. The estimated cost per life-year saved was pound 684 and the figure is even lower if the potential future health care cost savings are taken into account at pound 438 per life-year saved. This compares with the benchmark of pound 20,000 per life-year saved, which the National Institute for Clinical Excellence (NICE) is using to recommend new health care interventions in the National Health Service. The services were also succeeding in reaching disadvantaged smokers. However, there have been problems, and other health care systems considering an initiative of this kind should: set national training standards and increase training capacity before launching the services; standardize the provision of pharmaceutical treatments and make them as accessible as possible before launching the services; and give the services at least 5 years of central funding to allow them to become well established. Monitoring is extremely important but should not be so much of a burden that it detracts from developing a quality service and although cessation targets can be helpful, care needs to be taken that they are reasonable and do not promote throughput at the expense of quality.

A national strategy for smoking cessation treatment in England

In 1998 the UK government published a White Paper on tobacco which set out the development of smoking cessation treatment services across England. This paper presents a detailed analysis of the events leading up to the inclusion of smoking cessation treatment services within the White Paper, and the background to the evaluation of those services, the results of which are the subject of the remaining papers in this supplement.

Smokeless tobacco cessation guidelines for health professionals in England

Smokeless tobacco is used in the UK predominantly by members of the Indian, Pakistani and especially Bangladeshi communities. The most commonly used form is tobacco mixed with lime and additional psychoactive compounds, most notably areca nut. The resulting "quid" is chewed or held in the mouth. Studies from Asia indicate that use of this kind of product is linked with an increased risk of oral cancers and possibly low birth-weight infants. There is little high quality research evaluating interventions to promote cessation of smokeless tobacco use, especially of the forms used in the UK. However, what evidence there is suggests that advice to stop coupled with behavioural support and counselling may increase long-term abstinence rates by some 5-10%. It seems appropriate therefore to recommend that dentists, GPs and other relevant health professionals should routinely assess and record smokeless tobacco use in patients belonging to relatively high prevalence groups, that they ensure that smokeless tobacco users know the potential health risks (as well as the health risks of smoking) and that they advise them to stop and keep a record of the outcome. Dental professionals should also examine the oral cavity of smokeless tobacco users for lesions when the opportunity arises. Patients expressing an interest in stopping should be referred to specialist smoking cessation services for behavioural support and specialists in areas of high smokeless tobacco use will need to ensure that they are sufficiently knowledgeable and their services sufficiently accessible to these users. There is insufficient evidence to recommend the use of nicotine replacement therapy or bupropion to aid smokeless tobacco cessation. Research is needed in the UK to quantify the personal and population health risks from smokeless tobacco, the benefits of stopping, the effectiveness of interventions aimed at promoting cessation and patterns of use, knowledge and attitudes of users.

Turning off the tap: the real solution to cigarette smuggling

The tobacco industry has argued that tobacco smuggling is caused by market forces, i.e., by the price differences between countries, which create an incentive to smuggle cigarettes from 'cheaper' to 'more expensive' countries, and so urged governments to solve the problem by reducing taxes to remove this differential, which will also, they say, restore revenue. Although such market forces have some effect, smuggling is in fact more prevalent in 'cheaper' countries, and reducing tax is not the solution. Where taxes have been reduced tobacco consumption has risen and revenue has fallen, with disastrous consequences for public health. The key to understanding cigarette smuggling is understanding the role of the tobacco industry. At the heart of cigarette smuggling is large scale fraud: container loads of cigarettes are exported, legally and duty unpaid, to countries where they have no market, and where they disappear into the contraband market. They are often smuggled back into the country of origin, where they are sold at a third to half price. It is therefore profitable because duty has been illegally evaded. The key to controlling cigarette smuggling is not lowering taxes, it is controlling the tobacco manufacturing industry and its exporting practices.

Fighting tobacco dependence in Europe

The World Health Organization estimates that tobacco will become the largest single health problem by 2020, causing an estimated 8.4 million deaths annually. But the smoking burden will not be distributed evenly across the globe; deaths in developed nations are set to rise 50% to 2.4 million while those in Asia will soar fourfold to an estimated 4.2 million in 2020. In the face of such discrepancy, Martin Raw, Honorary Lecturer in evidence-based treatment at Guys, Kings and St Thomas' School of Medicine, London, explains why attention can not be focused solely on Asia and why efforts are still needed to stop smoking in Europe.

Smoking cessation guidelines for health professionals: an update. Health Education Authority

This paper updates the evidence base and key recommendations of the Health Education Authority (HEA) smoking cessation guidelines for health professionals published in Thorax in 1998. The strategy for updating the evidence base makes use of updated Cochrane reviews supplemented by individual studies where appropriate. This update contains additional detail concerning the effectiveness of interventions as well as comments on issues relating to implementation. The recommendations include clarification of some important issues addressed only in general terms in the original guidelines. The conclusion that smoking cessation interventions delivered through the National Health Service are an extremely cost effective way of preserving life and reducing ill health remains unchanged. The strategy recommended by the guidelines involves: (1) GPs opportunistically advising smokers to stop during routine consultations, giving advice on and/or prescribing effective medications to help them and referring them to specialist cessation services; (2) specialist smokers' services providing behavioural support (in groups or individually) for smokers who want help with stopping and using effective medications wherever possible; (3) specialist cessation counsellors providing behavioural support for hospital patients and pregnant smokers who want help with stopping; (4) all health professionals involved in smoking cessation encouraging and assisting smokers in use of nicotine replacement therapies (NRT) or bupropion where appropriate. The key points of clarification of the previous guidelines include: (1) primary health care teams and hospitals should create and maintain readily accessible records on the current smoking status of patients; (2) GPs should aim to advise smokers to stop, and record having done so, at least once a year; (3) inpatient, outpatient, and pregnant smokers should be advised to stop as early as possible and the advice recorded in the notes in a readily accessible form; (4) there is currently little scientific basis for matching individual smokers to particular forms of NRT; (5) NHS specialist smokers' clinics should be the first point of referral for smokers wanting help beyond what can be provided through brief advice from the GP; (6) help from trained health care professionals specialising in smoking cessation such as practice nurses should be available for smokers who do not have access to specialist clinics; (7) the provision of specialist NHS smokers' clinics should be commensurate with demand; this is currently one or two full time clinics or their equivalent per average sized health authority, but demand may rise as publicity surrounding the services increases.