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WHO Europe evidence based recommendations on thetreatment of tobacco dependence M Raw, P Anderson, A Batra, G Dubois, P Harrington, A Hirsch, J Le Houezec,A McNeill, D Milner, M Poetschke Langer, W Zatonski—Recommendations panel. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The following recommendations on the treatment oftobacco dependence have been written as an initiative of the World Health Organization European Partnership At the time of going to press the followingorganisations have endorsed these guidelines: Project to Reduce Tobacco Dependence.
ASH England, ASH Scotland, Alliance pour la . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
santé; coalition contre le tabagisme (France),British Medical Association, Comité NationalContre le Tabagisme (CNCT), Comité Nacional de Thiswasathreeyearproject,fundedlargelyby PrevencióndelTabaquismo(Spain),CzechMedi- three pharmaceutical companies that manu- cal Association, Danish Medical Association, facture treatment products for tobacco de- Dentistry against Tobacco (Sweden), European pendence, but managed by WHO Europe and a steering group which included government repre- sentatives and many public sector organisations.
Against Tobacco, The European Review Group on The project focused on five areas: tracking smokers’ Prevention and Health Promotion in Family behaviour and intention to change; the regulation Medicine and General Practice (EUROPREV), of tobacco products and tobacco dependence treat- Europharm Forum, Georgian Medical Associ- ment products; smoke free places and workplace ation, German Coalition against Smoking, Ger- policies; the implementation of evidence based man Medical Association, German Scientific treatment; and communicating the health mes- Society for Smoking Cessation, German Society sages about stopping smoking. These recommen- for Addiction Research and Therapy, German dations were written as part of the activities in Society for Nicotine Research, Norwegian Medical support of evidence based treatment, and are one Association, Slovenian Medical Association, Soci- of a number of outputs available from the project ety for Research on Nicotine and Tobacco (SRNT) Europe, Swedish Medical Association, Quit (UK), They were commissioned by the World Health World Self-Medication Industry. The latest en- Organization and have drawn on the experience dorsement was received on 15 November 2001.
of a number of European countries, including thefour original target countries of the partnership project: France, Germany, Poland, and the UK.
Tobacco dependence treatment includes (singly or in combination) behavioural and pharmacologi- meetings on evidence based treatment, in London cal interventions such as brief advice and in November 1999 and in Barcelona in October counselling, intensive support, and administra- 2000, and revised in the light of feedback follow- tion of pharmaceuticals, that contribute to reduc- ing those meetings. They also take into account ing or overcoming tobacco dependence in indi- feedback from a wide variety of individuals and viduals and in the population as a whole. A organisations, including the 25 professional asso- smoking cessation specialist is someone trained and ciations that have endorsed them to date.
paid to deliver skilled support to smokers who It is recognised that individual countries will need help in stopping, over and above brief translate and adapt these recommendations to opportunistic advice. They need not be medically suit their own terminologies and healthcare trained but should not be offering this support systems, but it is hoped that throughout this unpaid and squeezed into their normal work, as process countries will stay as close as possible to the evidence suggests this is not effective.
Tobacco dependence is recognised as a condition As these are evidence based recommendations in the WHO’s International classification of diseases and this is a rapidly developing field, they will (ICD-10)1 and the American Psychiatric Associa- . . . . . . . . . . . . . . . . . . . . . . .
need periodic updating. Comments are thus wel- tion’s Diagnostic and statistical manual, fourth come, as are organisations that would like to add edition (DSM-IV).2 In Europe millions of smokers their name to the list of endorsers. New endorsers want to stop smoking and many have tried to do will be added to the document posted on the web.
so but have difficulty succeeding because tobacco The recommendations can be found on the WHO use is such a powerful addiction.3 Although the [email protected] (www.who.dk/tobacco) and ASH (www.ash. majority of cessation attempts are unaided, the . . . . . . . . . . . . . . . . . . . . . . .
success rate of these unaided attempts is low.
Recommendations on treating tobacco dependence Smoking is a chronically relapsing condition, and even in the and Swedish Council on Technology Assessment in Health general population of smokers trying to stop, the relapse rate Care, Sweden, 19988; Conclusions and recommendations of the con- is high. The natural population cessation rate, measured over sensus conference, France, 19999; Smoking cessation guidelines for a long period in the UK, where the tobacco control movement health professionals: an update, UK, 200010; and the Cochrane is long established, is only about 2% each year.3 Library systematic reviews.11 These reviews and guidelines Tobacco use is recognised as a major cause of lung cancer, draw on hundreds of well controlled trials, and emphasise not cardiovascular disease, and chronic obstructive lung disease only that treatment for tobacco dependence is effective, but (including bronchitis and emphysema), and causes 1 200 000 also that it is extremely cost effective: Guidance for commission- deaths each year in WHO’s European region (14% of all ers on the cost effectiveness of smoking cessation interventions, deaths). Unless more is done to help the 200 million European England, 199812; Curbing the epidemic. Governments and the adult smokers stop, the result will be 2 000 000 European economics of tobacco control, 1999.13 These WHO recommendations are complemented by a Support and treatment to help smokers stop is one of a range WHO report on the regulation of tobacco dependence of approaches to tobacco control. It is an issue not just for indi- treatment products, which emerged from a meeting held in vidual health professionals in their work with smokers, but for Helsinki in October 1999. The Helsinki report notes the the entire healthcare system. It complements other approaches contrast between the easy availability of tobacco products and (like policies to tax tobacco products, restrictions on their use tobacco dependence treatment products, which are much and advertising, regulation of their contents and labelling, pub- harder to obtain, and urges the development of regulatory lic information, and education) but addresses a specific group: approaches which will redress this imbalance.5 those who want to stop and need help.5 However, it is acknowl- The evidence supports the development of three main types edged that education remains crucially important in informing of intervention for health care systems: brief opportunistic smokers about the dangers of smoking and motivating them to interventions delivered by health professionals in the course of stop, and in many countries health education campaigns are their routine work; more intensive support delivered by conducted by the health care system. Furthermore, preventive treatment specialists, often in what have been called “smokers approaches with young people, if effective, prevent disease clinics”; and pharmacological aids, which approximately double 30–50 years in the future, whereas smoking cessation in current cessation in minimal or more intensive settings. The principal adult smokers brings population health gain more quickly, over aids in the last category are nicotine replacement therapy (NRT) and bupropion, which is now widely available in Europe. NRT However, support and treatment to help smokers stop is not can be found on prescription, over-the-counter, and on general yet widely available. It is generally not integrated into sale in Europe. Bupropion is a prescription only medicine.
European healthcare systems, although some countries are Although the evidence base is stronger for some health pro- now making a start. Paradoxically, in contrast to the restricted fessionals than others, the involvement of health professionals availability of help for smokers in stopping (including in offering smokers help should be based on factors such as pharmaceutical products designed to alleviate tobacco with- their access to smokers and level of training and skill, rather drawal), the tobacco products whose use causes the enormous than professional discipline. Thus the recommendations for burden of death and disease described above are extremely health professionals are relevant for all health professionals and not only those based in primary care. The essentialfeatures of individual smoking cessation advice have been described as the four As: ask (about smoking at every oppor- These recommendations propose the core interventions that tunity); advise (all smokers to stop); assist (the smoker to should be integrated into healthcare systems, interventions stop); arrange (follow up).14 The updated US guideline has that have been shown to work by a large and consistent inter- introduced a new A in between advise and assist: assess will- national body of evidence. The recommendations are deliber- ately brief and general, rather than comprehensive, and detail It is hoped that periodically, as new evidence becomes should be sought from the reviews and guidelines they draw available, as well as experience gained from the implementa- on (see below). This is because there is such a diversity of tion of these recommendations, they will be revised and social and healthcare systems throughout Europe, including different regulatory and pharmaceutical treatment productlicensing regimes. We hope each country will use these core evidence based recommendations as a skeleton on which they 1) Recommendations for brief interventions will add their own country specific detail. Because the recom- As part of their normal clinical work, health professionals mendations are brief, they need to be read bearing in mind the should provide brief interventions including the following context set out in this introduction. They also cover the roles of individual health professionals working to help and treat Ask about and record smoking status, keep record up to date
smokers as well as the roles of the wider healthcare system.
Advise smokers of the benefit of stopping in a personalised
This is important as public health impact will be a result not and appropriate manner (this may include linking the advice only of individual clinical effectiveness but also of coverage – hence the importance of engaging the entire system locally, Assess motivation to stop
Assist smokers in their stop attempt if possible; this might
include the offer of support, recommendation to use NRT or These recommendations reflect a global movement towards bupropion and accurate information and advice about them, evidence based medicine, and reflect the fact that an increas- referral to a specialist cessation service if necessary ing number of countries are adopting evidence based Arrange follow up if possible.
guidelines for the treatment of tobacco dependence. A number If help can be offered a few key points can be covered in a of authoritative reviews and guidelines have been used as the basis for these recommendations: US Department of Healthand Human Services Public Health Service Clinical Practice • set a stop day and stop completely on that day Guideline Treating tobacco use and dependence, 20007; Conclusions: • review past experience and learn from it (what helped? smoking cessation methods, National Institute of Public Health treatments should be as wide as possible with due regard to • identify likely problems and plan how to cope with them local regulatory frameworks and other circumstances. Mecha-nisms should be found to increase the availability of treatment • ask family and friends for support.
to low income smokers, including at a reduced cost or free of Smoking and smoking cessation should be part of the core curriculum of the basic training of all health professionals.
Health professionals should be trained to advise and help smokers stop smoking, and health care purchasers should 2) Recommendations for smoking cessation specialists ensure the provision of adequate training budgets and The health care system should offer treatment as back up to training programmes. Education and training for the different brief opportunistic interventions for those smokers who need types of interventions should be provided not only at the post- more intensive support. This support can be offered individu- graduate and clinical level, but should start at undergraduate ally or in groups, and should include coping skills training and and basic level, in medical and nursing schools and other rel- social support. A well tested group format includes around five sessions of about one hour over about one month with follow Telephone helplines can be effective and are very popular up. Intensive support should include the offer of or with smokers. Although more research is needed on their encouragement to use NRT or bupropion (as appropriate) and effectiveness, they seem likely to provide a valuable service to clear advice and instruction on how to use them.
smokers and should be made available where possible.
3) PharmacotherapiesAt the moment the principal aids in this category are NRT and . . . . . . . . . . . . . . . . . . . . .
bupropion. There are currently six NRT products: patch, gum, nasal spray, inhalator, tablet, lozenge. Smokers of 10 or more M Raw, Guy’s King’s and St Thomas’ School of Medicine, University ofLondon, London, UK cigarettes a day who are ready to stop should be encouraged to P Anderson, Department of Primary Health Care, Oxford University, use NRT or bupropion as a cessation aid. Health professionals who deliver smoking cessation interventions should give A Batra, Department of Psychiatry and Psychotherapy, University of smokers accurate information and advice on these products.
Tübingen, GermanyG Dubois, Medical School of Amiens, France; French National In Europe NRT can be found on prescription, over-the-counter, and on general sale. Bupropion is a prescription only medicine P Harrington, WHO European Partnership Project to Reduce Tobacco and on current evidence should remain so. Evidence on the Dependence, WHO Regional Office for Europe, Copenhagen, Denmark effectiveness of bupropion is currently limited to medium to A Hirsch, Alliance pour la Santé; coalition contre le tabagisme, Paris,France heavy smokers receiving behavioural support.
J Le Houezec, R&D Consumer Healthcare, Pharmacia; SRNT Europe,Rennes, France A McNeill, St George’s Hospital Medical School, University of London, Treatment research has tended to focus on health profession- als such as doctors (especially in primary care), nurses, D Milner, Department of Health, London, UK midwives, pharmacists, and smoking cessation specialists.
M Poetschke Langer, Cancer Prevention Unit, DeutschesKrebsforschungszentrum, Heidelberg, Germany However, advising and supporting smokers in stopping is an W Zatonski, Department of Cancer Epidemiology and Prevention, M activity for the whole health care system and should, eventu- Skodowska-Curie Memorial Cancer Centre and Institute of Oncology, ally, be integrated into as many settings as possible throughout the system. This includes hospital and communitysettings. In many countries, however, there is still a high smoking prevalence among health professionals, so in 1 World Health Organization. International statistical classification of diseases and related health problems, 10th revision. Geneva: WHO, addition to the education and training recommended below, health professionals should where appropriate be targeted for 2 American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV). Washington DC: American Hospital staff should ask about patients’ smoking status 3 Tobacco Advisory Group, Royal College of Physicians. Nicotine before or on admission, and offer brief advice and assistance to addiction in Britain. London: Royal College of Physicians, 2000.
those interested in stopping. Patients should be advised of the 4 World Health Organization Europe. Partnership to reduce tobacco hospital’s smoke free status before admission. Hospital 5 World Health Organization. Conclusions of conference on the patients who need it should also be offered NRT or bupropion.
regulation ot tobacco dependence treatment products. Copenhagen: Healthcare premises and their immediate surroundings 6 Peto R, Lopez A. Future worldwide health effects of current smoking patterns. In: Koop CE, Pearson CE, Schwarz MR, eds. Critical issues in Pregnant smokers should receive clear and accurate global health. San Francisco: Jossey-Bass, 2000.
information on the risks of smoking to the fetus, and be 7 Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and advised to stop smoking. They should be offered specialist dependence. Clinical Practice Guideline. Rockville, US Department ofHealth and Human Services, 2000.
8 SBU Board of Directors and Scientific Advisory Committee.
Cessation interventions shown to be effective with adults Conclusions: smoking cessation methods. Stockholm: National Institute of should be considered for use with young people, with the con- Public Health and Swedish Council on Technology Assessment in HealthCare, 1998.
9 Agence Nationale d’Accreditation et d’Evaluation en Sante.
Consensus conference on smoking cessation; English summary by 5) Recommendations for health care purchasers and Jacques Le Houezec. Paris: ANAES, 1999.
10 West R, McNeill A, Raw M. Smoking cessation guidelines for health Purchasing treatment for tobacco dependence represents an 11 Lancaster T, Stead L, Silagy C, et al. Effectiveness of interventions to extremely cost effective way of reducing ill health and help people stop smoking: findings from the Cochrane Library. BMJ prolonging life. Health care purchasers should purchase tobacco dependence treatments, choosing a blend of interven- 12 Parrott S, Godfrey C, Raw M, et al. Guidance for commissioners on the cost-effectiveness of smoking cessation interventions. Thorax tions relevant to local circumstances but emphasising those interventions which have the strongest evidence base.
13 World Bank. Curbing the epidemic. Governments and the economics of Because tobacco dependence treatment is so cost effective, tobacco control. Washington DC: World Bank, 1999.
14 Glynn TJ, Manley MW. How to help your patients stop smoking. A it should be provided by public and private health care National Cancer Institute manual for physicians. Washington DC: US systems. Access to both behavioural and pharmaceutical Department of Health and Human Services, 1989.

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