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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.
A questionnaire on tobacco dependence treatment services was emailed to a convenience sample of contacts in 2007. Completed questionnaires were received from contacts in 36 countries.
The survey instrument was a ten item questionnaire asking about treatment policy and practice, including medications.
According to our informants, fewer than half the countries in our survey (44%) had an official written policy on or a government official responsible for treatment (49%). Only 19% had a specialised national treatment system and only 24% said help was easily available in general practice. Most countries (94%) allowed the sale of 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.
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.
The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) (1) and $500 million of new funding from the Bloomberg and Gates Foundations (2) have injected new energy into the tobacco control field, helping to drive the implementation of effective interventions at national and international level. The FCTC recognizes the addictive nature of tobacco use and Article 14 (Box) obliges countries to develop evidence based treatment guidelines and take effective measures to promote adequate treatment for tobacco dependence. Thus this is a critical time for the treatment of tobacco dependence.
The recently published 2008 WHO Global Tobacco Epidemic report recommends six policies to counter the tobacco epidemic (the MPOWER package): monitor tobacco use and prevention polices, protect people from tobacco smoke, offer help with quitting, warn about the dangers of tobacco, enforce bans on advertising and promotion, and raise tobacco taxes (3). Public health policies (these policies except treatment) create a culture in which smokers want to stop, however in many countries although a high proportion want to stop the unaided quit rate is extremely low (4) and many smokers need help (5). Backing up public health policies with help for smokers who need it will make public health approaches more acceptable politically (3) and more effective (6). In the UK, which has a tobacco dependence treatment system integrated into its national health service, approximately 5% of all smokers receive treatment each year, suggesting that a treatment service can achieve good population coverage (7). These figures are comparable to the reach of quitlines, 1% to 8% of smokers in one review (8).
Furthermore tobacco dependence treatment is effective (9, 10), and so cost effective and inexpensive compared with most other healthcare interventions (11) that it should be a top priority for healthcare systems. Investing in treatment will save substantial future costs from treating illnesses such as lung cancer and heart disease (12).
This paper reports the results of a survey of national tobacco dependence treatment services in 36 countries in 2007. The goal was to collect detailed information on the availability of treatment in a diverse group of countries around the world, in order to assess the state of treatment in these countries, and help us understand the barriers to action and opportunities for improvement. A parallel survey of tobacco dependence treatment guidelines in 31 countries will be reported in another paper.
Because there is potential confusion over use of the terms smoking cessation and tobacco dependence treatment we use the definition of treatment from WHO'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” (13). We use the term smoking cessation to mean all cessation, whether it occurs as a result of public health 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.
For this study we surveyed a convenience sample of people working in tobacco control in 36 countries. We drew up the sample in the following manner: in 2005 we asked to hear from people whose countries had treatment guidelines, through the listserves of the Society for Research in Nicotine and Tobacco and UICC Globalink; in 2007 we contacted the Framework Convention Alliance (FCA) who were surveying 27 of the first 41 countries that ratified the FCTC (14) and asked if we could send out guidelines questionnaire to them; in 2007 we repeated the SRNT and Globalink listserve enquiries; from all these enquiries we made contact with people in 31 countries who filled in our guidelines questionnaire; in July 2007 we sent the treatment questionnaire to these contacts and received 29 completed questionnaires; this process resulted in a list of 14 countries that did not have treatment guidelines; we asked these contacts to fill in the treatment questionnaire and 7 agreed; thus our final sample was of contacts in 36 countries. Data collection ended in October 2007.
Most of the 36 informants were members of the SRNT and Globalink listserves, the main listserves in the field, both long established and well regarded. Most worked outside government but a few were government officials. Some were treatment specialists, many were not, but all were active in the tobacco control field. The final sample (Table 1) included countries from all four World Bank income bands and almost every region of the world. A fuller description of the methods is available at url from Addiction.
Our questionnaire was developed from two earlier survey instruments, “A tool to assess the available services for smoking cessation at the country or regional level” (15) and the Tobacco Control Scale (16). A draft was circulated to a group of treatment specialists (see acknowledgements) and it was finalised after receiving their feedback. The questionnaire asked about: the country's official treatment policy and what is in it; if there is an officially identified person in government managing treatment services; if the country has a quitline (answered by staff and not mainly by recorded message); if the country has a specialised treatment system; in which settings smokers can easily get help; the availability and licensing of medications; reimbursement of treatment; and reimbursement of health professional time. The full questionnaire is available at url from Addiction.
We calculated a composite treatment score (CTS), based in part on the Tobacco Control Scale (16), from five items, on official treatment policy, quitlines, treatment systems, availability of medications and other cessation support, and reimbursement to patients for medication costs and to providers for treatment, corresponding to items 4 to 9 of Table 1, plus a question about reimbursement. These items were chosen on the basis of the evidence for their efficacy, WHO's recommendations, and our own judgment of their importance in an overall treatment programme. The maximum composite score is 18. If a respondent failed to give an answer to a CTS subscale item, it was excluded and the other items in the subscale were reweighted, so that the subscale retained the original maximum score. The CTS is available at url from Addiction.
Table 1 shows key treatment policies by country, with countries listed by their World Bank income level (17). Within income level we have listed countries in order of how many policies they have (fewest at top). The median composite treatment score ranged from 3 for the lowest income group to 10.5 for the high income countries.
Sixteen of 36 respondents (44%) said they have an official written government policy on treatment and 17 (49%) said that there is an officially identified person in charge of treatment services. Approximately half of respondents said that the official policy included strategies on training, a research strategy, supporting interventions by primary care professionals, and promoting the use of pharmaceutical products. Forty four percent said that the policy included intensive support in specialised treatment facilities, and 75% that the policy included quitlines. Only 31% said that the policy included the mandatory recording of patients' smoking status in medical notes. The second column of Table 1 shows whether a country has tobacco dependence treatment guidelines.
Twenty two respondents (61%) said they had a quitline with national coverage (Table 1) while 14 countries (39%) said they did not have a national quitline. Of the 14 Chile, Japan, Portugal, the Russian Federation and the USA said they had a patchwork of local lines, Ghana and Mongolia said they were planning a quitline, and Bangladesh, India, Kyrgyzstan, Mauritius, Pakistan, Palau and Spain said they did not have a quitline and did not indicate that they were planning one. Almost all (96%) had quitlines staffed by people most of the time, with just 15% using mostly recorded messages. Almost three-quarters offered free calls, almost half provided mutliple sessions with counsellors calling back to offer support, three-quarters referred callers to local treatment services, and one fifth provided medications. The Netherlands quitline offered the most comprehensive service including a person answering, free calls, multiple sessions with calling back, referral, and medications. New Zealand comes close, but does not provide referrals.
Seven respondents (19%) said their country had a national treatment system: Czech Republic, Slovakia, England, France, Japan, Scotland and Slovenia (Table 1). Almost all the others, 28 (78%), said they have a network of support but only in selected areas or a few centres, with one country, Palau, with no treatment services at all.
Eight respondents reported that help was not easily available in any setting: Germany, India, Kyrgystan, Mauritius, Mongolia, Russia, Spain, and Sweden.
Table 1 shows that almost all countries had NRT available for sale in some fashion; three-quarters had bupropion, two-thirds had varenicline, and around one in seven cytisine for sale. Details of availability, licensing and television advertising are presented in Table 3. Of the NRTs only the gum and patch are available in almost all countries, nicotine nasal spray was the least available, in around a quarter of countries. Respondents in eight countries mentioned “other” medications: clonidine, nortriptyline and rimonabant. One country said that antidepressants were available for the depressant phase of withdrawal and anxiolytics for the anxiety phase of withdrawal. Very few countries permit stop smoking medications on general sale (ie. in any shop, for example supermarkets) and the few that do typically permit just nicotine gum and patches. Most countries allow the sale of NRT through pharmacies (called “over-the-counter” or OTC in some countries) but relatively few allow the sale of non-nicotine medications through pharmacies without prescription. Very few countries make NRT available on doctor's prescription. Finally, only nicotine gum and patches can be advertised on television in a significant number of countries.
In Tables 4 and and55 we present results on reimbursement of treatment (behavioural and pharmaceutical) and reimbursement of health professionals' time. According to our informants very few countries fully reimburse medications (more than two thirds provided no reimbursement of medications at all), fewer than half fully reimburse brief advice, fewer than one third fully reimburse intensive specialised support, and almost two thirds of GPs and almost half of general practice nurses and hospital doctors were reimbursed for providing smoking cessation support, or it was considered part of their normal contract and salary.
This paper reports on the state of tobacco dependence treatment in 36 countries at a level of detail not previously published, on the basis of a survey completed mostly by contacts outside government. Our findings clearly show that in our sample most countries have a long way to go to achieve comprehensive treatment services for dependent smokers.
Fewer than half the countries in our survey had an official written policy on treatment or a government official responsible for treatment, suggesting that at national level treatment is not yet a priority in many countries. Very few countries had a treatment system with national coverage; fewer than a quarter said help was easily available in general practice; few countries permitted NRT on general sale; in most countries NRT was not available on a doctor's prescription; few countries fully reimbursed any of the medications; fewer than half of countries reimbursed brief advice/support; and fewer than one third reimbursed intensive specialist support. Taken together these findings show that few countries provide comprehensive tobacco dependence treatment services.
Of the countries that had an official written policy on treatment (only 44% of our sample), fewer than a third (31%) included in the policy the mandatory recording of patients' smoking status in medical notes. Without such basic information it seems unlikely that health professionals will routinely intervene with smokers, and this finding clearly shows one of the barriers to engaging national healthcare systems in dealing with smoking. The recommendation in the recent WHO MPOWER report that brief advice should be part of all tobacco prevention programmes (3) is clearly a long way from being realised. It is perhaps not surprising then that respondents in fewer than a quarter of countries reported that smokers could easily get help in general practice.
It is encouraging that almost two thirds of countries surveyed had quitlines with national coverage, and almost all were staffed by counsellors (as opposed to offering mainly recorded messages), but disappointing that less than half offered multiple sessions with call back counselling, the approach for which the evidence is strongest (18). Obviously such an approach would cost more but quitlines would still be a relatively inexpensive way of offering support to smokers given their potential reach. Smokers in lower income countries in particular stand to benefit from phone counselling because they frequently have no access to face-to-face treatment services but do possess mobile phones. Even in high income countries, there is room for improvement in quitlines: only the Netherlands has a quitline providing a full range of services.
It is also encouraging that nicotine gum and patch (but not the other NRTs) were very widely available and, to a slightly lesser extent, so were bupropion, and varenicline. Most countries allowed the sale of nicotine gum and patches through pharmacies. However since few countries fully reimbursed any of the medications, and most countries only partially reimburse health professionals' time for giving smoking cessation support, it remains the case that for most smokers in most countries treatment is not easily accessible.
The composite treatment score (CTS) was higher in countries with higher incomes (Table 1). England and Scotland top the table, reflecting the fact that they offer tobacco dependence treatment to all smokers through their national healthcare systems, which is free at the point of use to all. England is also the only country which has all the policy elements in Table 1. However, the median CT scores by income group in Table 1 show that even upper-middle and high income countries only scored around half the maximum possible score. There is much room for progress. On the basis of these findings, we intend to refine the CTS and develop it further.
A limitation of our study is that it was not of a representative sample of countries, and that our responses from each country depended on the accuracy of reports from the contacts who filled in the questionnaires. Most were members of the SRNT and Globalink listserves, the main listserves in the field, both long established and well regarded. Some were treatment specialists but many were not. Although we made a considerable effort to find people knowledgeable about treatment services, some may not have known of all activities or plans in their country, and building this sample of just 36 contacts took a considerable amount of time. Nevertheless this survey provides a level detailed information on treatment in 36 countries not previously published, and the countries represent all the four World Bank income levels (17) and all major regions of the world, and thus we feel gives a useful snapshot of the state of tobacco dependence treatment services around the world.
Furthermore our findings are broadly consistent with those presented in the 2007 FCA Monitor (19) and the WHO MPOWER report (3) and reinforce WHO's conclusion that “the overwhelming majority of the world's population - - - does not have adequate access to help for quitting tobacco use”. We hope that the FCTC will stimulate the development evidence based tobacco dependence treatment and that our results help us understand some of the barriers action, opportunities for improvement, and help inform the process of developing guidelines on Article 14.
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.
We gratefully acknowledge the Society for the Study of Addiction for financial support for the data analysis and writing up of this report, Doreen McIntyre and the Global Treatment Partnership for financial support of the survey, and Catherine Slevin for research assistance with the survey. We thank the following for advice on various aspects of the project including developing the questionnaire: Mira Aghi, Peter Anderson, Linda Bailey, Rick Botelho, David Graham, Joe Gitchell, Paul Hooper, John Hughes, Natasha Jategaonkar, Luk Joossens, Hayden McRobbie, Yumiko Mochizukiy, Hana Ross, Peter Selby, Karen Slama, Fran Stillman, Ken Wassum, Robert West, Heather Wipfli. Finally we sincerely thank the many country contacts who filled in the questionnaire and without whom this survey could not have happened.
The Society for the Study of Addiction is a learned society based in Britain. The Global Treatment Partnership is a project funded by Pfizer and other organisations hosted by the International Non-Governmental Coalition Against Tobacco (INGCAT), whose director is Doreen McIntyre.