Presentation by Hayden McRobbie, M.B., Ch.B., Ph.D., Auckland University of Technology, New Zealand, at the Global Bridges Preconference at the 15th World Conference on Tobacco OR Health in Singapore.

1. Europe
Tobacco Dependence Treatment
Hayden McRobbie MB ChB PhD
Wolfson Institute of Preventive Medicine, Queen Mary University of London
Faculty of Health & Environmental Sciences, Auckland University of Technology
Inspiring Limited

2. Male smoking prevalence
World Health Organization. The Tobacco Atlas. http://www.who.int/tobacco/statistics/tobacco_atlas/en

3. Europe on the Tobacco Control
Scale

4. Treatment to help dependent
smokers stop
Item Score /10
Recording of smoking status in medical notes
Legal or financial incentive to record smoking status in all medical notes or patient files 1
Brief advice in primary care
Family doctors reimbursed for providing brief advice 1
Quitline
National quitline or quitlines in all major regions of country 1
ADDITIONAL POINT FOR
Quitline counselors answering at least 30 hours a week (not recorded messages) 1
Network of smoking cessation support and its reimbursement
Cessation support network covering whole country; free 4
Cessation support network but only in selected areas; free 3
Cessation support network covering whole country; partially or not free 3
Cessation support network but only in selected areas; partially or not free 2
Reimbursement of medications
Medications totally reimbursed or free to users or 2
Medications partially reimbursed 1

5. Tobacco Treatment Scores
Country Treatment Score Country Treatment Score
UK 9 Italy 5
Denmark 7 Portugal 5
Romania 7 Hungary 5
Poland 7 Finland 4
Luxembourg 7 Spain 4
Ireland 6 Cyprus 4
France 6 Germany 4
Malta 6 Czech Republic 4
Sweden 6 Austria 4
Belgium 6 Turkey 3
Switzerland 6 Lithuania 3
Netherlands 6 Greece 3
Slovenia 6 Iceland 2
Estonia 6 Bulgaria 2
Slovakia 6 Latvia 0
Norway 5

6. Challenges
 Lack of routine brief interventions
 Lack of systems to help HCPs to
deliver brief interventions and
referral
 Lack of reimbursement

7. CASE STUDIES

8. Belgium
 ~350 "tobaccologists" trained for at least 1 year in smoking cessation
• Majority of them work within CAF (Centre d'Aide Aux Fumeurs)
• Staffed by at least one MD and one tobaccologist
• The majority of CAF are situated in hospital facilities.
 Pharmacotherapy
• NRT is not reimbursed, but mutual funds give 50 € for help in smoking cessation
• Varenicline is reimbursed after the first 15 days of treatment which are paid by the
smokers
• Bupropion is reimbursed in patients with COPD
 8 consultations for smoking cessation (over a maximum of 2 years) are
reimbursed for any MD, or a psychologist-tobaccologist.
 A minority of GP received a short training in smoking cessation provided by their
professional scientific association.
With thanks to Dr. Pierre Bartsch, professor of lung medicine at the University of Liege in Belgium

9. France
 Train ‘Tobaccologists’ (Smoking Cessation Specialist) in post-graduate courses at 5
medical schools
• 100 hours of classes, 20 hours of clinical practice, written exam, 20-30 page thesis
• Physicians can put this after their name (although not recognized as a medical
specialty), and midwives can use the title “Smoking Cessation Specialist Midwife”
 SCS can have a
• dedicated state paid position in hospitals and/or private practice
• Approximately 600 smoking cessation clinics/practices across France
 Society: http://www.societe-francaise-de-tabacologie.com/
 Treatments
• All forms of NRT (except Nasal Spray) available on prescription and OTC
• Varenicline and bupropion are prescription drugs
• Counseling is mandatory with prescription medicines
• All but varenicline is reimbursed (50 euros/year/person)
• Pregnant women: NRT reimbursed up to 150 euros/pregnancy
With thanks to Professor Ivan Berlin

10. Spain
 Three regions (Madrid, Navarra and La Rioja) have well designed smoking cessation
programmes
• Clinics in primary and secondary care facilities
• Staffed by part-time specialists
• Medications are reimbursed in some cases
• E.g. Smokers with COPD, CVD, asthma, diabetes, cancer, pregnant women and
those with psychiatric illness
 In regions where no good smoking cessation programmes exist
• A few clinics, most in hospitals
• Treatments not reimbursed
 Treatments
• NRT – gum lozenges and patch (OTC)
• Bupropion and varenicline on prescription
 Training is provided by medical societies and some universities in post-graduate courses
 The US Tobacco Dependence Treatment Guidelines have been translated into Spanish
With thanks to Professor Carlos Jimenez-Ruiz
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11. Germany
 Smoking cessation services vary across Germany, especially in the new Federal states
 In the new Federal states, the supply of smoking cessation services is insufficient
• Smoking cessation providers lack the specialised skills needed for smoking
cessation counselling and treatment
 The barriers against engagement most commonly reported included:
• lack of adequate reimbursement
• lack of training in smoking cessation promotion
• lack of demonstration materials.
 Most German health insurance funds provide reimbursement for cognitive-behavioural
group-based courses for smoking cessation
• However, the reimbursement for non-pharmacological interventions which is around
€75-100 is insufficient to cover the staff costs for providing these services
• Although physicians, hospital departments and insurance companies may provide
smoking cessation services, smokers have to pay for any pharmacotherapies they
receive
With thanks to Dr Tobias Raupach
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12. United Kingdom
 Behavioural support and pharmacotherapy fully subsidized
 Services reaching high needs areas
 In 2010/11 the English services
• Saw over 700,000 people
• About 384,000 people reported successfully quitting
at the 4 week follow-up
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13. Treatment format
∗ Brose L, West R, McDermott M, Fidler J, Croghan E, McEwen A (2011) What makes for an
effective stop-smoking service? Thorax.
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14. Medication options used
 Brose L, West R, McDermott M, Fidler J, Croghan E, McEwen A (2011) What makes for
an effective stop-smoking service? Thorax.
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15. United Kingdom
 Behavioural support and pharmacotherapy fully subsidized
 Services reaching high needs areas
 In 2010/11 the English services
• Saw over 700,000 people
• About 384,000 people reported successfully quitting
at the 4 week follow-up
 However more basic levels of brief intervention are not
routinely occurring in secondary care, and primary care
could do more
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16. Addressing the Basics
My Intervention :: Page1-Opening http://ncsct-training.co.uk/player/play/VBA
Very Brief Advice on Smoking
Introduction
A training module developed by the National Centre
for Smoking Cessation and Training (NCSCT) on
how to deliver very brief advice to smokers
This training module should take you less than 30
minutes to complete
To begin click the 'Continue' button below
Continue
http://ncsct-training.co.uk/player/play/VBA?thiz=Page1-Opening
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17. Western Pacific
Tobacco Dependence Treatment
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18. The Western Pacific
 Large geographical
area
 Many different
cultures and
languages
 Vastly different
levels of tobacco
control
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19. Barriers to smoking cessation
 Economic factors
 Lack of awareness by policy makers of the health
consequences and costs of tobacco
 Low perception of risks among the public
 Lack of policies that promote cessation
 Smoking behaviour of service providers and their own lack
of knowledge or awareness
 Poor healthcare systems
 Lack of infrastructure
 Industry action
Abdullah & Husten Thorax 2004;59:623–630
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20. Pacific Smoking Prevalence
Males Females
Rasanathan &TukuitongaJournal of the New Zealand Medical Association, 12-October-2007, Vol 120 No 1263
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21. Tobacco Control in the Pacific
 All independent Pacific countries are parties to the FCTC
 Willingness to adopt strong solutions
• Smokefree villages
• In 2007 Premier of Niue has suggested the novel
approach of financial payments of up to NZ$1700 to
each of Niue’s estimated 200 smokers to quit smoking
as a means of reducing the greater cost to the
Government of treating smoking-related illnesses
 Extensive provision of smoking cessation support which
could include face-to-face services at community meetings,
village events, and sports clubs as well as personalised
services via quitlines.
Wilson et al (2007) Journal of the New Zealand Medical
Association, 30-November-2007, Vol 120 No 1266
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22. A smokefree Fijian village
 1986 – a group of HCPs (Surfers Medical
Association) started a small scale treatment
and health promotion programme in the
Fijian village of Nabila
 1990 – ‘stocktake’
• 238 ethnic Fijians in Nabila
• 147 > 16 years of age
• 31% smokers
Groth-Marnat et al (1996) Soc. Sci. Med 43(4) 473-477
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23. A pledge to become smokefree
 If all of the smokers in the
village abstained, then the
medical team promised to
match whatever money was
raised for building a
community centre
 3 months later the medical
team received a letter to
say that Nabila was now a
smokefree village
Groth-Marnat et al (1996) Soc. Sci. Med 43(4) 473-477
2

24. Becoming smokefree
 Village aversive smoking
 Followed by a ceremony where all remaining
cigarettes were destroyed
 Kava ceremony
 Tabu established
 Village wide commitment
 Further kava ceremonies to reinforce
commitment
Groth-Marnat et al (1996) Soc. Sci. Med 43(4) 473-477
2

25. Relapse did happen
 In 4 people – with consequences
• The 1st tripped after smoking and lacerated his
scalp
• The 2nd was attacked by a dog
• The 3rd developed testicular swelling
• The 4th collapsed unconscious immediately
after smoking, whilst drinking kava
 All sought forgiveness from the elders and
got back on track
Groth-Marnat et al (1996) Soc. Sci. Med 43(4) 473-477
2

26. Australian GP Guidelines
 Recommend that HCPs
should
• Give brief advice to stop
smoking
• Make an assessment of the
smoker’s interest in quitting
• Make an offer of
pharmacotherapy and
counselling where
appropriate
• Provide self help material
• Refer to more intensive
support such as Quitline and
other local programs that
may be available in each
state.
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27. Guidelines aim to address barriers
Belief Evidence
Assistance with smoking Most patients think smoking cessation
cessation is not part of my role assistance is part of your clinical role
I have counselled all my smokers Only 45–71% of smokers are counselled
Smokers aren’t interested in Nearly all smokers are interested in quitting and more
quitting than 40% of smokers make quit attempts each year
and more think about it
I routinely refer patients for Referrals to Quitline are low (10–25%)
smoking cessation assistance
I’m not effective Clinicians can achieve substantial quit rates over 6–12
months, 12–25% abstinence, which have important
public health benefits
Smokers will be offended by Visit satisfaction is higher when smoking is addressed
enquiry appropriately
I don’t have time to counsel Effective counselling can take as little as a minute
smokers
The RACGP, Supporting smoking cessation: a guide for health professionals
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28. Smokefree Aotearoa
2025
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29. The ABCs
 A - ask whether a
person smokes
 B - give brief advice
to quit to all people
who smoke and
 C – make and offer
of and refer to
cessation treatment
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30. The Health Target
 95% of hospitalised
smokers will be provided
with advice and help to
quit by July 2012
 90% of enrolled patients
who smoke and are seen
in General Practice, will
be provided with advice
and help to quit by July
2012. 3

31. 3

32. The case in Malaysia
 Have TDT guidelines
 Lack of training for HCPs to
undertake brief interventions
 Over 300 Quit Clinics in almost every
district
• Not well utilized
 Access to most pharmacotherapies
• NRT is expensive
• Pharmacists can supply
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33. Are TDTs Cost-effective?
 Agreed that TDTs are extremely cost-effective – but it depends upon the
definition
 World Health Organization thresholds of being ‘cost-effective’ if less
than three times gross domestic product (GDP) per capita and ‘very
cost-effective’ if less than GDP per capita
 Vietnam example: GDP per capita VND 11 500 000 ($US1160)
Intervention VND per DALY averted
Physician brief advice 1,742,000
Nicotine patch 287,684,000
Bupropion 172,582,000
Varenicline 108,412,000
Higashi & Barendregt (2011) Addiction, 107, 658–670
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34. WAYS FORWARD?
Email me hayden.mcrobbie@inspiringlimited.com
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