Technical Paper 2:
Tobacco Control in Australia: making smoking history
Services and treatment
Data collected in the International Tobacco Control Policy Evaluation Project confirms that while measures of smokers’ motivation to quit do strongly predict quit attempts, they do not predict success in sustained cessation.
Smoke-free healh care
Ensure all state- or territory-funded healthcare facilities (general, maternity and psychiatric) are smoke-free, protecting staff, patients and visitors from exposure to second-hand smoke, both indoors and on health service grounds.
As of 20 April 2009 in the United States, the 1658 healthcare facilities operated by the Mayo Clinic and by SSM Health Care were all 100% smoke-free indoors and out.
Clear advice from health professionals
Ensure all patients, each time they consult a health professional – regardless of whether they are being seen in private or public, in community, general practice or institutional settings – are routinely asked about smoking status and are advised to quit.
Hospital-sponsored stop-smoking programs for inpatients that include follow-up counselling for longer than one month significantly improve patients' ability to stay smoke-free. An update of the Cochrane analysis of clinical trials of programs offered at hospitals around the world finds that efforts featuring long-term support can increase participants’ chances of success by 65%.
The results of a simulation on the effects of physician advice and smoking cessation show that offering basic advice and medication could prevent about 13% and 19% of myocardial infarctions and strokes, respectively.
A meta-analysis of the effects of subsidies for pharmacological treatments for tobacco dependence found that there was a statistically significant favourable effect of full financial interventions directed at smokers on continuous abstinence compared to no interventions with a risk ratio (RR) of 4.38 (95% CI 1.94 to 9.87). There was also a significant effect of full financial interventions when compared to no interventions on the number of participants making a quit attempt (RR 1.19; 95% CI 1.07 to 1.32; N = 3). There was a significant effect of financial interventions directed at healthcare providers in increasing the utilisation of behavioural interventions for smoking cessation (RR 1.33; 95% CI 1.01 to 1.77). Comparison of full benefit with partial or no benefit resulted in costs per additional quitter ranging from $US260 to $1453. The authors concluded that full financial interventions directed at smokers when compared to no financial interventions could increase the proportion quitting, quit attempts and utilisation of pharmacotherapy by smokers. Although the absolute differences were small the costs per additional quitter were low.
The US Preventive Services Task Force has reaffirmed its 2003 recommendation that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. The Task Force also recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counselling for those who smoke. The reaffirmation is based on information found in the updated US Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update. The US Preventive Services Task Force is the leading independent panel of experts in prevention and primary care. The Task Force, which is supported by the Agency for Healthcare Research and Quality, conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counselling and preventive medications. Its recommendations are considered the gold standard for clinical preventive services.
The New York State Department of Health has released a new round of advertisements urging healthcare providers to make it a priority to urge their patients who smoke to quit. ‘Your Patients Are Listening’ features images of patients with oversized ears to dramatise smokers' receptiveness to cessation assistance from their doctor. ‘Your Patients Are Listening’ is the second phase of the award-winning ‘Don't Be Silent About Smoking’ campaign launched last year by the State Health Department's Tobacco Control Program and its 19 Cessation Centers across the state. The campaign reached nearly four in 10 physicians in New York State. ‘Among doctors, nurse practitioners, and physician assistants who saw the campaign, 80% said the advertisements grabbed their attention and 65% reported the advertisements made them think about doing more to help their patients stop using tobacco,’ said Jeff Willett, Director of the state Tobacco Control Program. ‘Clinicians who saw the campaign were significantly more likely to ask their patients about smoking, advise them to quit, and provide medication to assist them. We expect the new advertisements to have an even greater impact on providers' behavior.’ The advertisements for the US$1.2 million campaign have run in medical journals, major daily newspapers, and other publications in New York, as well as on medical websites. The campaign's website, http://talktoyourpatients.org
, offers easy-to-access information and resources to help healthcare providers assist their patients who smoke. Source: New Anti-Smoking Ads Tell Doctors Their Patients Are 'All Ears', Yahoo, 4 March 2009.
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Developments in Australia
A study assessing the effectiveness of a smoking cessation guideline relevant to the public maternity care settings, with an accompanying implementation program throughout Queensland maternity hospitals, found that where hospitals implemented the guidelines, more women reported being satisfied with advice and the way information on smoking was presented. This smoking program resulted in a decrease of women continuing smoking during pregnancy.
Wolfenden and Wiggers have demonstrated the feasibility and effectiveness of a computer-based intervention to identify smokers and provide smoking cessation advice in a New South Wales (Hunter Valley) pre-operative clinic. The intervention was effective in encouraging patient cessation, and was inexpensive to deliver relative to other surgical costs. Furthermore, the computer-based intervention continues to operate in the preoperative clinic in the absence of ongoing research support.
The Cancer Council WA is conducting a survey of smoking cessation programs offered by Australian universities as part of the undergraduate medical curriculum. Results are pending.
Pharmacotherapies and services
Improve quality of use of pharmaco-therapies and services demonstrated to assist with smoking cessation.
With genotyping costs declining and the cost of conducting conventional trials increasing, researchers from the US National Institutes of Health and Duke University have modelled data suggesting it may save money to genetically stratify patients in clinical trials for smoking cessation. In mid-sized Phase II trials enrolling around 200 patients, ‘there was the clearest benefit for genotyping under a wide range of assumptions, [such as] cost per subject for the trial and genotyping cost per subject’, according to lead study author George Uhl of the National Institute on Drug Abuse.
Nicotine replacement therapy
Abstinence rates increase among highly dependent smokers when they are given a higher-dose nicotine patch, according to findings presented at the 2009 Joint Conference of the Society for Research on Nicotine and Tobacco (SRNT) and SRNT-Europe (Presentation title: 42 Mg/Day Pre-Cessation Nicotine Patch Treatment for Highly Dependent Smokers. Abstract PA2-3).
Researchers at The Scripps Research Institute in La Jolla, California, report learning, for the first time, that a breakdown product of nicotine, called nornicotine, has the ability to interfere with a broad range of chemical reactions in the body, and that this interaction has the potential to trigger adverse health effects. The study suggests that those who take medications while smoking or using nicotine patches or gum may be at greater risk for potentially adverse drug interactions. Nornicotine could modify these drugs, possibly reducing drug potency and causing side effects, according to the researchers. Source: Bio-Medicine.org, 2002-03-27, http://news.bio-medicine.org/medicine-news-2/Nicotine-patches-and-gum-may-pose-health-hazards-8510-1/
. Other research has indicated that endogenous formation of NNN is virtually nonexistent in long-term patch users.
Australian Researcher Raoul Walsh has reviewed previous studies relating to the effectiveness of over-the-counter nicotine replacement therapy (NRT) and concluded that the results of the studies did not convincingly demonstrate that the therapy, when used alone without additional support, was effective in helping smokers to quit.
A study of use of NRT in patients who wished to cut down smoking but who were not yet prepared to quit showed that use of NRT to cut down smoking did in fact prompt many people to quit smoking altogether.
A study of open-label varenicline augmentation found a significant improvement in mood in a small sample of outpatient smokers with persistent depressive symptoms. Larger, double-blind studies are needed to investigate the potential antidepressant effects of varenicline augmentation.
A study of smokers taking varenicline has found that those who had a prior diagnosis of probable lifetime depression did not report qualitatively worse neuropsychiatric symptoms, more new/worsening mood disturbance, or differential abstinence rates compared to smokers who were not prone to depression.
Varenicline also reduces use of alcohol in heavy-drinking smokers.
In view of the potential, if unproven, risk that varenicline may be associated with serious neuropsychiatric adverse outcomes, Cahill and Stead have recommended in their preliminary benefit-risk assessment that patients attempting to quit smoking with varenicline, and their families and caregivers, should be alerted about the need to monitor for neuropsychiatric symptoms, including changes in behaviour, agitation, depressed mood, suicidal ideation and suicidal behaviour, and to report such symptoms immediately to the patient's healthcare provider.
A review of the potential for vaccines against nicotine to increase abstinence rates in smoking cessation[146, 147] reports on three anti-nicotine vaccines currently in the advanced stage of clinical evaluation. Results show that the efficiency of the vaccines is directly related to the antibody levels of the probates, a fact that will help to further optimise the vaccine effect. The vaccines are expected to appear on the market between 2009 and 2011.
A Yale psychiatrist, Dr Judson A. Brewer, is bringing together neuroscience and Buddhist practices to help people overcome their addictions. Brewer, Medical Director of the Yale Therapeutic Neuroscience Clinic, has conducted studies with alcoholics and cocaine addicts and is now beginning research to see if teaching people Buddhist practices to increase mindfulness will help them quit smoking. Source: Ed Stannard, Register Metro Editor New Haven (CT) Register, 2009-02-23, www.newhavenregister.com/articles/2009/02/23/news/new_haven/a1_mon_buddhistsmoking.txt.
Pfizer India plans to launch 600 smoking cessation clinics across the country in the next two years, in partnership with private sector hospitals and clinics. The government had last year announced to launch the same number of clinics. The government clinics will use NRT such as chewing gum and patches, along with counselling, to help people quit smoking, a method that doctors say has far less success rate than medication which blocks the receptors in the brain absorbing nicotine. Source: The Economic Times (India), 2009-03-10.
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Developments in Australia
The Therapeutic Goods Administration has issued a warning to doctors regarding the association between varenicline (Champix®) and mental problems. By October 2008, the TGA had received 255 adverse reports describing psychiatric symptoms such as depression, abnormal dreams, insomnia, anger and aggression.
Increase the availability of Quitline services, expanding the modes of delivery of advice and support, and tailoring services for high-need and highly disadvantaged groups including pregnant women and their partners, people with chronic health conditions, those who do not speak English and people with mental illness. Ensure that funding is provided in line with increased demand generated by advertising, improved health warnings and greater activity by health professionals.
Several new reviews[148, 149] and pilot studies[150-155] have indicated the feasibility and usefulness of internet and mobile phone text messaging in encouraging and supporting smokers to quit. A meta-analysis of 22 randomised controlled trials covering a total of 29,549 participants has concluded that there is sufficient evidence to support the use of a Web- or computer-based smoking cessation program for adult smokers.
Telephone-based interventions are also feasible for assisting support persons who want to help smokers to quit.
In the United Kingdom, health insurance company Bupa has developed a ‘QuitClock’ to encourage quitters to stay off cigarettes. QuitClock is a Facebook application that not only helps track the time since the last cigarette was smoked but also offers an at-a-glance view of how much money has been saved. By using Facebook, Bupa enables users to also draw on the online support of friends and family to track progress and leave messages of support. Quitclock encourages users with a week-by-week approach, plus the added support and encouragement from family and friends. Quitclock is freely available to install on Facebook profiles at http://apps.facebook.com/quitclock
, or search for ‘Quitclock’ on Facebook. Source: Eileen Scott, Bupa Corporate Communications, www.bupa.com.
A consortium headed up by University College London has been chosen by the Department of Health to lead a nationally accredited training system for NHS Stop Smoking practitioners. The United Kingdom is the only country in the world that has a nationwide network of free stop smoking services. As part of the drive to modernise and professionalise the work of these life-saving NHS services, in July 2007 the Minister for Public Health, Dawn Primarolo, announced the government's intention to create a nationally accredited training system for the stop smoking workforce. In October 2008, the Department of Health launched a procurement process to find an organisation to set up an NHS Centre for Smoking Cessation & Training (NCSCT) and develop evidence-based training systems for the stop smoking workforce. National charity Quit and NHS Leeds are both involved in University College London's bid. Subject to contract, the NCSCT is expected to be fully operational by the end of June 2009. The initial contract will be for a period of three years. Source: The Department of Health, 30 March 2009, http://tinyurl.com/c25ykp.
Ensure that nicotine replacement therapy is affordable for all those for whom it is clinically appropriate.
Another study has indicated the potential usefulness of providing NRT to callers of the Quitline. The study found that offering a free direct mail starter pack of NRT along with telephone counselling is an effective, cost-sharing method for promoting Quitline use, enhancing participant satisfaction, and increasing the reach and effectiveness of Quitlines among Quitline callers with health insurance.
A study of quit rates among NHS patients prescribed various forms of medication suggests that ease of access may be important in determining outcomes in real-world as opposed to research settings.
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A review in the Millbank Quarterly has called on the US government to include cessation benefits in all federally funded insurance plans as part of six measures the authors argue are crucial to increasing smoking cessation in the United States.
The Department of Health and Human Services (DHHS), Division of Medicaid and Long-Term Care, held a public hearing in October 2008 to accept comments on proposed changes to regulations for the Nebraska Medical Assistance Program, also known as Medicaid. The proposed changes will provide for Medicaid coverage of tobacco cessation products and services. The Kaiser Family Foundation noted that Nebraska is one of just seven states where Medicaid does not cover smoking cessation costs. Source: AP, 2008-10-25.
In November 2008 the American Lung Association released a report on Treatments and Services Provided by Each State to Help Smokers Quit, available at www.lungusa.org. The American Lung Association called upon each state to provide all Medicaid recipients and state employees with comprehensive, easily accessible tobacco cessation medications and counselling. The Lung Association recommends states eliminate artificial barriers such as co-pays, limits on the length of treatment and prior authorisation requirements that can make it harder for smokers to get help. Eliminating these barriers is critically important for people with limited incomes, because they create obstacles that greatly discourage these smokers from getting the help they need.
The Lung Association recommends that private insurance plans should also offer comprehensive cessation coverage and encourages states to require all insurance companies to cover these treatments. To date, only eight states (California, Colorado, Maryland, New Jersey, New Mexico, New York, North Dakota and Rhode Island) have enacted legislative or regulatory standards mandating private health insurance companies to provide cessation coverage. Comprehensive coverage requires providing open access to the seven cessation medications and three forms of counselling recommended to treat nicotine addiction by the US Department of Health and Human Services (HHS). These medications include over-the-counter and prescription NRT and two non-nicotine prescription drugs: bupropion and varenicline. According to HHS, counselling should include at least four individual, group or telephone therapy sessions lasting no less than 10 minutes each. Source: Helping Smokers Quit, State Cessation Coverage, www.lungnet.org/site_files/Helping_Smokers_Quit_State_Cessation_Coverage_11-13-08.pdf.
Explore whether financial incentives might be effective in helping people to quit or stay non-smokers.
Several commentators have called for exploration of whether payments to patients might be effective in helping people to quit smoking.[161-164]
A US study of General Electric workers has found that those who were paid more than US$1140 were three times more likely to quit for at least six months.
An article in the BMJ reports that new websites in the United States are encouraging people to make public commitments to change their behaviour. Over 20,000 people have publicly signed up to change their behaviour at the online commitment store StickK (pronounced ‘stick’ – the silent second letter ‘k’ refers to the legal shorthand for contract) since the website launched in January 2008. Of these, about a third have placed a financial stake – promising to hand over a total of US$1.28 million if they fail to meet their goals. A similar initiative in the Philippines resulted in around one-third of people achieving their goals, so this approach may have some benefit for smokers in developed countries such as Australia.
Pregnant women who smoke may be offered vouchers to encourage them to give up under several health services in the United Kingdom. Telford and Wrekin Primary Care Trust said plans would include women being tested to ensure they had given up. Source: BBC Online, 2008-10-17.
Expectant mothers in the North-East Essex NHS will get £20 after a week off cigarettes, followed by £40 after another month, and a further £40 if they manage a whole year. The payments will be given as Co-op vouchers to buy anything except tobacco and alcohol. The service will pay for the scheme from its £451,000 annual ‘smoking cessation budget’. Source: Andrew Levy, The Daily Mail and Mail on Sunday (uk), 2009-01-23.
The Suffolk Stop Smoking Services is offering women free haircuts and beauty treatments under a pilot Health Enhancement Reward Scheme (HERS). Source: The Daily Mail and Mail on Sunday (uk), 2009-02-05.
A scheme was launched offering smokers in deprived areas of Dundee Scotland £12.50 a week to quit. Smokers will get the cash in the form of a credit which they can spend on groceries. It follows the success of a similar scheme by NHS Tayside for pregnant mothers. Source: £12.50 a week offer to quit smoking, Press Association, 25 March 2009.
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In the United States, a new policy at Clark Memorial Hospital gives employees who identify themselves as smokers a month to complete a smoking-cessation and education program provided by the state. Those who fail to do so will have a tobacco-use surcharge deducted from their bi-weekly pay. Feedback from smokers about the tobacco-use surcharge has been mixed. Source: Matt Koesters, News-Tribune.net (The Online Edition of the New Albany Tribune and Jeffersonville (IN) Evening News), 2009-03-26.
In Singapore, from 1 May 2009, students who are caught smoking will participate in a mandatory brief online intervention that encourages them to consider quitting smoking. There will also be more concerted efforts to reach upper primary level students. A new initiative called the ‘No Butts Project’ will provide young smokers with a redemption card when they sign up. The stamps can be redeemed for vouchers and discounts from a book store, hair salon and optician when they attend quit smoking events or counselling sessions. Source: Online counselling to be mandatory for underaged smokers, Yahoo, 29 April 2009, www.breathe.sg and www.hpb.gov.sg/quit4life.