Treating tobacco dependence: guidance for primary care on life-saving interventions. Position statement of the IPCRG

Abstract

Tobacco smoking is the world’s leading cause of premature death and disability. Global targets to reduce premature deaths by 25% by 2025 will require a substantial increase in the number of smokers making a quit attempt, and a significant improvement in the success rates of those attempts in low, middle and high income countries. In many countries the only place where the majority of smokers can access support to quit is primary care. There is strong evidence of cost-effective interventions in primary care yet many opportunities to put these into practice are missed. This paper revises the approach proposed by the International Primary Care Respiratory Group published in 2008 in this journal to reflect important new evidence and the global variation in primary-care experience and knowledge of smoking cessation. Specific for primary care, that advocates for a holistic, bio-psycho-social approach to most problems, the starting point is to approach tobacco dependence as an eminently treatable condition. We offer a hierarchy of interventions depending on time and available resources. We present an equitable approach to behavioural and drug interventions. This includes an update to the evidence on behaviour change, gender difference, comparative information on numbers needed to treat, drug safety and availability of drugs, including the relatively cheap drug cytisine, and a summary of new approaches such as harm reduction. This paper also extends the guidance on special populations such as people with long-term conditions including tuberculosis, human immunodeficiency virus, cardiovascular disease and respiratory disease, pregnant women, children and adolescents, and people with serious mental illness. We use expert clinical opinion where the research evidence is insufficient or inconclusive. The paper describes trends in the use of waterpipes and cannabis smoking and offers guidance to primary-care clinicians on what to do faced with uncertain evidence. Throughout, it recognises that clinical decisions should be tailored to the individual’s circumstances and attitudes and be influenced by the availability and affordability of drugs and specialist services. Finally it argues that the role of the International Primary Care Respiratory Group is to improve the confidence as well as the competence of primary care and, therefore, makes recommendations about clinical education and evaluation. We also advocate for an update to the WHO Model List of Essential Medicines to optimise each primary-care intervention. This International Primary Care Respiratory Group statement has been endorsed by the Member Organisations of World Organization of Family Doctors Europe.

Examining inequality in trials of smoking cessation interventions delivered in primary care: critique and reanalysis of Cochrane reviews

“…The following intervention types were included: behavioural interventions (including lea ets/booklets, brief advice and very brief advice); pharmacological (nicotine replacement therapy and medication such as varenicline and bupropion); and any combination of these interventions. These interventions were chosen because they are the predominant smoking cessation interventions delivered in primary care, as indicated in a position statement by the International Primary Care Respiratory Group in 2017 (35).…”

From Good to Great: The Role of Performance Coaching in Enhancing Tobacco-Dependence Treatment Rates

“…18 All teams were exposed to this multicomponent intervention that combines several evidence-based strategies including (1) outreach facilitation, (2) clinician training, (3) EHR tools and prompts, (4) practice tools and patient self-help material, and (5) smoker's follow-up system. 5,10,11 Table 2 provides a description of the OMSC intervention components.…”

“…[1][2][3] The 5 As strategy (Ask, Advise, Assess, Assist, Arrange) is the basis for tobacco-dependence treatment in clinical settings; however, integrating evidence-based tobacco-dependence treatment into clinical practice routines remains a challenge. [1][2][3][4][5][6][7][8] The important role of family medicine in addressing tobacco use with patients is well recognized, and multiple international guidelines and reports have identified the need to increase rates of tobacco-dependence treatment in primary care settings. [1][2][3][4][5][6][7][8][9] Strategies, including clinician training, electronic health record (EHR) prompts, and adjunct counseling, have been shown to significantly increase rates of tobacco-dependence treatment in primary care settings.…”

“…[1][2][3][4][5][6][7][8] The important role of family medicine in addressing tobacco use with patients is well recognized, and multiple international guidelines and reports have identified the need to increase rates of tobacco-dependence treatment in primary care settings. [1][2][3][4][5][6][7][8][9] Strategies, including clinician training, electronic health record (EHR) prompts, and adjunct counseling, have been shown to significantly increase rates of tobacco-dependence treatment in primary care settings. [10][11][12][13][14] Metaanalyses show that multicomponent interventions combining several intervention strategies are the reference standard for increasing clinician performance in delivering tobacco-dependence treatment.…”

Tobacco cessation in low‐ and middle‐income countries: some challenges and opportunities

“…support should be mandatory in HIV/AIDS and tuberculosis services because of worse outcomes reported in smokers [6]. Additionally, enlisting community leaders such as teachers and religious leaders to discourage tobacco use and promote cessation is likely to yield success [8].…”