National Drug Strategy
National Drug Strategy

This is a submission on the Draft of the National Tobacco Strategy 2012-2018 on behalf of the Australian Association of Tobacco Treatment Specialist (AASCP)

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Overview

This submission links with the National Tobacco Strategy Draft Proposal 2012-2018 which outlines priorities and targets for improved health, through reduced smoking rates by delivering better national services to “improve the health of all Australians by reducing the prevalence of smoking and its associated health, social and economic costs, and the inequalities it causes”.

Further this submission is aligned with the World Health Organisation’s Evidence Based Recommendations on the Treatment of Tobacco Dependence, which state that “purchasing treatment for tobacco dependence represents an extremely cost effective way of reducing ill health and prolonging life”.

Moreover, the recommendations in this proposal concur with the report of the NSW Joint Parliamentary Select Committee’s Inquiry into Tobacco Smoking in NSW (June 2006) regarding the need for resource enhancement for smoking clinics and/or smoking cessation therapists within area health services.

Importantly, this submission is also aligned with the Framework Convention on Tobacco Control, Article 14, to which Australia is a signatory, and which states “that each country should take effective measures to promote cessation of tobacco use and provide adequate treatment for tobacco dependence” (W.H.O., 2005).

This submission points out priority gaps
a) in services and treatment for tobacco dependence.
b) the need for evidence –based training for health professionals

Introduction

Notwithstanding a decrease in the prevalence of tobacco smoking in Australia over the last 25 years, there is universal consensus on the continuing burden of tobacco smoking, and the benefits of reducing smoking prevalence.

Aside from the enormous financial costs to Australia community ($31.5 billlion AUD in 2004/5. (Collins, 2004), and the costs to Australia in direct health care (gross cost $1.836 billion AUD), many of the personal costs are borne by the most disadvantaged members of the population.
Forty per cent of Australia’s smokers make at least one serious quit attempt in a twelve month period (on average 2.1 attempts) (Borland, 2011). However, over 95 percent of unaided quit attempts, fail (Hughes, 2004) adding to the potential risk of morbidity and mortality occurring with each progressive year of smoking (Doll, 2004).

Public health approaches, such as mass media campaigns, cigarette tax rises and smoking bans have been effective for some smokers. However, quitting rates have stalled in recent years as the relative proportion of more heavily addicted smokers increases (Hughes, 2011). Many of these smokers need specialist evidence-based professional advice and medication to quit successfully long-term (Rennard, 2012, Mohiuddin, 2007) and save their lives.

Prevalence of Tobacco Smoking

The prevalence of tobacco smoking in Australia has fallen substantially over the last 25 years. This decline has been largely attributed to population based approaches to smoking cessation. However, smokers are not a homogenous group (Markou, 2008, Benowitz, 2010). There is a wide range of nicotine dependence as measured by nicotine plasma levels and urine cotinine concentrations, genetic metabolic and neurological responses to nicotine. Public health approaches, including television advertising and public education campaigns, have demonstrated acceptable quit rates in smokers and may positively address some but not all smokers.

There are still approximately 3.3 million smokers in Australia. Smokers live 10 years less on average than non-smokers and every second continuing smoker dies prematurely from their smoking.

Clearly, it is time that best practice, evidence-based smoking cessation for tobacco dependent patient should be given a much higher priority in the health care system than it currently receives in this country (Bittoun,2010).

Tobacco Dependence as a substance abuse disorder

Smoking (nicotine or tobacco dependence) is now coded as a substance abuse disorder by the WHO and DSM IV, recognising the powerful addictive nature of the behaviour and the difficulty some smokers have in quitting.

Only 3-5% of unaided quit attempts are successful six to 12 months later.(Hughes 2004) Even among those who do quit, there is a steady attrition over time. Even after12 months, about half of all quitters will subsequently relapse. One in two smokers who have a myocardial infarction will relapse to smoking (Mohiuddin, 2007).

However with professional help and pharmacotherapy, 20-30% of quit attempts will succeed (Fiore, 2008).

Tobacco Dependence as a Chronic Disease

It is well established that the driving force behind tobacco smoking is the requirement the body has to maintain nicotine blood and brain levels for normal daily functioning (nicotine dependence).

Nicotine dependence is classified as a chronic disease, which requires ongoing medical treatment as do all other chronic diseases (such as diabetes and hypertension) and drug dependencies. (DSM IV, 1994; WHO ICD)

On attempting smoking cessation, smoking behaviour involves periods of remission and relapse mainly due to re-stimulation of nicotine receptors via environmental exposure to nicotine, stress hormone release and cue conditioning (Markou, 2008)

Clinical Neglect of Tobacco Dependence

Nicotine dependence is a complex disease which has faced clinical neglect over the last 20 – 30 years resulting in thousands of preventable deaths in Australia. Overall, smokers have been expected to self treat and as a consequence, relapse rates are high. Increasingly however, smokers are seeking assistance to quit. In a recent Australian study, nearly 60% of smokers used some assistance, either pharmacotherapy or professional help in trying to quit. This is thought to reflect the increasing difficulty for the remaining smokers to quit.

However, research has repeatedly shown that health care professionals do not have the time or expertise to give the assistance smokers need. Interventions are infrequent and sub-optimally delivered. There is clearly a need for trained professional smoking cessation services to assist these smokers (Hughes, 2007)

Our understanding of smoking behaviour has changed dramatically in recent years. Continuing smokers are not weak willed nor are they simply making a bad life - style choice. Rather, they are victims of a potent drug addiction mediated by powerful neurochemical processes, often with an underlying genetic predisposition. As a result, many smokers need specialised help.

Treatment of Nicotine Dependence

It is imperative that smokers quit as soon as possible with the best available treatments. Every year a smoker over the age of 35 years delays quitting, often while using ineffective or suboptimal treatments, their life expectancy is reduced by 3 months.

An individual’s chances of success in quitting smoking can increased by 4-5 times with the use of best practice professional treatment compared to unaided cessation (Fiore 2008).

The effects of pharmacological and non-pharmacological treatments are additive, and success rates are maximised when treatment is comprehensive. Motivated patients undertaking comprehensive treatment including both behavioural and pharmacological approaches have more than a one in three chance of succeeding (Fiore, 2008).

As with other specialty areas of medicine, professionals specifically trained in this field can deliver the best results.

The Target Population is Harder to Treat

There is emerging evidence that the current population of smokers has become harder to treat with overall higher nicotine dependence scores (Fagerstrom, 2008) increasing number of attempts at quitting and the existence of complex psychiatric co-morbidities (Sellman, 2005). As the tobacco dependence level rises, a more intensive approach is required to treatment, including tailored treatment with a combination of evidence based medications, higher medication dosing and more frequent clinic visits.


Effectiveness of Smoking Cessation Interventions

The effectiveness of smoking cessation interventions, including brief advice, individual counselling and pharmacotherapy, is well established (multiple Cochrane reviews). It should be remembered, though, that there is a strong dose-response relationship between intensity of treatment (dosage of medications and frequency of visits) of tobacco dependence and long term clinical outcomes (abstinence rates) (Fiore, 2008, Alterman, 2001).

The cost-effectiveness of smoking cessation interventions is also well documented. In the United Kingdom, treatment services for smokers is now fully funded through the National Health Service (NHS) through a network of free smoking cessation clinics ((see attached NHS Smoking Cessation Centre for Smoking Cessation and Training Report).

The cost per quitter in the NHS has been calculated at £231. Successful services have also been established in France, Canada, many countries in South East Asia and New Zealand, amongst others.

Though there may be some debate regarding the need for assistance to quit, these fallacies have been well argued against (West, 2010). The right to treatment for any disease, including nicotine dependence, is a moral as well as a medico-legal obligation Bittoun, 2010).
In Australia, however, smoking cessation interventions are provided on an ad-hoc basis and in limited capacity. Most clinicians believe it is important to ask patients about smoking and to provide advice on how to quit, however, in practice, many opportunities to intervene are missed.

Organisational change and resource enhancements, including greater investments in the training of professionals, in the usage of pharmacotherapies and behavioural interventions are required to facilitate an effective range of intervention practises and, thus, cessation outcomes.

Cost Effectiveness of Smoking Cessation Interventions

The cost effectiveness of smoking cessation interventions is well documented. Helping a smoker to quit is one of the most cost-effective medical interventions (Parrott, 2004. Godfrey, 2005). Treating tobacco dependence produces a strong return on investment.

Recommendations

Easy and evidence-based clinical interventions in clinical services in tobacco cessation
Qualified and well trained smoking cessation specialists that provide services
The development of a national training programme that accredits and qualifies health professionals to become tobacco treatment specialists
The subsidising of these professionals to encourage health professionals to engage in evidence based practice

Clinical Services

We have a responsibility to provide the most effective stop smoking assistance available to smokers. The best results are provided by trained tobacco treatment specialists. Currently these providers are unavailable in most areas in Australia.

Primary care providers do not have the time or expertise to provide high quality smoking cessation treatment, which should be provided by specialists in the field (Hughes, 2007).

These new clinical positions would be dedicated to the delivery of specialised smoking cessation interventions in hospital and community settings to nicotine-dependent patients across all medical specialties.

Smoking Cessation Specialist Clinicians may have clinical backgrounds in either medicine, nursing or allied health but would need to be highly trained in the field of smoking cessation.

The minimum standard of smoking cessation training required for smoking cessation clinicians would be the successful completion of a course in smoking cessation, nicotine addiction and evidence-based smoking cessation techniques, of equivalent standard. In addition, clinicians will be required to complete a period of clinical supervision and show continuing medical education in this field.

Smokers could self-refer to specialists or be referred by other health professionals. The model proposed is the same as for other medical specialties.

Training of Tobacco treatment Specialists

There is evidence from the UK Smoking Cessation Services that well trained clinicians effect a better outcome than poorly trained individuals and that their clinical impact is as great as pharmacotherapies in smoking cessation (see attached document: National Health Services ).

As smoking cessation interventions are increasingly more complex, with increasingly more complex patients suffering multimorbidities a deeper understanding and knowledge is required in order to effectively clinically manage smokers in addressing their smoking.
These complexities involve the understanding of the neuropsychopharmacology, the pharmacokinetics of nicotine, the important metabolic interactions between other substances (such as caffeine and alcohol) and the impact these have in effecting a successful quit attempt.

The UK experience (see attached)

The NHS in the UK now provides an extensive network of fully funded smoking cessation providers. It is recognised that primary health care workers do not have the time and expertise to help smokers. GPs are encouraged to spend minimal time and to refer smokers to the local specialist services for treatment.

There are over 5,000 full-time accredited, trained smoking cessation professionals providing this service across the UK. The service is continuously evaluated and has been shown to be effective and cost effective (£231 per quitter).


References

Alterman AI, Gariti P, Mulvaney F. (2001) Short- and long-term smoking cessation for three levels of intensity of behavioural treatment. Psychology of Addictive Behaviors. 15(3):261-4.

Bittoun, R., Fagerstrom, K.O., Mendelsohn, C., Baker, J. (2010) Advocating for the Nicotine-Addicted Patient: Duty of Care and Negligence. Editorial, The Journal of Smoking Cessation 5 (1) 1.

Benowitz, N. Nicotine Addiction NEJM (2010) 24 362:2295-2303

Borland R, Partos,T.R., Yong, h.H., Cummings, K.M., Hyland, A. (2011). How much unsuccessful quitting activity is going on among adult smokers? Data from the International Tobacco Control Four Country cohort survey. Addiction 107;673-682

Collins DJ, Lapsley HM.( 2008). The costs of tobacco, alcohol and illicit drug abuse to Australian society in 2004/05. Commonwealth of Australia 2008

Doll R., Peto R., Boreham J., Sutherland I. (2004) Mortality in relation to smoking: 50 years’ observations on male British doctors. British Medical Journal 2004;328:1519-

Fagerstrom, K.O. (2008) A comparison of the Fagerstrom test Nicotine Dependence and Prevalence across countries. Addiction, 2190

Fiore MC, Jaén CR, Baker TB, et al, (2008) Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008

Hughes JR, Keely, J and Naud,S (2004) Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 99:29-38

Hughes JR., (2007) Tobacco Treatment Specialists: A New Profession. Journal of Smoking Cessation, 2:2-7

Hughes J.R., (2011)., The hardening hypothesis: Is the ability to quit decreasing due to increasing nicotine dependence? A review and commentry. Drug and Alcohol Dependence. 117(2-3):111-7

Hughes JR. The hardening hypothesis: Is the ability to quit decreasing due to increasing nicotine dependence? A review and commentary. Drug and Alcohol Dependence 2011

Markou A., (2008). Neurobiology of nicotine dependence. Phil. Trans. R. Soc. B.. 363:3159-3168

Mohiuddin S.M., Mooss A.N., Hunter C.B., Grollmes T.L., Cloutier B.S., Hilleman D.E., (2007). Intensive Smoking Cessation Intervention Reduces Mortality in High-Risk Smokers with Cardiovascular Disease. Chest 131(2):446-452

Parrott S, and Godfrey C. (2004) ABC of smoking cessation: Economics of smoking cessation. British Medical Journal, Volume 328,.

Godfrey C. Parrott S. Coleman T. Pound E. (2005) The cost-effectiveness of the English smoking treatment services: evidence from practice. Addiction. 100 Suppl 2:70-83, 2005 Apr

Rennard, S.I., Rigotti, N., Daughton, D. 2012 Overview of smoking cessation management in adults. (2012). UpToDate. Retrieved June 21, 2012, from uptodate website

West R., McNeill A., Britton J., Bauld L., Raw M., Hajek P., ….. Stapleton J., (2010). Should smokers be offered assistance with stopping? Addiction. Doi:10.1111/j.1360-0443.2010.03111.x

World Health Organisation (W.H.O). (2005). WHO Framework Convention on Tobacco Control. Retrieved from World Health Organisation website

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