GRF 2nd One Health S, National Center of Public Health and Analyses, Bulgaria & Michgan State Univeristy

1. Smoking Cessation Programs In Primary
Health Care – An Approach For Reducing
Health-Related Behavioral Risk Factors
Plamen Dimitrov - National Center of Public Health and Analyses, Bulgaria and
Michigan State University, USA
Antoaneta Manolova - National Center of Public Health and Analyses, Bulgaria
Galia Tsolova - National Center of Public Health and Analyses, Bulgaria
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

2. The global tobacco epidemic
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According to the WHO, the total number of smokers in the
world is about 1.2 billion, or about 1/3 of the total population
aged 15 years and older (47.0% of men and 12.0% of women).
Each year, over 5.4 million people worldwide die of a
tobacco-related diseases. By 2030, their number is expected
to reach 10 million and smoking to become the LEADING
single cause of death.
Tobacco kills up to half of all users
100 million deaths were caused by tobacco in the 20th
century. If current trends continue, there will be up to one
billion deaths in the 21st century.
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

3. Tobacco is a risk factor for six of the eight
leading causes of deaths in the world
Ischemic Cerebrovascular
heart
disease disease
Tuberculosis Trachea Tobacco
Chronic
Lower
HIV/AIDS Diarrhoeal
disease
bronchus use
respiratory obstructive
lung
infections pulmonary
cancers
disease
http://www.who.int/nmh/publications/fact_sheet_tobacco_en.pdf
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

4. Health risks associated with smoking
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Tobacco is proven or probable causal factor in
about 25 diseases and its impact on global health
is great, though not fully appreciated.
Cigarette smoking is one of the main factors of
chronic non-communicable diseases.
Cigarette smoking formed 12.2% of the global
disease burden in the WHO European Region
(from 3.0% to 26.8% for different countries) and is
responsible for 2.3% to 20.9% of all deaths. For
Bulgaria, these indicators are 13.5% and 12.4%.
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

5. Overall risk in smokers and non-smokers
Never smokers
% Alive and in good health
100
80%
80
Smokers
60
59%
7.5 years
40
33%
20
12%
0
40
55
70
85
100
Age (years)
Doll et al. BMJ 1994
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

6. Smoking in Bulgaria
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Bulgaria is among the countries with high smoking prevalence
in Europe.
Smoking is a major factor for current high incidence and
mortality rates from non-communicable diseases.
The indicators will continue to deteriorate if necessary
measures will not be taken.
Urgent actions are needed in order to reduce smoking
prevalence in Bulgaria.
It is recommended tobacco control, including prevention,
quitting smoking, and therapeutic measures to be integrated
into primary health care.
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

7. Smoking among adults in Europe
OECD, “Smoking among adults”, in Health at a Glance: Europe 2012, OECD Publishing. 2012. http://dx.doi.
org/10.1787/9789264183896-24-en
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

8. Tobacco attributable mortality among Bulgarian
male population by age groups and causes of deaths
100
90
80
70
60
35-44
45-64
>65
50
40
30
20
10
0
Lung cancer
All cancers
CVD
All causes
HEM – Closing the Gap EU Project, Partly funded by the European Commission
http://www.hem.waw.pl/index.php?idm=87,108,116&cmd=1
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

9. Non-communicable diseases epidemic
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Of the 57 million global deaths in 2008, 36 million, or 63%,
were due to NCDs, principally cardiovascular diseases,
diabetes, cancers and chronic respiratory diseases.
As the impact of NCDs increases, and as populations age,
annual NCD deaths are projected to continue to rise
worldwide, and the greatest increase is expected to be seen
in low- and middle-income regions.
A large percentage of NCDs are preventable through the
reduction of their four main behavioural risk factors: tobacco
use, physical inactivity, harmful use of alcohol and unhealthy
diet.
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

10. WHO-NCD “best-buys” interventions
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Cost-effective
Feasible
Low cost
Appropriate to implement within the constrains of the local
health system
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

11. WHO-NCD “best-buys” interventions
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Protecting people from tobacco smoke and banning smoking
in public places;
Warning about the dangers of tobacco use;
Enforcing bans on tobacco advertising, promotion and
sponsorship;
Raising taxes on tobacco;
Restricting access to retailed alcohol;
Enforcing bans on alcohol advertising;
Raising taxes on alcohol;
Reduce salt intake and salt content of food;
Replacing trans-fat in food with polyunsaturated fat;
Promoting public awareness about diet and physical activity,
including through mass media.
http://www.who.int/nmh/publications/ncd_report_summary_en.pdf
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

12. Health Act - banning smoking in public places
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

13. Ban on tobacco advertising, promotion and sponsorship
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

14. http://ec.europa.eu/taxation_customs/taxation/excise_duties/tobacco_products/rates/index_en.htm
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

15. Tobacco cessation
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Tobacco cessation includes (singly or in combination)
behavioral and pharmacological interventions such as
brief advice and counseling, intensive support, and
administration of pharmaceuticals.
Quitting tobacco is not easy as tobacco dependence is
a cluster of behavioural, cognitive and physiological
phenomena.
But the evidence is strong that it can be done. From
quit lines to counselling to prescription medicines,
there are numerous effective ways to quit.
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

16. Summary of effectiveness data for smoking cessation
interventions (abstinence at least six months)
Intervention (source)
Comparator
Odds ratio (95%
confidence interval)
Increased chances of
quitting successfully
Self-help interventions
No intervention
1.24(1.07-1.45)
24%
Brief advice vs. no advice
1.66(1.42-1.94)
66%
Intensive advice vs. no
advice
1.84(1.60-2.13)
84%
Intensive vs. minimal
1.37(1.20 to 1.56)
37%
Nursing intervention
Usual care
1.28(1.18 to 1.38)
28%
Individual behavioural
counselling
Minimal behavioural
intervention
1.39(1.24 to 1.57)
39%
Group behaviour
therapy
Self-help programme
1.98(1.60-2.46)
98%
Without telephone
counselling
1.41(1.27-1.57)
41%
Less intensive vs. no
1.33(1.21-1.47)
33%
Physician advice
Telephone counselling
Source: http://www.who.int/tobacco/quitting/summary_data/en/index.html
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

17. The situation in Bulgaria
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The development and implementation of effective prevention
of tobacco-related diseases are needed; combined policy
measures as well as individual and population strategies have
to be implemented.
Development and optimization of integrated approaches to
solving the problem is particularly important in terms of
reforming the healthcare services in the country.
Crucial role in the fight against smoking play medical
professionals from primary care
GPs do not develop sufficient activity and are not prepared
enough in this area. They neither systematically assess the
tobacco smoking nor control it as a risk factor.
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

18. Guide to good practice for healthcare professionals
on the evaluation and control of the risk in smokers
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Prepared with the support of Operational Program “Human
Resources Development” financed by the Europe Social Fund
of the EU, issued in Bulgaria in 2013, presents the needed
actions for smoking cessation programs in the health care
settings and will serve as a tool in that direction.
The guide aims to assist medical professionals in their
activities focused both on preventing smoking among the
population and to effective interventions for its cessation
among smokers.
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

19. 2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

20. Types of interventions, implementation in
healthcare systems
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Brief interventions by health professionals in the context
of their routine activities;
Intensive support provided by professionals directly
involved in the treatment of tobacco dependence in
specialized laboratories for quitting;
Pharmacological support of the change.
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

21. Steps in the approach to smoking cessation
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Step 1: Health education and general information to enhance
motivation for quitting. Major effect on light smokers.
Step 2: Brief advice from a health professional to quit smoking.
Major effect on light smokers.
Step 3: Advice, nicotine replacement, follow-up by a specialist.
Suitable for moderately motivated and medium dependence
smokers.
Step 4: Specialized counseling rooms and agencies working
with group sessions. Provide assistance to high-dependent
smokers.
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

22. Algorithm of the organization of medical care
for patients-smokers
smoking
yes
no
passive
Primary Health
Care –
General
practitioners,
Specialized
health care
yes
NCD risk assessment
no
brief intervention strategy- 5 A
Desire for quitting
no
Not sure
Specialized
rooms for
smoking
cessation
yes
Intensive
counseling
Treatment
programs
Motivational counseling 5 R
Monitoring and surveillance
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

23. Brief intervention strategy
At this stage, the health care professional advises and informs
the patient about the dangers of smoking on health – “quick
consultation” or “brief intervention strategy”
5 A – Ask, Advise, Assess, Assist, and Arrange. This method is
used as a guide for the physician and the duration is for no
more than 5 minutes.
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

24. Individual behavioral counseling
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These are more intensive interventions by medical
professionals who take more than 10 minutes.
The choice of tactics in therapy depends on the type of
behavior of the patient and the mode of his/her psychological
readiness and level of motivation for smoking cessation.
Most patients go through different stages in the process of
quitting. In each of them smokers have their individual
characteristics and needs that must be considered by the
medical specialist in the choice of strategy.
For those who are not yet ready to make their experience,
the physician should direct its efforts towards motivating.
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

25. Motivational interview
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Many patients do not feel ready to quit smoking.
The reason for this behavior is the lack of awareness about
the harmful effects of tobacco smoke on the body, the fear
from the consequences of quitting smoking - stress, weight
gain, withdrawal symptoms, failed previous attempts and
others.
Motivational counseling is a set of questions that medical
specialist discusses with the patient to improve his knowledge
about the effects of smoking on health and readiness to quit
smoking – the system of 5 R - Relevance, Risks, Rewards,
Roadblocks, and Repetition.
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

26. Conclusions
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The problem with smoking prevention and diseases that arise
from it is an important task of primary healthcare.
Early detection, prevention and treatment of tobacco
smoking and dependence needs to be part of the programs
for the prevention of chronic non-communicable diseases
(NCD), and to be integrated into primary health care in the
healthcare system.
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

27. Conclusions
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Smoking cessation programs require long and systematic
intervention and control.
Support and assistance to patients to quit smoking is related
to how physicians perceive their role in this process.
They must not only possess the necessary knowledge and
skills for intervention, but also to apply skills for advice and
support in their clinical practice and for this to be routinely
included in the scope of primary care.
Health care professionals needs training for consultation and
support to smokers and help overcome smoking
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland

28. Conclusions
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The guidance “Guide to good practice for healthcare
professionals on the evaluation and control of the risk in
smokers” will be used in primary health care settings for the
purposes of smoking cessation programs. The effectiveness of
the implemented approaches and methods of quitting will be
evaluated on regular basis.
The guide will be useful not only for a better understanding of
the problem, but with the proposed schemes and solutions
successfully used in many countries of the world, will help
reduce smoking among the Bulgarian population in the
future.
2nd GRF One Health Summit 2013
17-20 November, Davos, Switzerland