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Summary of Presentation on "The Context for Treating Tobacco Addiction"

By Dr. Beatriz Marcet Champagne
January 12, 1999

PanAmerican Health Organization
Consejo Latinoamericano Coordinador para el Control del Tabaquismo
InterAmerican Heart Foundation

To help people who smoke abandon cigarette smoking, there has to be a societal context that contributes to supporting this change of behavior. In developed countries, it is estimated that approximately 70% of smokers want to quit. But to increase their motivation to quit, support their actions in smoking cessation and promote maintenance of a smoke-free status once achieved, there needs to be a context of coordinated messages, resources and services that encourages the new behavior.

To increase the number of smokers that quit, it is necessary:

To increase the availability, access and use of resources that permit smokers to successfully quit smoking in an environment that supports their quitting in multiple ways.

To create such a tobacco-free promoting environment it is useful to consider a "coordinated systems approach" to addressing the challenge of smoking cessation. In such an environment, for example, a smoker would turn on the television to find an anti-smoking message playing. Her child would come home from school and say, "Mom, smoking is bad for you…and me. Our teacher said so. Please quit smoking." She would read a newspaper or magazine and learn that there are effective ways to quit smoking. She would go to work and her employer would have declared the workplace smoke-free. She would go to her physician and hear that her doctor is concerned about her smoking and wants to help her quit. Nicotine replacement therapy would be easily available and affordable in her community. And the price of cigarettes would be going through the roof.

A Coordinated Systems Approach

 

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Fig.1

The model presented in Figure 1 provides a suggested framework for such a coordinated systems approach (d’Avernas, 1997). It was developed in Ontario, Canada, to help coordinate the work of many groups, avoid duplication and identify service gaps. Being a model, it requires tailoring to the specific situation in a community to be most effective. This framework consists of:

  1. Three aspects of smoking cessation.
  2. Services must be offered to match the needs of smokers at different stages in the change process. Those who have not considered quitting will require motivation. Those who are ready to abandon cigarettes require practical tools and strategies for action. Those who have recently quit smoking must be supported to stay smoke-free. They are in the maintenance stage.

  3. Five access channels.
  4. People who smoke access information and services through different channels. The media reaches the most people, including those hard to reach through other means. Schools have the potential not only to intervene with adolescent smokers but also reach their families. Worksites that go smoke-free help make smoking socially undesirable and inconvenient. Smokers entering the healthcare setting, particularly if for smoking related health problems, are frequently motivated to quit. Finally, a variety of community networks may provide yet another channel for accessing smoking cessation services.

  5. Five types of cessation interventions
  6. A systems approach calls for the availability of a variety of types of interventions that meet the various needs of smokers attempting to quit. Public education helps increase awareness and motivate smokers to quit. While less effective, self-help materials are still a highly cost-effective intervention for the large proportion of smokers that choose to quit on their own. The minimal intervention opportunities in a healthcare professional’s office have been shown to be very effective due to the large number of smokers that visit health professionals every year. Group programs have a high degree of success but few smokers participate. Changes in public policy by, for example, raising taxes on cigarettes, have been shown repeatedly to be highly effective interventions. All interventions are more effective when combined with the use of nicotine replacement therapies.

  7. Seven functions or roles for effective interventions
  8. A coordinated systems approach to smoking cessation requires that certain functions be performed. These include researching new methods and programs, synthesizing new information and transferring it to practice, developing programs and policies, promoting and marketing smoking cessation services, making educational tools available, providing training and consultation to service providers, delivering services and providing referrals.

  9. Various sectors to carry out these functions
  10. Many organizations play a role in smoking cessation by performing key functions, supporting various interventions, facilitating access through multiple channels so that the person who smokes may receive the services appropriate to his/her stage of change. These organizations may be divided broadly into government institutions, non-government organizations and industry. They include addiction services, health and social services providers, hospitals, community health centers and health maintenance organizations, public health, the research community, voluntary organizations, advocacy and resource organizations.

Motivating the Health Professional

While it is critical to motivate the smoker to quit, it is just as critical to motivate the many organizations and service providers that must be a part of a tobacco-free promoting environment. As an example, let’s consider the task of motivating the health professional to intervene with those patients who smoke. There is much evidence showing the significant role that the health professional plays in helping the smoker quit. Yet, it has been difficult to change healthcare professionals’ clinical practices to include minimal interventions and counseling or to make the necessary changes in the office, clinic or hospital that support smoking cessation.

Many physicians may participate in training programs such as "Guide Your Patients to a Smoke Free Future" and incorporate smoking cessation interventions in their clinical practice as a matter of fact. They consider it part of their duty and responsibility to their patients. For most, however, changes in their clinical practices may be considerably more challenging. Lack of time, uneasiness with taking a counseling role, lack of economic incentives may be some of the barriers to effective implementation of smoking cessation interventions through the health professional’s office.

The following is a series of suggested approaches to encouraging the health professional to participate in training and making the necessary changes in clinical practice:

  1. Make training part of Continued Education requirements for health professionals in given specialties through their societies, foundations and associations.
  2. Negotiate with managed care organizations, social security systems, medical centers and institutes, ambulatory care systems, insurance companies and other such organizations to require training for their member health professionals.
  3. Have individuals make personal commitments and resolutions to be trained and provide consultation to their patients who smoke. This may be done in conjunction with a motivational speaker or some other event.
  4. Where appropriate, it may be possible to work with local, provincial and national governments to pass legislation that requires health professionals to be trained and provide counseling regarding smoking cessation.
  5. Influence medical schools and other healthcare teaching institutions to incorporate tobacco cessation, as well as other issues regarding tobacco, as part of their clinical practice curriculum.

Conclusion

People who smoke do not quit smoking in a vacuum. Their smoking behavior is maintained by physiological and psychological addiction, supported by psychosocial, behavioral and even spiritual factors. Likewise, abandoning smoking and remaining smoke-free also requires not only individual determination but also a supportive context.

A coordinated systems approach helps identify the aspects of that context that may be engaged to support smoking cessation. It shows that changes in existing institutions in support of smoking cessation may produce a powerful force to increase the number of smokers who successfully quit and remain smoke-free.

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Update
10/01/99