From Tobacco Info No. 9 -
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The art of quitting: Ottawa Conference tackles low abstinence rates
By Geoffrey Lansdell
How can hospitals, doctors, pharmacists, dentists, quitlines, and nicotine dependence clinics provide smokers with better cessation assistance and improve their ability to remain abstinent in the long term? This was the central question presenters explored at the Ottawa Conference on Smoking Cessation, which took place on February 3 and 4 at the Fairmont Château Laurier.
The solution, according to many cessation specialists, is for clinical settings throughout Canada to implement an integrated approach to smoking cessation.
“Smokers don’t require more information, they need assistance,” says Dr. Andrew Pipe, chief of the division of prevention and rehabilitation at the Ottawa Heart Institute. “Although rates of advising are very high (60-70 per cent), rates of actual assistance are abysmal (around 30 per cent).”
Dr. Pipe, who co-chairs the Ottawa Conference along with Dr. Robert Reid, provides the Ottawa Model for Smoking Cessation (OMSC) as an example of a systematic assistance model that is gaining traction in a variety of health settings.“Variants of the Ottawa Model are now being used in 122 settings across Canada,” said Dr. Pipe.
Despite improved efforts to provide smokers with sustained assistance, in the six years since the Canadian Tobacco Use Monitoring Survey (CTUMS) has been collecting data on successful quit attempts by Canadians, abstinence rates have remained relatively stable at around 10 per cent.
In essence, the OMSC’s goal is to improve this figure. The first step is to identify and document the smoking status of every patient that comes into the Ottawa Heart Institute using a patient admission questionnaire. The next step is to provide smokers with some strategic advice and brief counselling to help them develop a game plan for quitting. The clinician would then offer medication options, and provide up to six months of follow-up to address the many issues that can cause a relapse.
The cessation market
Despite the low abstinence rate of 10 per cent, David Hammond, PhD, an associate professor in the School of Public Health and Health Systems at the University of Waterloo, and one of the world’s leading authorities on tobacco control policy, pointed out in his presentation on government policy that statistics from CTUMS tell us that most Canadian smokers want to quit, which makes for a large cessation market.
“It’s about 80 per cent that say they would like to quit sometime; about 60 per cent say in the next six months; and about a third (roughly 28 per cent, according to CTUMS) say in the next three months,” Hammond noted. “And in fact Canadian smokers do try to quit. Almost half of smokers in Canada tried to quit in 2010, and about a third tried to quit more than once. So the demand is there for (cessation). The bad news is that as much as we have a large proportion of the market trying to exit, they are having a very hard time doing so. Abstinence rates remain miserably low.”
Hammond, who works with Health Canada in a variety of roles, categorizes much of the census data Health Canada and Statistics Canada collects, which is then published in its annual Canadian Tobacco Use Monitoring Survey (CTUMS). In effect, CTUMS analyzes patterns and trends among smokers to help determine future tobacco control policy.
The majority of smokers in 2010 tried to quit by cutting down, although many combine cutting down with the use of nicotine replacement therapies (NRTs) or medications like buproprion (Zyban) and varenicline (Champix). But the question remains: why is it that with such a dramatic increase in nearly every smoker’s desire to quit and the introduction of so many cessation aids over the past decade, there remains such a poor rate of abstinence among smokers who are trying to quit?
Unfortunately, there is no easy answer, and although some health experts have pointed out that quitting cold turkey remains the most common way to successfully quit and there may be an over-medicalization of the cessation industry, the common theme at the Ottawa Conference for improving abstinence rates is to better integrate cessation services. For Hammond, the question he would like Canadian health professionals, tobacco control advocates, and policy makers to consider is, “How can public policy drive demand by ‘selling’ cessation services with its messaging?”
Of course, part of the answer is to provide long-term support for smokers by introducing systems such as the Ottawa Model into more clinical settings. After all, if every smoker who walked into a hospital or health clinic were offered sustained support and assistance, successful quit rates would no doubt be much higher.
The other part of the solution, according to Hammond, is to create stronger messaging on cigarette packs and at points of sale, where policy could be more innovative. Health Canada’s new health warnings (mandatory for all manufacturers and importers as of March 21, 2012 and for all retailers as of June 19, 2012) will help update the stale 10-year old warnings with updated graphic images that will cover 75 per cent of the packs, up from the current 50 per cent.
Along with the new warnings, manufacturers will also have to include inserts with real-life testimonials and a nationwide quitline that Health Canada is hoping will refer more smokers to that means of assistance. And finally, Hammond points to an interesting shift in provincial public policy that is something of an experiment, as many provinces are now subsidizing the cost of NRT and cessation medications.
The policy experiment
Since 2000, Quebec has subsidized various cessation medications, and until very recently, Quebec was the only Canadian province to do so. But in 2011, British Columbia, Ontario, Saskatchewan, the Northwest Territories, Alberta, and Manitoba have all brought in legislation to help smokers quit.
“When you think about smoking medications,” Hammond says, “you have this intersection between clinical interventions and the policy sector. A number of provinces have, very recently, begun to provide subsidies. Cost is, and has been, a significant barrier. For a long time before there was generic NRT, it was more expensive to use NRT than it was to buy cigarettes. That’s not quite the case anymore, but what we had for a very long time was only one province — Quebec — that did anything to meaningfully subsidize the cost. But in the last year, we’ve seen a number of provinces bring in new subsidization policies. This is a policy experiment, and we’ll see how it goes.”
At the same time as provinces are spending large sums of money to help smokers purchase NRT, access remains a crucial issue. Although the number of points of sale has been reduced in recent years, it is still much easier to access cigarettes than it is to access NRT. By and large, NRT is sold exclusively in drug stores, whereas cigarettes are available at nearly every gas station, corner store, and grocery store in the country, and British Columbia, Manitoba, and the Yukon still sell cigarettes in pharmacies.
CAN-ADAPTT: Canada’s first national guidelines for smoking cessation
Although the Ottawa Model has developed into Canada’s foremost methodology for assisting smokers in the clinical setting, it is a process that was designed by and for the University of Ottawa Heart Institute. It has therefore been used and adapted to suit a variety of other clinical settings, but Canada has never had national guidelines for smoking cessation until Health Canada provided Ontario’s Centre for Addiction and Mental Health (CAMH) with the funding to research and develop a set of guidelines tailored to the Canadian setting.
After three years of research, the result is the birth of the Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment, or CAN-ADAPTT.
The CAN-ADAPTT team is led by principal investigator Dr. Peter Selby, whose goal has been to develop a practice-based research network that could be easily implemented by clinicians who deal directly with smokers. Whether the clinician is a general practitioner, a counsellor at a nicotine dependence clinic, a nurse at a hospital, or a pharmacist, CAN-ADAPTT’s vision is to bridge the gap between cessation research and the clinical practice of providing cessation assistance.
For the general population, CAN-ADAPTT has used the “5 As model” (ask, advise, assess, assist, arrange) as its clinical practice guidelines. The guidelines also provide clinicians with a tailored approach for dealing with specific populations, including Aboriginal peoples, hospital-based populations, individuals dealing with mental health problems and/or addiction issues, pregnant and breastfeeding women, and youth.
One of the inevitable challenges of developing a set of guidelines is to ensure they make sense to clinicians and are therefore implemented. To address this potential shortcoming, CAN-ADAPTT has instituted a seed grant initiative, which awards grants of up to $5,000 for researcher-practitioner teams to implement and sustain the new guidelines.
“Canada didn’t have smoking cessation guidelines,” Dr. Selby points out. “But I wasn’t about to go back to the same literature and come up with the same conclusion. I wanted Canadians to look at it; and so we brought in a whole range of professionals to look at the data and the guidelines that exist already and adapt them to the Canadian setting.”
“My goal was to create a process by which guidelines could be readily adopted, that they had a sense of being owned by the people who use them, as opposed to coming up from on high from a bunch of researchers who then push it into practice.”
For more information, visit www.can-adaptt.net.