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Primary health care: The cornerstone for tobacco cessation

Dec 10, 2014

Physicians have an extremely important role to play in tobacco control, write Dr Hayden McRobbie and Dr Rajmohan Panda.

New Delhi: The recent news that sale of loose cigarettes may soon be banned and the minimum age for buying cigarettes and other tobacco products could be increased from 18 to 21 is a step towards the right direction. This will no doubt be a useful strategy for preventing initiating of smoking and will stimulate many users to try to quit. Recognising the problem and seeking advice and assistance from their primary care providers is a good starting point which will enable them to quit tobacco and work towards staying tobacco free forever.

Physicians have an extremely important role to play in tobacco control. In many countries, including India, doctors have been instrumental in championing effective tobacco control measures such as price increases, advertising bans and restrictions on sales. These measures, however, are often seen as only relevant to those working in Public Health and not those physicians who work on the ‘front line’. This is not true as the impact of brief tobacco cessation interventions provided by frontline physicians is potentially huge and can save thousands of tobacco users from premature death and disease.

Traditionally physicians have motivated tobacco uses to stop by simply informing people of the health risks of smoking and the benefits of quitting. Professor Mike Russell and his team, from the Institute of Psychiatry in London, first showed the benefits of this type of advice back in 1978. Since this time many more papers have been published on this topic and combining these data show that brief advice to quit tobacco increases the proportion of people who go on to quit long-term. In fact for around every 40 people advised to quit, one will go on to stop tobacco use for good.

At first glance this may not appear to be particularly effective, but given that this brief intervention can be delivered in as little as 30 seconds to every tobacco user in primary care it can have an import population effect. This is also important for countries like India which have a huge no of tobacco users. This type of intervention is so important that it is recommended by the WHO as a key step towards getting the tobacco user to quit and live a healthy and productive life.

For cessation to succeed, tobacco use must be recast from a disorder which is typically treated acutely to a more chronic, relapsing condition that requires long-term patient management as in chronic condition such as diabetes. Most tobacco users try to quit multiple times, and repeated interventions are necessary to support this iterative process. A brief tobacco intervention consists of two key steps. The first is to screen for tobacco use and the second is to motivate the user to quit tobacco.

Some people will manage to stop on their own once they understand the devastating health risks of tobacco use and the benefits of quitting. There is also the question of which age to quit? Whilst the benefits are greatest when people quit before middle age it is never too late to quit. For people with smoking related illness (e.g. heart disease and chronic obstructive pulmonary disease) quitting tobacco use is was of the most effective treatments doctors can recommend. There are some people who will find quitting more difficult and these people will benefit from some assistance. Physicians, and their staff, can help here also by providing behavioural support and pharmacotherapy or referring their patients to tobacco cessation services, where these exist.

These are all parts of the 5 As model, a behaviour change communication process that is used worldwide for tobacco cessation. This process is best done through services where repeated opportunistic interventions by health care providers is possible and where the patient has a long term relationship with the doctor.  This is where primary health care provides a great opportunity. Most patients live within an accessible distance and directly report for health care needs. Patients with conditions like Diabetes, early onset of stroke, precancerous lesions present initially at primary care.

This is an opportunity for the primary care providers to intervene and deliver cessation related services. The last decade saw huge investments in infrastructure as well as human resources in primary care in India with notable improvements in health service delivery. Health planners should now ensure that tobacco cessation is an integral part of this improved care. A number of barriers may be encountered in implementing brief tobacco cessation interventions such as lack of time, treatment options, and knowledge. However training, tools to support physicians, and strong leadership can help overcome these and facilitate system wide implementation.

This can potentially prevent the need for hospitalization at a later stage due to these conditions as well as a host of many other complication arising due to tobacco use. This, in effect, would reduce health care costs for both government as well as and reduce significant out of pocket expenditure for the population at risk.

The Public Health Foundation of India in partnership with Global Bridges and the Wolfson Institute of Preventive Medicine, Queen Mary University of London, is about to embark on a project that addresses these issues. The project combines elements of clinical leadership, training, and tools and resources and aims to help equip primary care physicians to provide better help for their patients who use tobacco to quit. Outcomes from this project will be used to better understand how primary care physicians can best provide brief tobacco cessation interventions throughout the country, further enhancing India’s leadership in tobacco control in developing nations.

The authors Dr Rajmohan Panda (Senior Public Health Specialist at Public Health Foundation of India) and Dr Hayden McRobbie (Reader at Wolfson Institute of Preventive Medicine, Queen Mary University of London.) are Co-PI’s of the Global Bridges Tobacco Cessation project. Views expressed are personal.

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