Abstract
Tobacco smoking is the world’s leading cause of premature death and disability. Global targets to reduce premature deaths by 25% by 2025 will require a substantial increase in the number of smokers making a quit attempt, and a significant improvement in the success rates of those attempts in low, middle and high income countries. In many countries the only place where the majority of smokers can access support to quit is primary care. There is strong evidence of cost-effective interventions in primary care yet many opportunities to put these into practice are missed. This paper revises the approach proposed by the International Primary Care Respiratory Group published in 2008 in this journal to reflect important new evidence and the global variation in primary-care experience and knowledge of smoking cessation. Specific for primary care, that advocates for a holistic, bio-psycho-social approach to most problems, the starting point is to approach tobacco dependence as an eminently treatable condition. We offer a hierarchy of interventions depending on time and available resources. We present an equitable approach to behavioural and drug interventions. This includes an update to the evidence on behaviour change, gender difference, comparative information on numbers needed to treat, drug safety and availability of drugs, including the relatively cheap drug cytisine, and a summary of new approaches such as harm reduction. This paper also extends the guidance on special populations such as people with long-term conditions including tuberculosis, human immunodeficiency virus, cardiovascular disease and respiratory disease, pregnant women, children and adolescents, and people with serious mental illness. We use expert clinical opinion where the research evidence is insufficient or inconclusive. The paper describes trends in the use of waterpipes and cannabis smoking and offers guidance to primary-care clinicians on what to do faced with uncertain evidence. Throughout, it recognises that clinical decisions should be tailored to the individual’s circumstances and attitudes and be influenced by the availability and affordability of drugs and specialist services. Finally it argues that the role of the International Primary Care Respiratory Group is to improve the confidence as well as the competence of primary care and, therefore, makes recommendations about clinical education and evaluation. We also advocate for an update to the WHO Model List of Essential Medicines to optimise each primary-care intervention. This International Primary Care Respiratory Group statement has been endorsed by the Member Organisations of World Organization of Family Doctors Europe.
Highlights
The health benefits of smoking cessation, and the efficacy and cost-effectiveness of medical treatment for tobacco dependence, are well established.[22]For pharmacological therapies, it has been estimated that one person will successfully quit for every 6–23 people treated.[23]
Nicotine is addictive; tobacco dependence is recognised by WHO as a chronic relapsing condition[16,17,18] that normally begins in childhood or adolescence.[19, 20]
The numbers needed to treat (NNT) to achieve abstinence can be translated into NNT to prevent premature death if we take into account that for every two smokers who stops long-term, one would otherwise die from a smoking-related disease.[1, 24]
Summary
This paper provides an update to the original paper IPCRG Consensus statement: Tackling the smoking epidemic—practical guidance for primary care of 2008 published in this journal.[1]. Individuals gain significant health benefits by quitting smoking (Table 1).[13] Helping smokers quit is one of the most cost-effective interventions available to clinicians.[14] Where smokers are aware of the dangers, most want to quit.[1, 2] in countries such as China, that consumes 30% of the world’s tobacco, there is less awareness of the dangers and many less affluent people who remain more dependent smokers do not yet have intention to quit.[15] Nicotine is addictive; tobacco dependence is recognised by WHO as a chronic relapsing condition[16,17,18] that normally begins in childhood or adolescence.[19, 20] Success rates are low for unaided attempts to quit.[21] Clinicians should apply the same principles to tobacco dependence as to other chronic relapsing conditions This includes offering patients accurate and timely diagnosis, evidencebased treatment that aims to co-produce outcomes with the patient using behavioural and pharmacological support, and regular review, anticipating the likelihood of relapse and, offering a system for repeated support to quit
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