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3 Please cite as: Bridgehead International, EQUIPP: Europe Quitting: Progress and Pathways, London, 2011

4 equipp CONTENTS ENDORSEMENTS AND EDITORIAL Endorsements Editorial EXECUTIVE SUMMARY Introduction Framework Convention on Tobacco Control Report methodology Key recommendations Country-specific recommendations INTRODUCTION Background Purpose, target audience, methodology and scope of this report Objectives of the report Target audience Methodology Geographical scope of the report THE SMOKING EPIDEMIC Smoking prevalence Morbidity and mortality Smoking is an addiction Second-hand smoke Economic burden of smoking Direct medical expenditures attributable to the treatment of smoking-related diseases Lost earnings and workplace productivity Other consequent costs Benefits of reducing smoking prevalence Economic benefits Health benefits for smokers who quit Benefits to non-smokers households of smokers Benefits to non-smokers co-workers Tackling social and health inequality Smoking cessation service costs

5 LEGISLATION AND POLICY ON TOBACCO CONTROL Framework Convention on Tobacco Control Protection from exposure to tobacco smoke Smoke-free legislation and policy Measures to control children s access to tobacco Legislation on tobacco advertising, promotion and sponsorship Price and tax measures Increasing tax on tobacco products Legislation on illicit trade in tobacco products Challenges to legislation and enforcement Economic issues Political issues The power of tobacco industry lobbying Tobacco subsidies SMOKING CESSATION SERVICES AND INFRASTRUCTURE FOR TOBACCO DEPENDENCE SUPPORT Strategies to promote smoking cessation Behavioural therapy support to help people stop smoking Primary care smoking cessation services Hospital-based interventions Brief interventions by other healthcare professionals Workplace smoking cessation School-based interventions GUIDELINES (EUROPEAN, NATIONAL AND REGIONAL) The need for guidelines European smoking cessation related guidelines Key principles addressed by guidelines Approaches suggested by the guidelines EDUCATION The role of the healthcare professional Smoking cessation education for medical students Smoking cessation education for postgraduate physicians Smoking cessation education for primary care physicians Smoking cessation education for secondary care Smoking cessation education for pharmacists Smoking cessation education for dentists and oral health professionals Smoking cessation education for nurses Smoking cessation education of other public officials (e.g. teachers, social workers and health workers) Smoking cessation education for the general public Formal qualifications for smoking cessation service providers

6 equipp CONTENTS COUNTRY-SPECIFIC DETAILS Austria Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education Recommendations Belgium Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education and healthcare professionals (HCPs ) attitudes towards smoking and smoking cessation Recommendations 70 Czech Republic Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education and HCPs attitudes towards smoking and smoking cessation Recommendations Denmark Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education HCPs attitudes towards smoking and smoking cessation Recommendations 83 Finland Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education Recommendations 89 France Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education and HCPs attitudes towards smoking and smoking cessation Recommendations

7 Germany Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education Recommendations 103 Greece Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education and HCPs attitudes towards smoking and smoking cessation Recommendations 109 Hungary Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education HCPs attitudes towards smoking and smoking cessation Recommendations Ireland Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education and HCPs attitudes towards smoking and smoking cessation Recommendations 121 Italy Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education and HCPs attitudes towards smoking and smoking cessation Recommendations Luxembourg Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education and HCPs attitudes towards smoking and smoking cessation Recommendations

8 equipp CONTENTS COUNTRY-SPECIFIC DETAILS c o n t Netherlands Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education and HCPs attitudes towards smoking and smoking cessation Recommendations 137 Norway Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education HCPs attitudes towards smoking and smoking cessation Recommendations 143 Poland Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education and HCPs attitudes towards smoking and smoking cessation Recommendations Portugal Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education and HCPs attitudes towards smoking and smoking cessation Recommendations 156 Spain Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education and HCPs attitudes towards smoking and smoking cessation Recommendations Sweden Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Tobacco cessation services and infrastructure for tobacco dependence support Guidelines and Health Technology Assessments Education HCPs attitudes towards smoking and tobacco cessation Recommendations

9 Switzerland Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education and HCPs attitudes towards smoking and smoking cessation Recommendations 176 United Kingdom Smoking prevalence and cost of smoking-related illnesses Legislation on smoking Smoking cessation services and infrastructure for tobacco dependence support Guidelines Education and HCPs attitudes towards smoking and smoking cessation Recommendations The new government s plans will impact the England s healthcare system and possibly their smoking cessation provision KEY RECOMMENDATIONS Background How the key recommendations were compiled Increase tobacco prices Reimburse time for providing smoking cessation counselling (or increase existing reimbursement) Reimburse smoking cessation medications Provide national guidance and clinical guidelines (or implement existing ones) National guidance National clinical guidelines Further training for primary care physicians More involvement of primary care physicians in smoking cessation programmes Improve training for all healthcare professionals Country-specific recommendations An ideal country and how the others compare Future steps for consideration Research initiatives Establish a European Smoking Control Centre (ESCC) Conclusion An integrated approach Key recommendations APPENDICES Appendix A: Terms and abbreviations Appendix B: Interviewees Appendix C: Background information The EQUIPP Report The Editorial Partners role Bridgehead s role Pfizer s role Selection of countries Selection of interviewees Appendix D: References

10 equipp endorsements endorsing organisations The following organisations have endorsed the EQUIPP report. The European Network for Smoking and Tobacco Prevention (ENSP) considers that the opinions expressed in this study by the well-known editorial partners and the interviewees are in line with and support Article 14 of the FCTC. ENSP therefore endorses the present report and its recommendations. The German Society for Pneumology (DGP, Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin) together with the Bundesverband der Pneumologen (BdP) (German Association of Pulomonologists) very much welcomes the EQUIPP Report, which underlines the shortcomings in tobacco prevention in Germany, and in particular in combating tobacco dependence. The DGP is a member of the German Coalition for Non-Smoking, which has developed a position paper for the 17. legislative period ( ) of the German Parliament (Deutscher Bundestag). Here, ten main postulates for better and consequent tobacco prevention in Germany are outlined, amongst them Development of counselling and therapy for tobacco cessation, which is urgently needed in order to help smokers quit (www.abnr.de). The European Respiratory Society endorses the Europe Quitting: Progress and Pathways report (EQUIPP). 010

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12 equipp EDITORIAL Editorial Partners Antonella Cardone, MS, MBA Expert in Tobacco Control and Public Health Director, Global Smokefree Partnership Rome, Italy Prof. Luke Clancy, BSc, MB, MD, PhD, FRCPI, FRCP (Edin), FFOMRCPI Director General TobaccoFree Research Institute Ireland Dublin, Ireland Dr. med. Thomas Hering, MD Physician for pneumology, allergies and sleep medicine Vice-Chairman of the German Association of Pulmonologists Berlin, Germany Prof. Witold Zato ński, MD, PhD Director, Department of Cancer Epidemiology & Prevention Maria Sklodowska-Curie Memorial Cancer Center & Institute of Oncology Warsaw, Poland Editorial Partner contributions Each Editorial Partner was involved in the conceptualisation, development, and approval of this report. See section for more details. Acknowledgements Pfizer provided the funding for this project and has worked in collaboration with the Editorial Partners, Bridgehead and the external experts to produce the report. The final report, its content and recommendations are the work and opinions of the Editorial Partners. This project does not focus on any specific products or treatments. The Editorial Partners are particularly grateful to the interviewees who freely gave their time and responded knowledgeably and independently on the topics discussed (see Appendix in section 11.02). Editorial support for this project was provided by Bridgehead International (Dr Deborah Hooker and Suzanne Elvidge). Competing interests Prof. Luke Clancy and Prof. Witold Zato ński have undertaken research and consultancy for companies that develop and manufacturing smoking cessation medications. Dr Thomas Hering has received speaker and advisor fees from a variety of pharmacotherapy manufacturers including Novartis, Pfizer, Johnson & Johnson and GlaxoSmithkline. Antonella Cardone has worked on projects receiving financial support from companies manufacturing smoking cessation medications. Terminology usage Tobacco dependence treatment and smoking cessation The World Health Organization s (WHO s) European guidelines define tobacco dependence treatment such that it includes (singly or in combination) behavioural and pharmacological interventions such as brief advice and counselling, intensive support, and administration of pharmaceuticals, that contribute to reducing or overcoming tobacco dependence in individuals and in the population as a whole. 1 Tobacco dependence treatment is helping and supporting tobacco users to overcome their dependence on nicotine and is a narrower term than the broader term of smoking cessation which encompasses all cessation whether that is as a result of broader tobacco control measures (such as smoke-free legislation) or through support of an individual to quit through tobacco dependence treatment. Smoking The term smoking is used in this document for the sake of brevity but this should be taken to include all tobacco use. 012

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14 01.00 EXECUTIVE SUMMARY Introduction Tobacco use continues to be the single largest cause of death and disease in the European Union (EU). 2 Tobacco kills as many as 650,000 Europeans every year more than the population of Malta or Luxembourg. 3 Smoking causes more health problems than, for example, alcohol, illicit drugs, blood pressure, obesity or cholesterol. 4 The economic cost of smoking was estimated at billion in 2000 or around 1% of the gross domestic product of the EU. 5 Smoking accounts for years of life lost and up to 21% of deaths according to the World Health Organization (WHO)/Europe tobacco control database, 6 and is a major cause of death from cancer, cardiovascular disease and pulmonary disease. 7 Tobacco smoking kills half of all lifetime users, with half of these dying in middle age (between 35 and 69 years old). 8 In Europe, the estimated daily smoking prevalence is around 28.6% 9 but even a small reduction in this figure could lead to a reduction in the number of smokers dying prematurely. 10 Smoking prevalence rates are generally stabilising or decreasing, however smoking rates for females are slightly increasing in some Eastern EU Member States. 11 Youth smoking is also still a significant problem in some European countries, 12 and the rate of smoking amongst European school children (aged 13-15) is 18%, which is about twice the global average for that age. 13 Children are starting smoking at a younger age and in some Member States, the average age for initiation has been reported as low as 11 years old. 14 Thus, tobacco use continues to be a major public health problem within Europe. The economic burden of smoking on society is tremendous, with the annual global cost of tobacco use estimated by the WHO at US$500 billion. 15 This figure includes direct healthcare expenditure, lost earnings and reduced productivity, and other costs. Quitting, or reducing smoking, has both economic and health benefits for the smoker 16 and there are also health benefits to the households of smokers when second-hand smoke is removed. 17 Similarly, the introduction of smoke-free legislation is associated with health benefits to co-workers. 18 Twenty years ago, smoking was regarded purely as a habit but now the WHO has provided an International Classification of Disease code (ICD-10 code 19 ) for tobacco dependence. 014

15 01.03 Likewise, nicotine dependence is listed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR ). The WHO estimates that 75%-85% of smokers would like to quit and that around one-third have made at least three serious attempts. However, less than half of smokers succeed in stopping permanently before the age of Although a smoker can quit without help, long-term abstinence is higher when the attempt is aided medically. 22 Smoking cessation services such as brief interventions, behavioural therapy, self-help materials, provision of pharmacotherapy or a combination of tactics can be a cost-effective way to help smokers quit. 23 Smoking cessation services led by General Practitioners (GPs) are cost-effective 24 and good value for money. However, other healthcare professionals (HCPs) such as secondary care physicians, pharmacists, dentists and oral health professionals, nurses, and respiratory therapists can all provide valuable smoking cessation interventions. For example, smoking cessation interventions for in-patients have been shown to reduce rehospitalisation and total mortality. 25, Framework Convention on Tobacco Control The Framework Convention on Tobacco Control (FCTC) is the first international public health treaty and it has contributed to a change in public perceptions about the need for regulations, and given new impetus to efforts to control the harm caused by tobacco. 27 The FCTC requires that signatories enact comprehensive legislation to, amongst other things, restrict exposure to second-hand smoke, raise tobacco taxes, reduce smuggling, restrict tobacco advertising and increase the health warnings on tobacco packaging. 28 The FCTC came into force in February 2005, and as of October 2010 it had been ratified by 172 countries. 29 It is important to remember that smoking is a disease of dependency that can be successfully treated, and this should be in the forefront of debate on smoking cessation. Article 14 of the FCTC represents a clear commitment of parties to the FCTC to tackle tobacco dependence. Guidelines on how countries should implement Article 14, produced by a working group of national experts, have recently been adopted by parties to the FCTC. 30 This report assesses the preparedness of 20 European countries (including Switzerland and the Czech Republic which have yet to ratify the FCTC) 31 to enact the required legislation and implement policies compliant with the FCTC Report methodology Experts in each of the 20 countries studied were interviewed from June to October 2010 and, where possible, factual information was verified and appropriate references supplied. The country-specific reports and country-specific recommendations were drawn from the views of the interviewees and their recommendations were endorsed by the Editorial Partners Key recommendations This report makes a number of recommendations to reduce smoking prevalence and the demand for tobacco products. These recommendations are based on country-specific recommendations provided by the interviewees combined with the Editorial Partners own experience and views. The following recommendations are presented in the order of the themes within this report (rather than editorial preference) and have been endorsed by the Editorial Partners. Increase tobacco prices Increasing tobacco prices (through increased taxation), is supportive of the FCTC and has been proven to lead to a decrease in tobacco consumption. 32,33 Increasing tobacco prices increases government revenue, 34 whilst encouraging smokers to quit and seek help, 35,36 and thereby decreasing the demand for tobacco

16 01.04 equipp EXECutive Summary Reimburse time for providing smoking cessation counselling (or increase existing reimbursement) The addictive nature of smoking makes it difficult for smokers to quit, however, they can quit, especially if provided with additional support such as behavioural therapy, counselling, primary care interventions and/or pharmacotherapy. Reimbursed smoking cessation services such as GP interventions and referral to specialist smoking cessation counselling have been shown to successfully attract significant numbers of people from deprived areas. 38 Smoking cessation services should therefore be made fully available and accessible in all European countries to avoid health inequalities. Reimburse smoking cessation medications Reimbursement of smoking cessation medications has been shown to increase access to such medication, 39 the numbers making a quit attempt, 40 the number of successful quitters 41 and those using smoking cessation services. 42 Medication reimbursement is cost-effective in primary care when associated with GP training. 43 Based on considerations of their effectiveness and costeffectiveness, patients should have access to, and reimbursement for, smoking cessation medications. Provide national guidance and clinical guidelines (or implement existing ones) National guidance National guidance should be prepared and implemented to ensure that smoking cessation services are directed where they are most needed and to provide a standardised service across the particular country. National clinical guidelines Development of appropriate guidelines and measures to promote tobacco cessation and adequate treatment for tobacco dependence are a requirement of the FCTC. 44 It is thought that such clinical guidelines will increase the ability of healthcare providers to deliver evidence-based services and ensure service consistency across the nation. Further training for primary care physicians Based on the research for this report, it is thought that a shift in attitude is required for many primary care physicians who currently do not consider smoking to be a disease or a condition that needs to be treated. Training, delivered nationally with a unified curriculum, is considered important so that primary care physicians will be confident to establish their patients smoking habits, treat smoking as a disease, promote and support smoking cessation programmes and follow up with their patients as required. More involvement of primary care physicians in smoking cessation programmes Motivating GPs to become more involved in smoking cessation requires training, but this could also be combined with personal incentives to GPs for identifying smokers, counselling them to quit smoking, referring them to the appropriate smoking cessation programmes or treating them with smoking cessation medications, and making follow-up appointments. Improve training for all healthcare professionals All HCPs have a role in providing smoking cessation advice to their patients. Therefore, HCPs should be empowered by the provision of appropriate education and training Country-specific recommendations In addition to the above key recommendations, this report provides recommendations relevant to each country such as tightening the existing smoke-free legislation, providing the healthcare professionals with guidelines in their local language and improving education for the general public so that they can better understand smoking as a disease and the resources available to help them quit (e.g. quitlines). 016

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18 02.00 INTRODUCTION Summary Tobacco dependence is a disease that causes other diseases and takes a heavy toll both on the individual s health and well-being and on society as a whole 45 Tobacco dependence is a major cause of death from cancer, and is a factor for cardiovascular disease and pulmonary disease. 46 The Framework Convention on Tobacco Control (FCTC) is the World s first international public health treaty 47 The FCTC came into force in February 2005 and has been ratified by 172 countries (as of October 2010) Background Tobacco dependence is a disease that causes other diseases and takes a heavy toll both on the individual s health and well-being and on society as a whole. 49 Smoking is a major cause of death from cancer, cardiovascular disease and pulmonary disease and a risk factor for many other diseases (e.g. respiratory tract and other infections, osteoporosis, and diabetes.) 50 Europe has battled with the problem of tobacco dependence for decades. Pressure is finally mounting on national governments to mobilise resources and enforce restrictions to minimise the impact of smoking on public health. The Framework Convention on Tobacco Control (FCTC) is the World s first international public health treaty, which came into force in February It was the first ever health treaty sponsored by the World Health Organization (WHO) and as of October 2010 it has been ratified by 172 countries, covering 87.3% of the world s population

19 02.02 The core demand reduction provisions in the FCTC consist of: 52 Price and tax measures to reduce the demand for tobacco (Article 6) Non-price measures to reduce the demand for tobacco (Article 7), including: Protection from exposure to tobacco smoke (Article 8) Regulation of the contents of tobacco products (Article 9) Regulation of tobacco product disclosures (Article 10) Packaging and labelling of tobacco products (Article 11) Education, communication, training and public awareness (Article 12) Tobacco advertising, promotion and sponsorship (Article 13) Demand reduction measures concerning tobacco dependence and cessation (Article 14). The European Union (EU) Council Recommendation on smoke-free environments of 30 November 2009 supports the effective implementation of Article 8 of the FCTC (protection from exposure to tobacco smoke). 53 The EU Council Recommendation calls upon Member States to: Adopt and implement laws to protect citizens from exposure to tobacco smoke in enclosed public places, workplaces and public transport within three years from the adoption of the recommendation. Enhance smoke-free laws with supporting measures such as protecting children, encouraging efforts to give up tobacco use and the use of pictorial warnings on tobacco packaging. Strengthen cooperation at EU level by setting up a network of national focal points of tobacco control. The EU Council proposes that national, binding legislation, rigorously enforced, monitored and evaluated, is an appropriate way to deal with the problem of second-hand smoke. Governmental intervention is paramount in the efforts to reduce the demand for and supply of tobacco. However, the Editorial Partners believe it is unlikely that government policies on issues such as tobacco advertising and smoke-free legislation alone will be sufficient. Instead, a concerted effort is likely to be the most successful and will require: Stronger legislation and enforcement Guidelines on smoking cessation integrated into each individual country s healthcare system Targeted smoking cessation advice and education for both healthcare professionals and smokers Provision of appropriate infrastructure to provide tobacco dependence services. World Bank 54 The best results are achieved when a comprehensive set of measures to reduce the use of tobacco are implemented together

20 equipp INTRODUCTION Purpose, target audience, methodology and scope of this report Objectives of the report This report aims to assess the current status of smoking cessation services across Europe and to provide recommendations to countries for improving their smoking cessation infrastructures. Secondary objectives of the report include: Reviewing country-specific data and opinion Highlighting which measures are already in place for the management of smoking cessation in the European countries covered Providing examples of best practice so other countries may be able to implement these actions in order to improve their own situation Providing recommendations to help countries improve their services, in order to improve patient care and reduce the prevalence of smoking by increasing cessation through tobacco control Providing recommendations to help European parties signed up to the FCTC to fulfil their commitment to implement the treaty in full and in particular to implement the Article 14 guidelines at a national level Target audience This report should be of interest to: Public health policy leaders responsible for European, national or regional healthcare Non-governmental organisations (NGOs) active on tobacco control issues Healthcare professionals (HCPs) Patient organisations (e.g. cancer, cardiology, respiratory care groups etc.) Methodology Desk research PubMed, Cochrane reviews and various other Internet resources were used by Bridgehead International to conduct desk research for this report. Interviews In order to establish the current status of smoking cessation services across Europe, interviews were conducted with expert stakeholders in each country covered in this report (see Appendix in section 11.02). Interviews were conducted from June to October 2010 utilising a structured interview guide but broader, free-ranging qualitative questions were also included. The interviewees were chosen because of their knowledge and experience in the field of smoking cessation. As far as possible, an attempt was made to include a cross-section of stakeholders, representing NGOs involved in smoking cessation, healthcare professionals, health policy makers and those advising national governments. In total, 57 experts were interviewed with generally three interviewees per country. The Editorial Partners would like to thank these stakeholders for their valuable contributions, both during the interview programme and in reviewing the countryspecific elements of the report (section 08). Where possible, factual information was verified and appropriate references were supplied. Each country-specific report was reviewed and approved by the interviewees and therefore includes their views and opinions. In particular, the country-specific reports and recommendations were drawn from the views expressed by the interviewees and these recommendations have been endorsed by the Editorial Partners. With editorial approval, additional information has been added to the country-specific reports where the situation has evolved since the interviews took place (e.g. a new law was enacted). 020

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