Call to action: Training in tobacco addiction in Canada

1Nicotine Dependence Service, Centre for Addiction and Mental Health; 2Department of Family and Community Medicine, University of Toronto; 3Dalla Lana School of Public Health, University of Toronto; 4Department of Psychiatry, University of Toronto, Toronto, Ontario Correspondence: Dr Peter Selby, Nicotine Dependence Service, Addictions Program, Centre for Addiction and Mental Health, 100 Stokes Street, Room 3288, Toronto, Ontario M6J 1H4. Telephone 416-535-8501 ext 36859, fax 416-595-6728, e-mail [email protected] Tobacco addiction is responsible for >37,000 deaths and economic costs of $17 billion in Canada (1), and continues to be the most preventable cause of morbidity and mortality in this country. Given the 7000 chemicals and 60 known carcinogens present in tobacco smoke, the secondary impact on individuals exposed to secondand third-hand smoke can be substantial. While the negative consequences associated with tobacco use are well documented and appear on every cigarette package in Canada with a link to a telephone quit line, approximately 15% to 20% of Canadians continue to smoke, on average, one cigarette per waking hour, with most smokers having made no serious quit attempt in the previous year. Consequently, achieving smoking cessation for these individuals presents a substantial challenge for health care practitioners. In addition to policy interventions such as smoke-free spaces, taxation and advertising bans, clinical interventions are also effective in addressing this endemic addiction. Pursuing assistance for cessation is imperative because a minimum of one tobacco-related death is prevented for every two smokers who quit using tobacco products (2). Smokers often have repeated contact with a variety of health care practitioners in primary, secondary and tertiary settings. Smokers expect and want health care practitioners to treat their tobacco addiction (3). Clinical practice guidelines suggest that the combination of counselling with evidence-based pharmacotherapy (monotherapy with nicotine replacement therapy [NRT], bupropion slow release, or varenicline or combination therapy of two forms of NRT, bupropion and NRT or varenicline and, in some cases, NRT and varenicline) can achieve long-term cessation in up to 30% of smokers who make a quit attempt. Counselling can be as brief as several minutes and can be delivered by a variety of health care practitioners (4-7). The findings of two Cochrane meta-analyses revealed that counselling from physicians has increased cessation rates by 66% (4), while advice from nurses has enhanced quit rates by 29% (5). More intensive interventions that have included behavioural counselling and NRT are also effective, and can be provided to patients depending on available resources (6). Health care practitioners have also reported success in aiding hospitalized patients in their cessation efforts. Hospitals represent an ideal setting for health care practitioners to implement smoking cessation interventions because these facilities are smokeor tobacco-free (8). Such institutions can enable smokers to concentrate on achieving cessation without the presence of external stimuli, which may interfere with the success of their cessation attempt (8). Consequently, health care practitioners could experience fewer obstacles and encounter more receptive smokers in hospital settings. While hospitalized patients can successfully obtain tobacco cessation, practitioner-based counselling interventions will need to incoporate supplementary follow-up contact for a minimum of one month following patient discharge (8). Unfortunately, achieving competence in treating tobacco addiction in undergraduate and graduate health care practitioner training falls short due to a variety of issues, leaving a workforce unable and sometimes unwilling to intervene effectively and consistently with tobacco-addicted patients. Training practitioners is an effective strategy for improving smoking cessation rates (9). However, effectively integrating cessation strategies in usual clinical practices without introducing onerous tasks and challenges to staff represents a substantial concern for health care practitioners (5,8). Barriers include the expense, time and effort involved in dissemination, the practitioner’s beliefs, confidence and familiarity with resources (10), and the lack of organization and system support for interventions (9). It is critical that practitioners accept the responsibility for providing smoking cessation counselling to patients, are confident in their abilities to deliver cessation strategies, and are proficient in referring patients to additional and appropriate cessation resources (10). Collectively, it is necessary to engage practitioners in comprehensive tobacco cessation training programs that can help them achieve these competencies that are not possible in short 1 h training opportunities alone. Inconsistencies among health care practitioners in delivering smoking cessation counselling to patients (10) further strengthens the case for providing standardized tobacco cessation training across various disciplines of the health care system. Through ongoing professional development, health professionals will not only become knowledgeable in the fundamentals of tobacco cessation strategies and community-based resources, they can also acquire a sense of their role in facilitating smoking cessation. Furthermore, providing training to health care practitioners may alleviate anxiety and enable them to feel more confident in delivering cessation counselling (9). Education efforts directed toward health care practitioners should consider adopting the ‘5 A’s’ smoking cessation framework for both brief and intensive interventions. The 5 A’s model involves: asking patients about their recent use of tobacco products; advising patients to stop smoking completely either abruptly or gradually; assessing patient’s motivational readiness for cessation; assisting patients during their cessation attempts; and arranging follow-up sessions with practitioners. This 5 A’s model represents an approach that is simple, brief and, most importantly, effective in aiding smokers to quit using tobacco products. In some situations, screening and treating is also proving to be effective in very busy clinics. In Canada, there have been investments in developing trainers and educators, notably in Ontario, Quebec, British Columbia, Alberta and, to a lesser extent, in other jurisdictions, to create a force-multiplier effect. These practice leaders, also known as ‘champions’, train others in cessation and are also involved in policy change and advocacy such as tobacco-free spaces, creation of medical directives and program development, to name a few. These agents for change are critical to ensure that staff are supported to help overcome practitioner barriers and build the necessary capacity in any health system to identify and treat patients with tobacco addiction. An example of such a program is the Training Enhancement in Applied Cessation Counselling and Health (TEACH) Project. TEACH is an internationally recognized commentary