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PESCE

General Practitioners and the economics of smoking cessation in Europe



POLICY RECOMMENDATONS and

IMPLEMENTATION STRATEGIES

Results from the European Stakeholder Conference

Barcelona, 27-28 March 2008

This project receives financial support from the European Commission Public Health Programme 2003-2008 (Grant Agreement 200 5319). The responsibility of the information contained in this document lies with the authors. The Commission is not responsible for any use that may be made of the information contained therein.


The European Consensus
Policy makers, researchers, public health specialists, economists as well as representatives from GP organisations and health professional associations collaborated at the development of the evidence based policy recommendations and practice oriented implementation strategies.
The consensus was reached through a comprehensive European wide consultation procedure. Once the scientific evidence on the cost-effectiveness of smoking cessation interventions was available and we had predictions of potential health and economic benefits of increased GP engagement in smoking cessation together with the knowledge of which factors facilitate or hinder such engagement, a comprehensive selection procedure was put into place to appoint experts that would develop policy recommendations.
At an expert workshop on 10th December 2007 in Warsaw, fifteen policy recommendations were elaborated by 33 experts from 18 countries. At a stakeholder conference in Barcelona on 27-28 March 2008, 96 Stakeholders from 23countries ( including participants from the United States, Brazil and Uruguay) pooled their knowledge and experience and came up with a comprehensive catalogue of implementation strategies to support the adoption of cost-effective measures to increase engagement of General Practitioners in smoking cessation.
We would like to take this opportunity to thank all those who contributed to the successful outcome of the PESCE project.
Based on the conclusions of the international literature search, and cost benefit projections, PESCE Project partners, researchers, experts and policy makers from 27 countries have developed 15 evidence based policy recommendations and practice oriented implementation strategies to increase engagement of GP’s in smoking cessation interventions. The recommendations have been categorized in 4 areas: Capacity Building, Resources, Policy Framework and Communication.

Policy Recommendations and Implementation Strategies


1. CAPACITY BUILDING


Policy Recommendations

Implementation Strategies

  1. To increase the professional competence in smoking cessation interventions, training in smoking cessation is needed for GPs at undergraduate and postgraduate levels as well as continued professional development (CPD).

Specific communication skills on smoking cessation should be integrated into GPs’ education and training programmes
Training in smoking cessation should be compulsory for undergraduate and postgraduate training. It should be encouraged for CPD. Regardless of methodology, all levels of learning should be included.

Ministries of Education, Ministries of Health and Health Professional Societies must promote and financially support the development of curricula in smoking prevention and smoking cessation.


A university chair for addiction should be established in each of the EU Member States. This chair would cover all aspects of addiction including smoking prevention, cessation and training as well as tobacco control policy.
Information on training programmes should be widely disseminated to the health professional body. Key persons should be identified to serve as messengers.
Education and training should be promoted through professional partnerships, in universities/medical schools and in clinical practice guidelines.

Smoking cessation programmes should be available on the Internet to allow GPs access to up-to-date information and freedom of choice. It would be both time saving and allow nurses and other practice staff to be integrated into the smoking cessation effort.


A forum for communication among colleagues should be established to allow regular exchange of experience in smoking cessation interventions. This could take the form of a web based forum, be organised at the occasion of local, regional and national conferences/meetings

  1. Participation of GPs in research projects such as clinical research trials and observational studies on smoking cessation should be promoted.

There is a need to improve the body of evidence available on smoking cessation and methodologies, as well as a need for standard research tools adapted to GP’s needs. General Practitioners should be consulted and involved from the beginning.

  1. All health professionals who smoke should be supported to stop smoking.

GP’s need to be smoke free in order to be credible in their relationship with patients. They are an important role model for the entire population.
Specific smoking cessation programs should be developed for health professionals and tailored to the needs and the professional environment of GP’s practice.
Access of GP’s and all health professionals to smoking cessation therapy (counselling and medication) must be free of charge or reimbursed by sickness funds/ health insurance.
GPs should be motivated to participate in smoking cessation courses. Non-smoking as an employment criterion should be encouraged
Non-smoking should be an obligation in medical schools for staff and students. Non-smoking should be taken up as a requirement in professional ethical guidelines.



2. RESOURCES


Policy Recommendations

Implementation strategies

4. GPs should be provided with comprehensive information on available evidence-based cessation services including type of service, location, referral procedures, cost and contact details

GPs associations, scientific societies, disease specific NGO’s, sickness funds, health insurance companies and the Health Ministries should routinely provide all health care providers with information packs on smoking cessation services and specialised clinics, telephone Quit-lines, etc. that correspond to agreed quality criteria.
A central database should be available on the internet allowing easy access to detailed information of all these services.

Direct marketing campaigns should be regularly organised to remind General Practitioners of the availability of these services.

  1. External cessation services should provide regular feedback to GPs on patient cessation outcomes




Feed-back to General Practitioners should be an obligation of all smoking cessation services and Quit-Lines.
Electronic registration systems should be used for the follow-up of referred patients.
Systems of “chain of care” or “stepped care” should be established.
Communication avenues between external cessation services and GP’s practices need to be opened and networking opportunities should be triggered at conferences and meetings

  1. GPs should routinely record and monitor the smoking status of all their patients and should record their subsequent actions in an integrated routine record system.

GPs associations, scientific societies, sickness funds, health insurance companies and the Health Ministries should make it obligatory to include smoking data and smoking cessation interventions into the prescription activity reports and patient’s health record.

  1. Simple recording systems on smoking cessation interventions should be incorporated into existing information systems. This should include smoking status, cessation activity and feedback

Existing medical record system providers and quality controllers should be required to adapt their programmes. Reminder tools (flags) should be developed for electronic records. To promote the general acceptance following measures could be taken:

  • Perform national pilots/examples

  • Identify champions/key persons

  • Create a budget depending on the national context

Embedding smoking/ cessation interventions in the quality control system

  1. Administrative obligations of GPs should be reviewed in the wider framework to save time for prevention activities.

Medical Associations and GP’s Unions should take up the issue with Health Ministries, sickness funds, health insurance companies as well as other relevant stakeholders and review the current administrative systems with a view to reduce the administrative burden on General Practitioners through innovative processes.


3. POLICY FRAMEWORK


Policy Recommendations

Implementation Strategies

  1. Extra resources for reimbursement for specified smoking cessation interventions should be included in the normal GP payment system;

Collect appropriate data to allow the application of the PESCE model on the health and economic benefits of reduced smoking to the national situation of countries in Europe.
Develop tools to compare the cost-effectiveness of different treatment methods. Promote the use of these tools in the decision making process on regional, national and European level, especially where reimbursement schemes of smoking cessation therapies are concerned.
Smoking cessation (in particular) and prevention interventions (in general), should be made an obligatory part of the GP’s contract and be related to specific payment schemes.
Disseminate the results of the PESCE evidence to Health and Finance Ministries, Health Professional Associations, Sickness Funds, Health Insurance companies and relevant stakeholders.


  1. GPs should play a central role in the formulation of evidence-based clinical guidelines on smoking cessation.



Within clinical guidelines, GPs should be given a central role in identifying and advising, intervening or referring smoking patients.
Health Ministries, Medical Societies and. Health Professional Associations who plan to develop clinical guidelines should involve GP´s from the beginning. This could be done by creating specific task forces on regional, national and European level.
An inventory of existing smoking cessation guidelines should be made.
To facilitate the use of clinical guidelines in every day practice, they should be translated into easily understood and comprehensive standards that fit into the GP’s everyday practice. Information on guidelines should be made available on the internet and systematically disseminated to GP’s in hard copies.


  1. Smoke free policies should be established and enforced in GPs’ working environment

Smoke-free policies should be implemented in compliance with the WHO Framework Convention on Tobacco Control.
On regional, national and European level, a legally binding ban on smoking in places open to the public should be enacted and include all health care facilities, including private practices of GP’s and other health professionals.
A ban on smoking in health care facilities should cover the whole “campus” of health care facilities.
General Practitioners and Health Care providers should be obliged to be non – smoking by their employers, when representing their institutions.


4. COMMUNICATION


Policy Recommendations

Implementation Strategies

  1. Smoking behaviour among GPs and other health professionals should be monitored regularly.

WHO, The European Union, Health Ministries, Medical and Health Professional Associations as well as Employers in the health care sector should specifically include monitoring of GP’s and health professionals smoking behaviour in their health surveys.
GP’s should routinely be asked about their smoking behaviour during the regular check-ups that health professionals have to undergo. Carbon monoxide and/or carboxyl haemoglobin measurements should be part of the routine monitoring process.


  1. To reduce the perceived lack of acceptance of smoking cessation advice interventions, the general population awareness of GPs as a point of contact for smoking cessation services should be increased




The European Union, Health Ministries, Health Professional Associations, the Pharmaceutical Industry should finance awareness campaigns reaching a large audience.

To promote the role of GP’s in smoking cessation, school campaigns should include information on GP’s as the contact point for cessation. This should reach both students and parents.


Warning labels on tobacco products should advertise GP’s as focal points for smoking cessation
A European prize could be created for the institutions that have played a major role in promoting the engagement of GP’s in smoking cessation


  1. GPs’ awareness of the importance of smoking prevention and cessation for the health of the general population has to be fostered.

Professional events and conferences on regional, national, European and International level attended by GP’s, should include sessions on the cost-effectiveness of smoking cessation therapies.
Professional media should publish articles on smoking cessation therapies and their effectiveness.
Networking of medical and non medical societies and associations should be promoted.

Leaders among Health Professionals should emphasise the necessity of GP’s engagement in smoking cessation. GP’s associations should be included in the overall tobacco control movement.

  1. GP’s and GP’s associations must not enter into collaboration of any sort with the tobacco industry.

Ethical guidelines of GP’s associations and health professional societies should expressly ban any collaboration with the tobacco industry. GP organizations should not establish links with the tobacco industry nor organizations and companies of any kind that have vested interests and will prohibit or influence freedom of choice for the optimal treatment of tobacco dependence.

CONCLUSIONS
Project partners have come to the conclusion that while we can agree on common objectives and efficient solutions that will lead to a better integration of General Practitioners in the overall effort to reduce tobacco consumption in Europe, the implementation and timing of activities must take place on a national level. General Practitioners’ role and activities must be integrated into the cultural environment, the legislative framework, the different health systems and according to the available financial resources of each country.
In the long term, by letting each country evolve individually towards a common objective at their own pace, we will succeed in integrating prevention into our health care systems to the greatest benefit of the citizens of Europe.
PESCE PROJECT PARTNERS
Project Leader :

  • Dr Jean Daver, President, Tabac & Liberté, France


Project Coordination

  • Ms. Antonella Cardone, Consultant on Social and Public Health issues,Italy – Financial co-ordination

  • Ms. Sibylle Fleitmann, Independent Consultant Tobacco Control, Germany – Project co-ordinator

  • Ms. Marie-Hélène Weber, Pierre Fabre European Affairs, France – Logistics


Associated Project Partners

  • Dr. Tibor Baska, Comenius University Jessenius Faculty of Medicine, Slovakia

  • Dr. Carmen Cabezas Peña , Health Department of the Autonomous Department of Catalonia, Spain

  • Prof. Luke Clancy, The Research Institute For a Tobacco Free Society (RIFTS), Ireland

  • Prof. David Cohen, School of Care Sciences, University of Glamorgan, Wales

  • Dr. Tibor Demjen, Smoking or Health Hungarian Foundation, Hungary

  • Dr Evangelos Filopoulos, Hellenic Cancer Society, Greece

  • Dr. Giovanni Invernizzi, Italian School of General Medicine (SIMG), Italy

  • Dr. Annelies Jacobs, Radboud University Medical Centre, Centre for Quality of Care Research (WOK), The Netherlands

  • Prof. Ulrich John and Dr. Sabina Ulbricht, University of Greifswald, Germany

  • Ms. Martine Stead, Centre for Tobacco Control Research, University of Stirling & the Open University, Scotland

  • Dr. Hans Storm, Danish Cancer Society, Denmark

  • Ms. Ann Van den Bruel, Katolieke Universiteit Leuven (KUL), Belgium

  • Prof. Dr. Antonio Vaz Carneiro, Faculty of Medicine, University of Lisbon, Portugal

  • Prof. Witold Zatonski and Ms. Marta Porêbiak , Health Promotion Foundation, Poland


Collaborating Project Partners

  • Prof. Olaf Aasland, Institute of Health Management and Health Economics, Norway

  • Dr. Andi Aristotelous, Ministry of Health, Cyprus

  • Dr. Michael Callens, Mutualité Chrétienne de Belgique, Belgium

  • Dr. Janis Caunitis, Health Promotion State Agency, Latvia

  • Dr. Jacques Cornuz, Swiss Smoking Cessation Network, Switzerland

  • Dr. Eirik Boe Larsen, European Union of General Practitioners (UEMO), Belgium

  • Dr. George Kotarov, National Centre of Public Health Protection, Bulgaria

  • Dr. Eva Kralikova, Institute of Hygiene and Epidemiology Charles University, Czech Republic

  • Dr. Wilfried Kunstmann, Bundesärztekammer, Germany

  • Mr Francis Grogna, European Network for Smoking Prevention, Belgium

  • Prof. Florin Mihaltan, Institute of Pneumology "M.Nasta", Romania

  • Dr Vera-Kerstin Petric, Ministry of Health, Health and Healthy Lifestyle Promotion Sector, Slovenia

  • Ms. Christina Dietscher, Ludwig Boltzmann Institute for Sociology of Health and Medicine, Austria

  • Mr Patrick Sandström, National Public Health Institute KTL, Finland

  • Prof. Hanne Tonnesen, Bispebjerg University Hospital, WHO-Collaborating Centre for Evidence Based Health Promotion in Hospitals and Health Services, Denmark

  • Dr Aurelijus Veryga, Kaunas University of Medicine, Lithuania


Researchers

  • Dr. Joao Costa, Faculty of Medicine, University of Lisbon, Portugal

  • Dr. Peter Csepe, Smoking or Health Hungarian Foundation, Hungary

  • Laura Currie, The Research Institute For a Tobacco Free Society (RIFTS), Ireland

  • Ms. Inge Haunstrup-Clemmensen, Danish Cancer Society, Denmark

  • Ms. Helena Koprivnikar, National Institute of Public Health, Slovenia

  • Ms.Sophie Massin, CES-MATISSE, Université Paris 1, Maison des Sciences Economiques, France

  • Dr. Ivo Nagels, Fondation contre le Cancer, Belgium

  • Ms.Maria Pilali, Hellenic Cancer Society, Greece

  • Dr Nicolo Seminara, European School of General Medicine (SEMG), Italy

  • Ms. Kathryn Angus, Gayle Tait and Ingrid Holme, Centre for Tobacco Control Research, University of Stirling & the Open University, Scotland

  • Dr. Fasihul Alam, Dr. Paul Jarvis and Dr. Sam Groves, Health Economics and Policy Research Unit, University of Glamorgan, Wales

  • Ms. Lotje Van Esch, Radboud University Medical Centre, Centre for Quality of Care Research (WOK), The Netherlands


Experts

  • Dr. Francisco Camarelles, Spanish Society of Family Medicine, Spain

  • Dr. Dongbo Fu, World Health Organization (WHO), Switzerland

  • Prof. Pierre Kopp, Université Paris 1 - Panthéon - Sorbonne, France

  • Ms. Jennifer Percival, Royal College of Nursing, UK

  • Dr. Luis Rebelo, Faculty of Medicine, University of Lisbon, Portugal

  • Dr Annie Sasco, INSERM, France

  • Mr. Kriztof Prezwosniak, Cancer Centre Institute, Poland

  • Prof. Joy Townsend, London School of Hygiene and Tropical Medicine, UK


Funding Bodies

  • European Commission, DG SANCO, Public Health Programme, Luxemburg

  • Ministry of Foreign Affaires, France

  • Mission Interministérielle de Lutte contre les Drogues et la Toxicomanie (MILDT), France

  • Institut National du Cancer (INCa), France

  • Cancer Research UK (CRUK), UK

  • Pierre Fabre Laboratories, France

Toulouse, 20 April 2008




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