Progress in implementation of the WHO FCTC Article 14 for tobacco dependence treatment internationally

Field: Health Professions (Health Sciences)

Tobacco use is the leading cause of preventable disease, disability and premature death globally. While tobacco consumption has decreased in many high income countries, demand for tobacco continues to grow in many low and middle income countries. Offering tobacco users help to stop using tobacco is a key demand reduction measure outlined under Article 14 of the World Health Organisation (WHO) Framework Convention on Tobacco Control (FCTC) a global public health treaty ratified by 180 countries and covering almost 90% of the world's population. The main aim of this thesis was to assess progress in implementation of FCTC Article 14 and its guidelines globally and explore the association between implementation and country income level, focussing on tobacco treatment guidelines development, tobacco dependence treatment provision, and tobacco use among healthcare workers (HCWs). A global online survey of a purposive sample of tobacco treatment experts was conducted to assess implementation of tobacco dependence treatment infrastructure and provision. A separate online survey of tobacco treatment guidelines was conducted to assess guidelines content (whether they reflect the Article 14 recommendations to be evidence based and comprehensive in terms of treatment settings and providers), and the association with country income level. Guidelines online accessibility was assessed and guidelines content reviewed for recommendations addressing tobacco use by HCWs. A systematic review and meta-analysis were used to estimate the global prevalence of tobacco use in HCWs by gender, occupation and country income level and changes in prevalence between 2000 and 2014. In 2015, only a minority of 142 respondent countries had comprehensive tobacco dependence treatment provision and had implemented key infrastructure measures as required by Article 14. Among the measures with the lowest level of reported implementation were a national tobacco treatment strategy (32%), national tobacco treatment guidelines (40%), mandatory recording patients’ tobacco use in medical notes (30%), helping HCWs to stop using tobacco (44%), and a budget for treatment (25%). Less than half of countries had brief advice integrated into existing healthcare services, 23% had free national quitlines and 26% had specialised tobacco cessation services. Availability and affordability of tobacco cessation medications were very limited in low income countries. There was little progress in implementation of Article 14 since 2012, and for most measures provision was positively associated with country income level. Approximately 61 countries had national tobacco treatment guidelines in 2016, of which five were newly developed, an increase of less than 10% since 2012. The guidelines were disproportionately distributed by income level, with over two thirds reported in high income countries, and none in low income countries. The guidelines varied by professions, settings and client groups. The majority of guidelines included doctors as tobacco treatment providers and primary care settings while other health professionals and settings were included mostly in high income country guidelines. Compared with high income countries, fewer middle income countries guidelines covered nurses and dentists. Guideline recommendations that did not differ by income level included brief advice, nicotine replacement therapy and recording tobacco use in medical notes, while quitlines, intensive specialist support, bupropion and varenicline were more common in high income countries’ guidelines. There was a positive association between guidelines updating (13% of guidelines had not been updated for 10 or more years) and country income level. Addressing tobacco use by HCWs in national treatment guidelines and provision of specific programmes promoting cessation and offering tobacco treatment to HCWs who use tobacco is another key recommendation laid out in the Article 14 guidelines. The review of 34 national guidelines that were available to access online showed that the majority did not include statements that HCWs should not use tobacco and only 12% recommended cessation support for HCWs who use tobacco. The overall estimated prevalence of tobacco use among HCWs between 2000 and 2014 was 22%, ranging from 7% in nurses in low and middle income countries to 27% in nurses in upper middle income countries, and from 17% in doctors in high income countries to 25% in doctors in upper middle income countries. Prevalence varied by gender, occupation and income level. Male medical doctors in middle and low income countries had the highest prevalence, 35% and 45% respectively. Female nurses in middle and high income countries also had elevated prevalence, 24% and 21% respectively. Despite some decreases in HIC and UMIC, the estimated prevalence did not show any significant declines in recent years. Compared with the smoking prevalence rates in the general population of their countries, male HCWs in high income countries tend to have lower prevalence rates while male and female HCWs in middle and low income countries tend to have similar or higher prevalence rates relative to their counterparts in the general population. Overall, there has been little progress in the implementation of FCTC Article 14 in recent years, with a growing gap in tobacco treatment provision between countries with different income levels. Cost, real or perceived, appears to be a major barrier to the implementation of tobacco dependence treatment measures. Smoking prevalence among HCWs is a seriously neglected area that needs urgent action. There is much room for improvement in low and middle income countries where most of the world’s smokers reside and the demand for cessation support is growing. While the lack of resources and funding for cessation is a significant barrier to implementation, there are a number of measures all countries can implement relatively quickly and at a low cost. Brief advice from a healthcare worker, printed self-help materials, automated text-messages, cytisine and nortriptyline have been identified as affordable treatment options for tobacco cessation across all countries. Countries also urgently need to address tobacco use among HCWs and implement cessation programmes and interventions specifically targeting these populations.