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Integrating tobacco cessation in primary health care

By Dr. Sushil Baral

Action plans for the development and implementation of locally appropriate tobacco cessation models in primary health care have been drawn up by the member states of the World Health Organization South East Asia Region (WHO SEAR). These include establishing quit-line services, introducing behaviour change approaches, and integrating tobacco cessation in routine primary health care settings.

A regional workshop organised by WHO SEARO on 23-24 April in New Delhi, India saw participants from all WHO SEARO member states and Cambodia (WHO Western Pacific Region) discuss the implementation of Article 14 of the WHO Framework Convention on Tobacco Control (WHO FCTC) and the WHO MPOWER technical package for tobacco cessation.

Article 14 requires parties of the Convention to design and implement effective programmes aimed at promoting the cessation of tobacco use. This includes developing and disseminating appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national context and priorities, and taking effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence. The WHO MPOWER (Monitor, Protect, Offer, Warn, Enforce and Raise) package is a tool used to assist countries with WHO demand reduction tobacco control measures. 

The "O" of MPOWER refers specifically to "Offering Help" to tobacco users to quit smoking. However, many countries in the South East Asia Region (SEAR) are struggling to find appropriate mechanisms to help tobacco users quit.

Nepal has the third highest number of young female tobacco users in the SEAR, while the percentage of young male tobacco users ranks fifth. The percentage of male (fifth) and female (fourth) tobacco users overall is also significant. While Nepal has made notable progress in introducing tobacco control related acts and policies in recent years, their effective implementation remains challenging. This includes support mechanisms for tobacco cessation.

A study conducted by the Health Research and Social Development Forum (HERD)/HERD International, Nepal in collaboration with the Nuffield Centre for International Health and Development, University of Leeds, UK in two primary health care centres in two districts of Nepal, showed 37% of smokers who received a behavioural support intervention to promote tobacco cessation were able to quit smoking. The study was funded by UKAid under the COMDIS HSD research programme consortium. 

Though the study highlighted a few limitations, the findings were clear enough to say that strengthening tobacco cessation in primary health care is the best way of "Offering Help" to tobacco users trying to quit.

 “To reach out to the large number of people who require support, we need to promote integrated partnership at the primary health care level,” said Dr Dongbo Fu of WHO FCTC.  “It could be programmes related to tuberculosis, oral health, maternal and child health, or non-communicable diseases like the package of essential non-communicable (PEN) disease interventions.

"If every primary care provider is able to give certified advice as part of their routine practice, we will be able to reach large numbers of tuberculosis patients. As this is an opportunity that they come to primary care level for other health problems," he added.

To provide support at the primary care level, suitable interventions need to be designed, healthcare providers need to be trained on how to use the interventions and supportive supervision is needed for the successful implementation of the interventions. This requires investment and political commitment. 

Dr Jagdish Kaur of WHO SEARO said: "Basically, tobacco cessation has to be a priority. There has to be political commitment, resources to meet their action plan and international cooperation and coordination among the partners and stakeholders. I think these are the important key issues."

Dr Tibor Szilagyi of WHO FCTC said: “Countries should come up with the plan to ensure that such resources are available. Of course there are international donors and assistance can always be found, but in some cases this might be difficult. So to start, every partner to the convention should think about how to ensure the necessary resources for its programmes.

“Tobacco taxation is a very good example, because taxing a product that kills every second consumer is a very good step. There is a need for advocacy with the Ministry of Finance that tobacco control is an intervention worth financing with more resources. It’s relatively easy to argue that part of the state income generated by tobacco taxation should be turned back into tobacco control programmes,” he added.

Dr. Baral is Managing Director of HERD INTERNATIONAL 


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