RÖKSLUT 2006 - SFDs
tema 2006 Aktuell avhandling
Sluta Röka Linjen visade sig vara
en kostnadseffektiv folkhälsointervention med ungefär en av tre rökfria
efter 12-månader. Den här typen av service ger god avkastning på
investering då kostnaden 3 023-3 898 kronor per vunnet levnadsår ska
jämföras med andra vanligtvis använda interventioner såsom
blodtrycksbehandling med kostnader på 250 000 kronor per vunnet levnadsår.
Utöver direkta hälsofördelar kan det också röra sig
om folkhälsoeffekter och spridningseffekter. Ett lyckat resultat kan nämligen
spridas till familj, vänner och kollegor vilket ytterligare ökar kostnadseffektiviteten.
THE GLOBAL TOBACCO EPIDEMIC
Tobacco is the
major preventable cause of death globally (WHO 2004). The World Health Organisation
(WHO) projects that by 2025, today's five million tobacco-related deaths will
have almost doubleded (WHO 2004). Altogether there are almost 1.3 billion smokers
worldwide. In high income countries, tobacco is the leading risk factor, accounting
for 12% of the disease burden (Ezzati et al., 2002). Over 13 million Europeans
suffer from a serious chronic disease as a result of their smoking, and over half
a million die every year. Those that die in middle age as a result of their smoking
lose on average 22 years of life. In 2004 the most common cause of death in Europe
was cancer accounting for 20% of all deaths. The overwhelming majority of lung
cancer cases are caused by tobacco smoking (Boyle & Ferlay 2005) and while
there has been a substantial decrease in incidence in males, the situation for
females is worrying.
In Sweden, the smoking prevalence among men has declined
during the 1980s and 1990s whereas smoking among females is considerably higher
compared to many other European countries (FHR 2005). In 2004, 14 % of men and
19% of women smoked on a daily basis. The heaviest smokers were in the 45-65 age
group and the least were found among the youngest and oldest groups. Smoking is
related to approximately 6 400 premature deaths annually and a further 500 die
from exposure to second-hand smoke (Statistics Sweden 2004). Social inequalities
in smoking persist among men with prevalence being higher among those in low income
groups. In recent years, there has been a tendency towards a similar pattern among
women. (FHR 2005). Sweden has a national public health strategy "Public health
objectives 2002/03:35" which provides the basis for creating conditions for
better public health for the entire population on equal terms. One of its eleven
target areas focuses on reduced use of tobacco. The Swedish Council on Technology
Assessment in Health Care carried out a systematic review on smoking cessation
guidelines (SBU 1998) and recommended that resources for professional counselling
and dissemination of smoking cessation be made available in every region. However,
no national tobacco guidelines have been issued.
The effects of tobacco place
a heavy burden on health care systems. The cost of treating tobacco-related illness
is very high not only for governments, but also for individuals and their families.
Given this, effective tobacco control has the "potential to be one of the
most rational, evidence-based policies in medicine" (WHO 2004).
Addiction and dependence are terms whose definition has
a social as well as a scientific dimension. In principle, they may be distinguished
from each other, but in practice such a distinction serves little purpose and
thus the terms are used interchangeably. They are socially and scientifically
defined in that their meaning can be, and has been, changed to reflect changing
perceptions. Under the current definition, the terms refer to a state in which
a drug or stimulus has unreasonably come to control behaviour (American Psychiatric
Association 1995). This definition is very different from that used in the past
and to which the general public usually subscribes (Bull WHO 1964). The earlier
and popular view is that addiction refers to a state in which an individual needs
to continue to take a drug in order to stave off unpleasant or dangerous withdrawal
effects. The main shortcoming of this approach to defining addiction is that it
addresses just one aspect of a wider problem. Certainly, many drug addicts experience
withdrawal discomfort when they abstain, and this provides an important motive
for continuing to use the drug. However, it has also long been recognized that
this motive plays a relatively modest role in the apparently unreasonable continued
use of a drug, despite protestations of users that they want to stop, and despite
the harm their drug use is doing both to them and to those around them.
characteristics of tobacco use are strikingly similar to those of heroin, alcohol,
and cocaine (Surgeon General 1988). None of these drugs are essential to normal
physiologic functioning. Tobacco and other drug addictions differ from such behaviour
as overeating or compulsive jogging in that the drug addictions are determined
primarily by the drug's action on the brain. Cigarette smoking and tobacco use
meet the criteria for drug dependence that are presented in the US Surgeon General's
report, The Health Consequences of Smoking (Surgeon General 1988). Nicotine is
clearly the dependence-producing component of tobacco use, and the concept of
dependence has been addressed by the American Psychiatric Association (APA 1994).
Addiction to nicotine has been established as the psychopharmacologic mechanism
that maintains cigarette smoking behaviour (Surgeon General 1988). Nicotine activates
the brain's mesolimbic dopaminergic reward system (Pontieri et al., 1996) and
produces dependence resulting in physical and neurobiological withdrawal symptoms
on abrupt cessation (Epping-Jordan et al., 1998). Nicotine has a distributional
half life of 15-20 minutes and a terminal half-life in the blood of two hours.
Smokers therefore experience a pattern of repetitive and transient high blood
nicotine concentrations from each cigarette, so that regular hourly cigarettes
are often needed to maintain raised concentrations further, overnight blood levels
drop to those of non-smokers (Jarvis 2004). Failure to maintain these concentrations
results in symptoms of nicotine withdrawal (APA 1994). Hence, describing nicotine
addiction as a disease of the brain seems justified.
There are two main approaches to smoking prevention. The first is to
prevent tobacco use initiation, that is, prevent young people from starting. The
second is to treat tobacco dependence in established users and to prevent them
from relapsing when they have stopped. Relapse appears to lead back into regular
smoking unless an effort is made to alter the smoking behaviour (Ossip-Klein et
al., 1986). This thesis focuses on the second approach. Tobacco control may be
achieved by decreasing demand for tobacco products through taxation, consumer
education, research, bans on advertising and promotion, warning labels, control
on smuggling, restrictions on public smoking, and education of children and adolescents.
Cessation methods traditionally include pharmacological treatment, behavioural
support through face-to-face counselling, and more recently through quitlines
and internet programmes. There is evidence that many of these methods are effective
in helping smokers to quit (Stead et al., 2003; Silagy et al., 2004; Zhu et al.,
2002). Pharmacological agents include nicotine replacement therapy (NRT) and buproprion.
On balance, NRT (Silagy et al., 2005) and buproprion (Hughes et al., 2004) approximately
double the effectiveness of other cessation efforts.
Studies have consistently
shown that methods of assistance for smoking cessation such as behavioural counselling
can significantly increase success rates in quitting (Fiore et al., 2000). Of
smokers who receive intensive cessation-focused interventions, about 70% resume
smoking within a year of treatment (Fiore et al., 2000). However, among unaided
quitters, the relapse rate is closer to 97% (CDC 1999). Behavioural cessation
interventions include group sessions, social support networks, or individual counselling
and can be clinic, school, community, or population-based. Formats range from
informal contacts with peers or professional counsellors to regularly scheduled
intensive counselling programmes. More recent initiatives include the use of internet-based
interactions and telephone counselling (quitlines). When offered the choice between
a telephone helpline and personal face-to-face consultation at a clinic, most
smokers (75-85%) prefer telephone counselling (Mc Afee et al., 1998).
Quitlines are telephone-based tobacco cessation services and since the late
1980's, they have been established in many countries such as Australia, Brazil,
Canada, New Zealand, in many U.S. states, South Africa, Iran, some Asian and most
European countries (World Bank 2004). They vary greatly in degree of sophistication.
Many have been set up recently and are in the early stages of development.
The contexts in which they operate vary considerably, both in terms of socio-economic
factors, literacy, telephone density, and use of information technology. (World
Bank 2004). Estimates from several countries show that quitlines may have reached
approximately 2-3% of the smoking population in the course of a year (Stead et
al., 2003). However, they are considered to have an impact beyond that which can
be measured in terms of quit rates amongst callers and fulfil a symbolic role,
communicating to smokers that smoking cessation is important (Wakefield &
Borland 2000). Most quitlines are accessed through a toll-free telephone number
and provide individual telephone counselling that may be combined with a variety
of services such as free educational materials, free-of-charge NRT, and referral
to local programs. Counsellors answer callers' questions about the cessation process
and help them develop an effective plan for quitting (World Bank 2004). Telephone
counselling can be reactive or proactive (Lichtenstein 1996). Reactive quitlines
only respond to incoming calls. Proactive quitlines handle incoming calls and
then follow up the initial contact with additional outbound calls, to help initiate
a quit attempt and/or to assist in preventing relapse. It is important to have
an understanding of the characteristics of a quitline when discussing performance
and results. Proactive telephone counselling has been shown to have a marked effect
on callers' probability of success in quitting and in maintaining long-term abstinence
from tobacco use, comparable to the effects of pharmacotherapies (World Bank 2004).
Although reactive helplines have been widely implemented, controlled evaluation
has been limited. Evaluations involving these services have been more likely to
compare variants in service than to use a no intervention control. Two studies
support use of a reactive quitline in the context of a comprehensive tobacco control
programme (Zhu et al., 1996; Ossip Klein et al., 1991).
have established that proactive telephone counselling is an effective intervention
for smoking cessation (Lichtenstein et al., 1996; Fiore et al., 2000; Stead et
al., 2003). The most recent of these (Stead et al., 2003) examined 13 studies
of proactive interventions and found that callers who received counselling were
successful at least 50% more often than those who only received self-help materials
OR 1.56 (95% CI 1.38-1.77). A large randomised, controlled trial served as the
basis for the California Smokers' Helpline, the first publicly supported and state-wide
quitline. This study found that the telephone counselling increased the percentage
of smokers making a quit attempt and decreased the rate of relapse for those attempts.
It also found a strong dose-response relationship between the level of intended
treatment intensity (i.e., number of follow-up sessions) and the treatment effect
(Zhu et al., 1996). Other research has demonstrated continued effectiveness in
randomised controlled trials and "real world" settings (Borland et al.,
2001; Zhu et al., 2002; World Bank 2004). In 2003, "The National Action Plan
for Tobacco Cessation in United States" (Fiore et al. 2004) recommended the
establishment of a federally funded National Tobacco Quitline that would provide
a national portal to available state or regionally managed quitlines. Worldwide,
there are several approaches for managing quitlines with some of them being non-governmental
organisations, group health cooperative's, health maintenance organisations, private
companies, charities but mostly as part of the public health care system.
HEALTH INDICATORS AND HEALTH CARE
By international standards, health
in Sweden is relatively good. Public health has steadily improved in recent years,
in terms of average life expectancy and premature mortality as is obvious from
some health indicators, (Table 1).
Deaths in injuries, alcohol-related diseases
and suicide have also been on the decline for many years. The proportion of the
population with allergic conditions, however, doubled during the 1980s, with more
than one third of people living in Sweden reporting that they suffer from some
form of allergy or over-sensitivity. Another public health problem is the growing
proportion of overweight individuals among children, young, and the middle-aged.
Mental health and psychosomatic problems are on the rise among children and young
people. The number of elderly has risen substantially-with the greatest growth
in the age group 80 years and older. There are differences in health between different
socio-economic groups, and these differences are growing (FHR 2005). In 2003,
the cost for health services in Sweden exceeded 225 billion Swedish kronor (31bn
USD) . This represents a substantial share (9.2%) of Sweden's gross domestic product
(GDP) and an intermediate position among 15 EU countries. Health services in Sweden
are overwhelmingly tax-financed, through county and municipal taxes. Patient fees
(i.e., out-of-pocket) charged by the county councils account for 2.7% of the revenues.
Privately financed care is marginal, approximately 500 million SEK annually. (SI
2003). The health care system in Sweden is highly decentralised. Mainly the 20
county councils (Stockholm County Council being one) and 290 municipalities in
Sweden finance and manage health services within their respective areas. Health
policy is a national-level responsibility that rests with the Government and the
Parliament. A fundamental principle is that the provision and financing of health
services for the entire population is a responsibility of the public sector (SALAR
2005). The county councils and municipalities are the main providers of health
care, with only about 10% of all health services delivered by private providers.
All counties contract to varying degrees with private providers, mainly in primary
care where approximately 25% of the primary care centres are managed privately.
There are nine regional hospitals, some 70 county and provincial hospitals and
just over 1000 health centres. The number of physicians and nurses are 3 and 9
per 1000 inhabitants respectively which is similar to the EU average (OECD 2005).
Health care providers such as physicians or nurses are natural partners for quitlines
and referral to quitlines for comprehensive cessation counselling can have a profound
impact on patient health (World Bank 2004). Therefore linkages with health care
providers create important opportunities for quitlines.
QUITLINE IN SWEDEN
The Swedish quitline - Sluta Röka Linjen (SRL) has been in
operation since May 1998 and has served over 70 000 people and over 50 000 of
these calls have been tobacco cessation calls (SRL Database). It is a nationwide
free-of-charge telephone service operated by Tobacco Prevention in Stockholm,
part of the Stockholm Centre of Public Health. Historically, financial support
was provided by the Swedish Cancer Society, the National Institute of Public Health,
the Swedish Lung and Heart Association and Apoteket AB (Swedish Pharmacies) and
since 2004, by the Ministry for Health and Social Affairs. The service is available
during: Monday - Thursday, 9.00-20.00 and Friday 9.00-16.00, weekends closed.
When the service is closed, or all lines are busy, an answering machine and a
24-hour interactive voice response serves as back-up. Smokers or concerned citizens
may call toll-free for advice or smoking cessation counselling. The quitline is
based on three interrelated elements: flow of patients, counselling, and preparatory
measures for evaluation. The typical caller is a woman of 47 years of age with
12 years of education. The calls are geographically evenly distributed with slightly
more calls from urban clients. The counselling is provided by health professionals
(with few exceptions) like nurses, health educators, dentists, dental hygienists,
psychologists, and doctors. All counsellors receive at least six months of training
followed by supervision for another six. Continuing education, mentoring and de-briefing
are provided for the counsellors. At present, Autumn 2005, the service employs
Clients calling the Swedish quitline receive tailored information
by mail according to the Stages of Change (see 1.5.2). They are offered four follow-up
phone calls in accordance with findings indicating that there is a relationship
between the intensity of treatment and outcome measured as rate of smoking abstinence
(Fiore et al., 2000). The average length of time for the first call is 22 minutes
and for the following calls approximately 12 minutes. All callers are encouraged
to call back as often as they need. A computerised client record is kept to enable
the smoking cessation counsellors to effectively identify a caller and to allow
for easy continuation of the treatment. The quitline is promoted as a referral
service for the primary health care.
Research into routines for Nordic general
practitioners' (GPs) work with tobacco prevention revealed that eight out of ten
reported shortage of smoking cessation experts to refer to as a main problem.
(Helgason & Lund 2002). Many physicians conceive even short advice to be too
time-consuming and feel that the results (outcome) may not be adequate to justify
the time spent (Cabana et al., 1999). A review analysing why physicians do not
follow clinical guidelines showed that, depending on the nature of the medical
problem, different barriers emerge stressing the need to assess each aspect separately
(McAvoy et al., 1999). Hence, physicians in primary care or elsewhere are invited
to refer smokers to quitlines where advice, assistance, and follow-up can be arranged.
The importance of the individual physician has been highlighted, (Fiore et al.,
2000; Cummings et al., 1989) but relatively few physicians actively engage in
smoking cessation support (Helgason & Lund 2002). According to a primary health
care survey carried out by the Swedish National Institute of Public Health in
2003, less than half the country's health care centres used smoking cessation
counsellors to help those wanting to stop smoking (NIPH 2004).
The treatment protocol is best described as a mix of motivational
interviewing (Miller & Rollnik 2002), cognitive behaviour therapy, the Transtheoretical
Model (TTM), and pharmacological consultation. Materials which are tailored to
the characteristics of individual smokers are more likely to be effective (Lancaster
& Stead 2005). The tailored treatment material sent to people calling the
quitline makes use of the Stages of Change, and this printed material is offered
free of charge. The four existing folders were developed with each corresponding
to one of the four stages. 1) What you gain if you quit, 2) Prepare to quit smoking,
3) NRT and withdrawal symptoms, and 4) Hold on!
One of the most widely used models of individual health behaviour of change
is the Transtheoretical Model (TTM). It focuses on the intention to change and
on the decision making of the individual. The model was developed by James Prochaska
and Carlo DiClemente in the early 80's, based on the experiences of people attempting
smoking cessation with and without professional help. Inspired by others before
them, the two researchers attempted to make explicit various aspects of the intentional
behaviour change process in a unifying model (Prochaska & DiClemente 1983).
One of the advantages of the TTM is that it postulates that the process of change
takes time and involves progress through a series of stages that characterise
different degrees of readiness to change (Prochaska & DiClemente 1983; Velicer
et al., 2000) and that people in different stages of change need different interventions
to progress in their behaviour change (Prochaska et al., 1992). Health promoters
have been developing tailored interventions by matching messages to the individuals'
readiness to change (Prochaska et al., 1992; Rakowski 1999). Over the past two
decades, there has been a substantial increase in the use and evaluation of stage-matched
interventions with regard to a variety of health behaviours (Rakowski 1999). In
Sweden smoking is becoming less acceptable, and many smokers express a desire
to quit. Individual differences in factors related to smoking cessation including
differences in readiness to change, may be important when designing effective
interventions (Prochaska & DiClemente 1983).
The Swedish quitline makes
use of the principles outlined in the Stages of Change of TTM. Stages are used
as outcome variables to assess success in study I. The central organising construct
of this model is an approach to assess readiness to change health behaviour (Prochaska
& DiClemente 1983; Prochaska et al., 1992). The TTM presumes that behavioural
change, for most people, occurs gradually through five different stages, ranging
from being unaware or unwilling to make a change (precontemplation) to attempting
to maintain a behaviour change. Relapse is considered to be a part of the process
of establishing a life-long change (Prochaska et al., 1992). The stages are both
stable and dynamic, that is, they may be constant over a longer period but are
still open to change. Precontemplation is a stage where individuals have no intention
of stopping an unhealthy behaviour or starting a healthy one in the near future,
usually within 6 months.
Contemplation is the stage in which people are considering
a behavioural change within the next six months but have not yet made a commitment.
Preparation is the stage in which people have made decisions to change their behaviour
within a given period (usually within 30 days). Action is the stage where people
have changed their behaviour within the past 6 months.
Maintenance is the
final stage in the change process. People are defined as being in the maintenance
stage after sustaining the behaviour change for at least 6 months (Prochaska et
al. 1992). Evidence in support of the TTM as applies to tobacco use is strong,
but not conclusive (Spencer et al. 2002). The model has recently been brought
into question (West 2005) which will be elaborated in the discussion section (5).
Public health is collaborative actions to improve sustained
population-wide health and reduce health inequalities (Beaglehole & Dal Poz
2003). Hallmarks of public health practice include the focus on actions and interventions
which require collective (or collaborative or organized) actions, sustainability,
and the need to embed policies within supportive systems. The goals of public
health are population-wide health improvement, which implies a concern to reduce
The importance of this definition is that it is broad
enough to include an overview of the activities of the medical care system and
recognizes the importance of responding to the underlying social, economic, and
cultural determinants of health and disease. Public health research is a multidisciplinary
activity. It involves the application of the entire range of biological, social,
and behavioral sciences to the health problems of human populations (Beaglehole
& Bonita 2004). The WHO Framework Convention on Tobacco Control (WHO FCTC)
- an international effort to protect the public's health from the "consequences
of tobacco consumption and exposure to tobacco smoke" - recommends comprehensive
tobacco control strategies to be implemented by participant members. Through the
FCTC, efforts to reduce tobacco use, one of the most significant risk factors
for premature death and disease, are strategically coordinated for an effective
global response. While the FCTC provides the framework for action against tobacco,
the actual work to combat tobacco use must necessarily occur at country level
(WHO 2004). Evidence is needed when a new technology is introduced. This is the
case with the Swedish quitline, an individualised quit smoking service which is
provided to a large geographic area from a single centralized base. Since essential
elements were documented -from the client to financial records- prerequisites
for an evaluation existed.
Real world research
One of the challenges
in carrying out investigations in the real world lies in seeking to say something
sensible about a complex, relatively poorly controlled, and generally "messy"
situation. Another way of saying this was developed by Robson who claimed that
the laboratory approximates a "closed" system shut off from external
influences, while studies outside the laboratory such as this thesis operate in
"open" systems (Robson 2004). Much inquiry in the real world is essentially
some form of evaluation. The intention is that the research and its findings will
be used in some way to make a difference to the lives and situations of those
involved in the study, and /or to others. This takes us into the field of evaluation
The purpose of an evaluation is to assess the effects and effectiveness
of something, typically an innovation, intervention, policy, practice or service
(Robson 2004). It is commonly referred to as program evaluation. In all aspects
of carrying out an evaluation, great attention has to be paid to feasibility.
The design must take note of constraints on time and resources; on how information
is to be collected; on the permissions and co-operation necessary to put this
into practice; on what records and other information are available. The Swedish
quitline provided the above mentioned aspects regarding both feasibility and relevance.
Inherent in the concept of real world is the notion of relevance. The tobacco
issue was listed by WHO as one of the three major threats (the others being HIV/AIDS
and malaria) to global health (WHO 1999).
Establishing trustworthiness is
fundamental in research. Two key issues about the inquiry itself are involved
here, that of validity and generalisability. Validity refers to the accuracy of
a result. Does it "really" correspond to, or adequately capture, the
actual state of affairs? Are any relationships established in the findings "true",
or due to the effect of something else? Generalisability refers to the extent
to which the findings of the enquiry are more generally applicable, for example,
in other contexts, situations or times, or to persons other than those directly
involved. Additional problems may come under the heading of reliability referring
to the stability or consistency with which we measure something. All these issues
will be discussed further in the methodological part of the discussion. Finally,
it is not only the treatment and related effects of outcome that is the focus
of this thesis, but also the ability to estimate the costs of the treatment.
"Health economy can be defined as the application of
the theories, tools and concepts of economics as a discipline to the topics of
health and health care" (Kobelt 2002). Since economy as a science is concerned
with the allocation of scarce resources, health economics is concerned with issues
relating to allocation of scarce resources to improve health. This includes both
resource allocation within the economy to health care system and within the health
care system to different activities and individuals (Kobelt 2002). There is an
increasing call for measuring the effectiveness of programs in financial terms.
Cost-effectiveness analysis (CEA) is one option and was used to establish the
value for money for the Swedish quitline.
A health economic evaluation is
a way of establishing the "value for money" of different health care
technologies (Kobelt 2002). Economic evaluations have become an important source
of information to aid decision making about the allocation of resources. Economic
analyses are always comparative and are applied to explicit alternatives. A treatment
cannot be cost-effective by itself, but only in relation to one or several relevant
alternatives, and for defined patient groups (Drummond et al., 1997). If a treatment
strategy is both better and less costly, it dominates the alternatives. Outcomes
are measured as health improvements expressed as either survival measured as lives
saved or life years saved or as disease measures such as events avoided or delayed
or patients successfully treated. Such analyses can be criticized for taking a
very narrow measure of outcome and failing to include many of the potential benefits
of the health promotion intervention. Their main advantage, however, is that they
allow quantification. Other measures are quality-adjusted survival expressed as
quality-adjusted life years (QALYS), and monetary value, expressed as willingness-to-pay
for a benefit (Kobelt 2002). There are different types of economic evaluations
and these are distinguished primarily by the way in which outcomes are treated.
In general, if the question being studied is whether a treatment is a good use
of resources within the disease area, the comparison should be with similar treatment
and the outcome measure can be disease specific. The type of evaluation will be
a CEA, if there is a single outcome (Kobelt 2002). The major advantage for economic
evaluation is that it explicitly values the costs and benefits of policy options.
Although the beneficial impact of quitlines has been supported by three meta-analyses
(Lichtenstein 1996, Fiore 2000, Stead Lancaster 2003) and by multiple individual
studies (Borland et al., 2001; El-Bastawissi et al., 2002) no evaluation of effectiveness
and cost-effectiveness of the Swedish national quitline has been conducted.
Tomson, Folkhälsovetare, Med dr Centrum för Folkhälsa Avd.
för Folkhälsoarbete Box 175 33 118 91 Stockholm
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