Training for Treatment

“A Tobacco Treatment Specialist is a professional who possesses the skills, knowledge and training to provide effective, evidence-based interventions for tobacco dependence across a range of intensities. The TTS may have various professional affiliations and may work in a variety of settings including but not limited to hospitals, community health centres, Health Maintenance Organisations, medical and dental practices, educational settings, social service agencies, public health organisations, tobacco treatment centres, telephone quitlines, drug abuse treatment programmes and mental health centres. The TTS may engage not only in providing treatment but also in educating others (health care professionals, administrators, scientists, smokers, non-smokers) about tobacco dependence treatments.”
Source: Association for the Treatment of Tobacco Use and Dependence, April 2005

Although there is almost universal recognition that health professionals have a duty to assist their patients to stop using tobacco, such as in the WHO Code of Practice on Tobacco Control for Health Professionals, there is limited provision of training for them in this area.  World-wide, the topic is rarely mentioned in health professional undergraduate education curricula, and postgraduate provision is limited. Systematic attempts to assess health professionals’ knowledge, attitudes and behaviour related to tobacco use and to providing treatment include the Global Health Professionals Survey led by the World Health Organisation (www.who.int/tobacco/surveillance/ghps/en/index.html). Key findings from the first round of that survey in 10 countries indicate that:

• Current cigarette smoking among third year health professional students ranged from 18.1% (Republic of Serbia medical students) to 47.1% (Albania pharmacy students).
• Students in all four health professional disciplines and in all ten countries believe that health professionals have a role in giving advice to patients about smoking cessation (86.6% among Albanian pharmacy students to over 99% among dental students in India and pharmacy students in the Philippines).
• Over 90% of health professional students in all four disciplines and in nine of ten countries believe that health professionals should be trained in cessation techniques.
• The percentage of health professional students who had received formal training to provide tobacco cessation counselling to patients ranged from 5.2% among medical students in Argentina to 36.6% among pharmacy students in the Philippines.

Of perhaps greatest concern is that it is common for uptake of tobacco use to increase among students during medical or nursing education in many countries.

It is relatively uncommon for medical providers to deliver tobacco dependence treatment beyond brief advice to quit, lasting 3 to 5 minutes. The 5 A’s (Ask, Advise, Assess, Assist, Arrange) has been the model in the US for the past 10+ years.  Physicians in the US cite limited time and training to deliver more intensive treatment.  As a result, the AAR model (Ask, Advise, Refer) has been receiving increased attention. Referral to treatment services by medical staff can include in-house treatment services, community-based treatment services, or to national or state telephone quit lines. Tobacco treatment can be delivered by a wide range of providers, from very brief interventions by outreach workers (the Arizona model) to highly trained tobacco treatment specialists capable of providing multi-session intensive treatment.

Training provision
There are many providers of training in tobacco dependence treatment world-wide, but most training provision currently exists or has been developed in high income countries that have national guidelines on treatment.  These training programs may address the needs of a wide range of treatment providers or focus on a targeted group and level of training. There is as yet no globally-endorsed curriculum on tobacco dependence treatment either at continuing education, undergraduate or postgraduate levels, but some countries have begun to set national training standards, and some international health professional organisations have developed training courses to fit their own requirements for continuing professional development. There are also some sources of online training, and a growing body of evidence that at least brief interventions may be effectively learned by health professionals via self-directed learning.

There is a strong need for enhanced curriculum development within medical and dental schools.  Enhanced and expanded curricula have been shown to increase awareness by health care providers of the importance of intervening with their tobacco-using patients. Coupled with proper system supports, increased rates of delivery of treatment have been observed, yielding reasonable rates of cessation.

The Association for the Treatment of Tobacco Use and Dependence (ATTUD) has developed a set of core competencies for tobacco treatment providers, including levels of proficiency required for delivering varying degrees of treatment – ranging from minimal to intensive interventions. This is receiving increasing recognition within the US and work is currently under way to extend the concept internationally.

Training course content and accreditation
GTP member ATTUD is leading work to develop expert consensus on core content for treatment provider training. Most curricula cover information about the health effects of tobacco use and benefits of quitting, the processes involved in quitting, and pharmaceutical aids to cessation and the management of withdrawal symptoms. Many training programs (particularly those addressing intensive treatments) provide skills training in communication and counselling techniques necessary to deliver interventions to tobacco users, as well as program evaluation processes, and administrative and service management issues like follow-up contact, record-keeping, prescribing and staffing.

It is relatively common for treatment training courses offered to health professionals to be recognised for Continuing Education Credits – this particularly applies to courses offered by professional organisations.

Please visit www.attud.org for up-to-date information on online and other courses on tobacco dependence treatment.

Code of Practice on Tobacco Control for Health Professional Organisations
This document was created in January 2004 at a meeting organised by WHO Tobacco Free Initiative. The purpose of that meeting was to explore with various international health professional organisations (medical doctors, as well as nurses, pharmacists, dentists, etc.) potential ways in which they could contribute to tobacco control goals.  The "code of practice" for health professional organisations outlines the potential role of health professional organisations in treatment of tobacco dependence and smoking cessation. It has since been widely adopted by health professional organisations. Several of its provisions address health professional training and education issues, as well as the need for them to be providers of treatment.

Code of Practice Text

Preamble: In order to contribute actively to the reduction of tobacco consumption and include tobacco control in the public health agenda at national, regional and global levels, it is hereby agreed that health professional organisation will:

• Encourage and support their members to be role models by not using tobacco and by promoting a tobacco-free culture.
• Assess and address the tobacco consumption patterns and tobacco-control attitudes of their members through surveys and the introduction of appropriate policies.
• Make their own organisations premises and events tobacco-free and encourage their members to do the same.
• Include tobacco control in the agenda of all relevant health-related congresses and conferences.
• Advise their members to routinely ask patients and clients about tobacco consumption and exposure to tobacco smoke –using evidence-based approaches and best practices–, give advice on how to quit smoking and ensure appropriate follow-up of their cessation goals.
• Influence health institutions and educational centres to include tobacco control in their health professionals' curricula, through continued education and other training programmes.
• Actively participate in World No Tobacco Day every 31 May.
• Refrain from accepting any kind of tobacco industry support – financial or otherwise –, and from investing in the tobacco industry, and encourage their members to do the same.
• Ensure that their organisation has a stated policy on any commercial or other kind of relationship with partners who interact with or have interests in the tobacco industry through a declaration of interest.
• Prohibit the sale or promotion of tobacco products on their premises, and encourage their members to do the same.
• Actively support governments in the process leading to signature, ratification and implementation of the WHO Framework Convention on Tobacco Control.
• Dedicate financial and/or other resources to tobacco control – including dedicating resources to the implementation of this code of practice.
• Participate in the tobacco-control activities of health professional networks.
• Support campaigns for tobacco-free public places.

Full information on the Code of Practice including organisational signatory list:
www.who.int/tobacco/communications/events/30jan_2004/en/index.html