Special Edition - June 2019

ENSP contribution towards the implementation of the WHO-FCTC article 14 in Europe 

Throughout years of work ENSP focused its effort on ensuring that the WHO Framework Convention on Tobacco Control was signed, ratified and implemented by all European countries. In particular ENSP concentrated on FCTC Article 14 to promote measures on tobacco dependence and cessation.

In compliance with the implementation of FCTC Article 14, ENSP developed the first European Smoking Cessation Guidelines (ESCG) back in 2012. The ESCG, which have been developed with a team of global smoking cessation experts, were published in English, Turkish, Greek, Romanian, Armenian, Georgian, Ukrainian and Russian.

Since 2016 and up until now the work on the guidelines continued within the framework of EPACTT PLUS Project. The guidelines are currently available in 15 languages and ENSP intends to extend project's geographic coverage adding new partner countries, along with the continuous update of the studying materials. The guidelines were also transformed into e-learning platform where health care professionals can complete the accredited course online.

Furthermore, since 2018 ENSP organises tobacco treatment specialists' trainings and specific country Support Visits providing expertise on tobacco dependence treatment and advice on creation and improvement of national cessation programmes.

ENSP is striving to ensure the topic is not lost among many tobacco control priorities both on national and European level.

ENSP urges the newly elected members of the European Parliament to adopt a Resolution on Tobacco Dependence Treatment

Resolution about Article 14 of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) which requires effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence.

The European Parliament,

  • having regard to the Commission's Green Paper Towards a Europe free from tobacco smoke: policy options at EU level' (COM (2007) 27),
  • having regard to the WHO Framework Convention on Tobacco Control (FCTC) and in particular, Article 14 (demand reduction measures concerning tobacco dependence and cessation),
  • having regard to the 2004 WHO European strategy for smoking cessation policy,
  • having regard to the 2007 WHO policy recommendations on protection from exposure to second-hand tobacco smoke,
  • having regard to the European Commission’s regulation of tobacco products on the EU market (e.g. packaging, labelling, and ingredients), (Tobacco Products Directive (2014/40/EU)),
  • having regard to the European Commission’s advertising restrictions for tobacco products, Tobacco Advertising Directive (2003/33/EC),
  • having regard to the European Commission’s Directive 2010/12/EU on tax measures on tobacco,
  • having regard to the international Protocol on illicit trade in tobacco products adopted under the WHO Framework Convention on Tobacco Control (2012),

A. whereas tobacco smoke is a complex toxic mixture of more than 4 000 substances, including poisons such as hydrogen cyanide, ammonia and carbon monoxide, as well as 50 substances proven to be carcinogenic,

B. whereas tobacco use is the leading cause of premature death and disability and the largest threat to public health for the European population,

C. whereas each year, 700,000 Europeans die from tobacco-related illness while approximately 50% of tobacco users die prematurely,resulting in the loss of an average of 14 years of life,

D. whereas the European region has one of the highest proportions of death attributable to tobacco, (16% of all deaths among adults over 30 years old),

E. whereas more than 125 million Europeans (26%) continue to smoke. This is the highest rate of tobacco use among all the WHO regions while Southern Europeans smoke more on the contrary with the Northern Europeans where people have stopped smoking in a greater percentage,

F. whereas it is known that tobacco consumption costs European economies hundreds of billions annually,

G. whereas exposure to smoking during pregnancy can result in a higher risk of deformities, miscarriages, still and premature births, stunted growth of the foetus, smaller head circumference and a lower birth weight and there is a link between passive smoking and middle ear infections, impaired lung function, asthma and sudden infant death syndrome,

H. whereas the European Union and all 28 Member States have already signed and ratified the WHO Framework Convention on Tobacco Control (FCTC) and Article 14 which highlights the demand for reduction measures concerning tobacco dependence and cessation,

I. whereas the majority of smokers in Europe have tried to quit (52%), but the vast majority of them (75%) tried to quit without assistance and only 5% used medical support or other services to help stop smoking, 

J. whereas cessation interventions have a more mid-term impact on the number of deaths and therefore must be encouraged. World Bank report explains that, if smoking initiation is reduced by 50% by 2020, the number of deaths from tobacco will decrease from 520 to around 500 million in 2050. On the other hand, 

K. whereas if half of the current smokers quit by 2020, the number of deaths from smoking would be reduced from 520 to 340 million in 2050,

L. whereas tobacco users who seek help from a healthcare professional are up to four times more likely to successfully quit than those who try unassisted,

M. whereas Article 14 of FCTC calls the Parties to facilitate accessibility and affordability for treatment of tobacco dependence’ as tobacco dependence treatment is very beneficial, and cessation interventions are ‘extremely cost-effective when compared with other healthcare system interventions,

N. whereas the combination of behavioral counseling and pharmacotherapy is the key component of successful tobacco treatment,

O. whereas brief smoking cessation advice provided by a health care professional significantly increases patient motivation to quit and smoking abstinence rates,

P. whereas a combination of behavioral support and pharmacotherapy can increase abstinence rates fourfold,

Q. whereas quitting smoking the excess risk of smoking-related coronary heart disease is reduced by approximately 50% within 1 year, and to normal levels within 5 years,

  1. Welcomes the Commission's Directives as a policy to protect citizens from harmful tobacco smoke;
  2. Welcomes the action taken by the Member States that have already ratified WHO Framework Convention on Tobacco Control (FCTC); 
  3. Welcomes the action taken by the Member States to adopt effective measures to ensure protection from passive smoking;
  4. Calls on the constant efforts of all European Member States towards providing children and young people the freedom to grow up independently and in good health, without being coaxed into a lifetime of addiction;
  5. Calls on the establishment of a wider coherence among smoking prevention activities, as well as promoting comprehensive tobacco control policies at a European and at the individual national level;
  6. Calls on the continuation of WHO FCTC implementation and in particular Article 14 as a public health priority;
  7. Calls on the establishment of effective services to support cessation of tobacco use available through health;
  8. Notes, that Member States are free to determine the form of the measures to be taken at national level, but that they should report to the Commission, on the progress made in implementing tobacco treatment delivery measures;
  9. Calls, on the Commission to produce a report on the available smoking cessation facilities in Europe and best practices based on the needs of the European population in total and regionally;
  10. Notes that the Commission has a supporting role to play in the achievement of the European objectives by helping the Member States to exchange knowledge and best practices and to carry out European research on combating smoking;
  11. Calls on the Member States, within two years, to introduce smoking cessation treatment into healthcare systems of their respective countries and facilities accessible from all smokers;
  12. Calls on the development of a Directive for treating tobacco dependence and adaption of the Directive from each Member State;
  13. Calls the Member States who want to help their citizens to quit smoking to support them by providing both behavioural counselling and pharmacotherapy;
  14. Considers that such smoking cessation support measures should ensure that smokers and in particular the young and those economically less well off, have access to affordable smoking cessation products and treatments, so as to ensure that there are no inequalities whereby less-advantaged members of society are discouraged from using them;
  15. Considers that information smoking cessation, including free call quit lines, text message services or a website address, should be visibly available in all outlets where tobacco products are sold;
  16. Calls for the necessity of all healthcare professionals to be trained on how to deliver tobacco treatment;
  17. Encourages the Commission to continue to implement support measures, awareness-raising measures; considers that education and further developing the skills of doctors and other healthcare professionals should be an important field, to which priority is assigned;
  18. Instructs its President to forward this resolution to the Council and Commission.
EPACTT Project

The goal of EPACTT PLUS is to continue the development and expansion of an accredited curriculum for tobacco cessation in 17 European countries (Albania, Armenia, Belgium, Bulgaria, France, Georgia, Greece, Italy, Kosovo, North Macedonia, Poland, Romania, Russia, Serbia, Slovenia, Spain, Ukraine) and in English and to enhance the formulation of a network of healthcare professionals that will be dedicated to advancing evidence-based tobacco dependence treatment.


Initially, EPACTT PLUS was a Global Bridges funded project. Nowadays, it became a ENSP project and is currently co-funded by the European Health Programme.

Key objectives:

  1. To further develop, accredit and deliver a user friendly, online training program in advanced tobacco treatment
  2. To update, adapt, translate and disseminate the ENSP European Guidelines for Treating Tobacco Dependence.
EPACTT Partners
  • European Network for Smoking and Tobacco Prevention - Belgium
  • AER PUR Romania - Romania
  • American University of Armenia - Armenia
  • Bulgarian Tobacco Control - Bulgaria
  • Comité Nacional de Prevención del Tabaquismo - Spain
  • Department of Healthcare, University of Vlora - Albania
  • Foundation ‘Smart Health - Health in 3D - Poland
  • French Alliance against Tobacco  - France
  • George D. Behrakis Research Lab - Hellenic Cancer Society - Greece
  • Institute of Public Health of Serbia - Serbia
  • Individual contributors - Portugal
  • Kosovo Advocacy and Development Center - Kosovo
  • Kyiv Health Center - Ukraine
  • Macedonian Respiratory Society - North Macedonia
  • Romanian Society of Pneumonology (SRP) - Romania
  • Russian Public Health Association - Russia
  • Slovenian Coalition for Tobacco Control - Slovenia
  • Società Italiana di Tabaccologia - Italy
  • Tobacco Control Alliance of Georgia - Georgia
  • University of Cantabria - Spain
  • Wallonie Tabac Prevention - Belgium
ENSP Guidelines for Treating Tobacco Dependence

The ENSP Guidelines (ISBN: 978-618-82526-6-0) for evidence-based smoking cessation are the most recent and globally up to date systematic clinical guidelines for smoking cessation and were created in 2018 according to best practice standards in clinical guideline development. 

The update of the ENSP Guidelines for Treating Tobacco Dependence took place within the 2018. Several expert writing teams were jointly working in order to prepare the most recently update Guidelines in Treating Tobacco Dependence by incorporating the latest evidence-based practices in the field.

 For the above purpose the following were performed:
  • Literature Review
  • Preparation of Recommendation Statements  
  • Grading of Recommendations (GRADE – A, B, C, D)

The content of the Guidelines was divided into six chapters as presented below:

The English version was then translated and nationally adapted from our partners in Albania, Armenia, Belgium (French), North Macedonia, Georgia, Greece, Italy, Kosovo, Poland, Romania, Russia, Serbia, Slovenia and Ukraine.

High Risk Populations chapter of the Guidelines
The ENSP Guidelines for evidence-based smoking cessation are the most recent and globally up to date systematic clinical guidelines for smoking cessation and were created according to best practice standards in clinical guideline development. Within the 2018, ENSP further enhanced its Guidelines so as to include the results of the ENSP TOB-G project (which concluded in late 2017 and was funded by the 3rd Health Programme, www.tob-g.eu).

The TOB-G project’s main results included guidelines for clinicians providing smoking cessation for 5 high-risk groups (pregnant women, adolescents, adults with cardiovascular disease, diabetes, and chronic obstructive pulmonary disease). To facilitate access to these updated clinical guidelines, ENSP incorporated and translated the summary recommendations of the TOB-G clinical guidelines into the ENSP Guidelines in six languages from EU and Acceding countries (English, French, Greek, Slovenian, Romanian, Albanian). 

For each of the high-risk populations included in this new chapter we incorporated information relevant to:

  • The risks and health effects from their exposure to smoking including second hand
  • The profile of the smoker for each of the high-risk population groups
  • Benefits of cessation
  • Best practises for smoking cessation including behavioral counseling techniques depending on the level of readiness to quit
  • Pharmacotherapy available and suitable for use taking into account the limitations for each group 
  • A summary of key recommendations for healthcare professionals working with each of these high-risk population groups
E-learning Platform for Healthcare Professionals

All our efforts and work were oriented to support Article 14 of the WHO FCTC implementation in the wider European region. This is the reason why in accordance with FCTC Article 14, the ENSP accredited e-learning platform has been developed and is freely available for all healthcare professionals and the public.

Access it here...


We are confident that the platform will help healthcare professionals to be equipped with the necessary skills to combat this fatal addiction and provide them with a wide range of vital tools in order to help them introduce tobacco treatment delivery into their daily clinical life. ENSP’s online training program provides the opportunity for healthcare professionals in Europe to receive training in the latest evidence-based practices for helping their patients quit smoking.

In this context, we developed 5 modules:

Module 1: Nicotine Addiction - Why people smoke?In this section of the ENSP training program we discuss why it is so difficult for so many individuals to quit smoking.

Module 2: How to help your patients quit smoking? In this section of the ENSP training program, we discuss the important role of health professionals in supporting cessation among patients who smoke as a clinical priority.

Module 3a & 3b: Behavioral counseling part 1 & 2. In this section of the ENSP training program we discuss the role of behavioural counselling as a treatment for supporting tobacco users with quitting.
Module 4: Pharmacotherapy. Pharmacological treatment is fundamental component of treating tobacco use. In this module of the ENSP Tobacco Treatment program, we review the use of first line quit smoking medications including Nicotine Replacement Therapy, Bupropion and Varenicline.

The e-learning material was also updated to include case studies, quizzes, and content evaluation which was translated/adapted into all the available languages. Due to questionnaires submitted by the participants before and after the successful completion of all the parts of the course, we are able to evaluate the e-learning content as for the change/improvement in health care professionals’ knowledge, beliefs, perceived behavioral control and intention of delivering tobacco treatment into their daily clinical practice.

Case study example
Accreditation of the e-Learning content:
EACCME certificate
The ENSP e-learning platform has also received accreditation by the European Accreditation Council for Continuing Medical Education (EACCME)  to provide CME activity for medical specialists. The EACCME is an institution of the European Union of Medical Specialists (UEMS). Only those e-learning materials that are displayed on the UEMS-EACCME website have formally been accredited. Through an agreement between the European Union of Medical Specialists (UEMS) and the American Medical Association (AMA), healthcare professionals may convert EACCME credits to an equivalent number of AMA PRA Category 1 CreditsTM if they wish to use them for international purposes.

At the same time, we tried to adapt to local context with the best possible way  as this part is very critical to successful knowledge translation programs. For this purpose, we engaged local champions in the adaptation of an evidence-based model.

Key achievement: direct impact of EPACTT PLUS project

In 2018, and within the context of EPACTT PLUS project, our partners worked hard in promoting the achievements of the project in several ways.

More specifically:

 

  • Armenia:Armenian partners have officially presented the guidelines in local level and also received local accreditation of the eLearning course from the Ministry of Health (2 CME).  Announcement on the official page extra regional accreditation from Armenia’s Ministry of Health for the e-learning curriculum of ENSP. 
  • Albania:The Albanian guidelines are officially adapted as a lesson in Public Health Master course of University of Vlora Albania (50 students each semester).
  • North Macedonia: 
    1. Promotion of printed form of the ENSP guidelines on a dedicated professional meeting of the Macedonian respiratory society (MRS) on the World COPD Day in November 2018
    2. Dissemination of the printed guidelines in the Electronic educational program to all of the members of the Macedonian Respiratory Society, the staff of the Clinic of Pulmology and Allerg and , Centers for public health.
    3. Presentation and distribution of the ENSP Guidelines and the Electronic educational program to the teaching personnel (profesors and assistant prof.) of the Section for Internal medicine at the Medical faculty in Skopje.
    4. Samples of the guidelines are distributed to the libraries of the Medical faculty in Skopje, the  Ministry of health and the University " Sts. Cyril and Methods", for public use. 
  • Guidelines and e-learning from Romania, Ukraine, Italy, Spain, were officially presented in local Conferences. 
  • The Greek version was disseminated through the General Practitioners network of the country and in Cyprus (approx. 200 members).
  • ENSP organized hands-on Tobacco Treatments trainings for healthcare professionals in Slovenia, Russia, Romania and Kosovo where the guidelines and the online program were disseminated.
  • During the 4th ENSP – SRP International Conference 2019 in Bucharest, Romania, Guidelines were printed and shared with the local participants while both Guidelines and eLearning platform were disseminated in a booth dedicated for this purpose.
  • Guidelines and eLearning platform are also disseminated in other important  events and conferences such as WCTOH 2018 and previous ENSP Conferences.
  • EPACTT project is also disseminated through Global Bridges blog.
  • All the introductory videos of the participating countries and promotional videos of International experts on the topic are available in the project’s Youtube channel.
E-Learning platform: user interaction

The e-learning platform was updated and operational again by the end of Spring 2018. As shown in the figure below, in just a short period 11,011 page views were recorded 

Figure 1: Number of users and views of the e-learning platform
(Source: Google Analytics)

 

It is also important to note that, the vast majority of the new users were from Europe (61.11%) followed by Americas  (20.95%) and Asia (14.72%)

Figure 2: New users of the platform by continent

We are happy to also announce that since December 2018, 444 participants have completed the online course successfully! 

Hands-on trainings for healthcare professionals:
how to treat tobacco dependence

To further support the Implementation of Article 14 of WHO FCTC, ENSP developed a hands-on training course from healthcare professionals who want to become champions of tobacco control by introducing smoking cessation into they daily clinical life. 

The format of the curriculum provides useful information on: 

  1. Nicotine Addiction by reviewing both the physical and psychological aspects of tobacco use, the pathophysiology of nicotine addiction and the associated withdrawal symptoms and cravings that can make quitting challenging.
  2. The important role of health professionals in supporting cessation among patients who smoke as a clinical priority by providing a brief overview the 5As model for integrating tobacco dependence treatment into clinical settings.
  3. The role of behavioural counselling as a treatment for supporting tobacco users with quitting where we review evidence-based counselling strategies designed for individuals ready or not ready to quit smoking in order to increase their likelihood of successfully quitting.
  4. Pharmacotherapy by reviewing first line quit smoking medications including Nicotine Replacement Therapy, Bupropion and Varenicline.
  5. Evidence regarding the health risks associated with tobacco use  as well as effective approaches to supporting cessation and preventing relapse of special populations in tobacco treatment, namely pregnant women, diabetic patients, adolescents, mentally ill patients,  COPD and CVD patients.

In all parts, case studies scenarios are also performed as an active learning method.

So far ENSP has co-organized along with partner organisations, hands-on trainings:

27 Feb 2017: Tobacco treatment specialists’ training Pristina, Kosovo.

Organiser: KACD – Kosovo Advocacy & Development Center, ENSP

23 Nov 2018: Tobacco treatment specialists’ training, Moscow, Russia.

Organisers: Department of Healthcare of Moscow city Government; Moscow Scientific Practical Center of Narcology, ENSP

13 Dec 2018: Tobacco treatment specialists’ training, Ljubljana, Slovenia.

Organisers: Ministry of Health of the Republic of Slovenia; Slovenian Coalition for Public Health, Environment and Tobacco Control – SCTC; ENSP

8 Jun 2019: Tobacco treatment specialists’ training, Bucharest, Romania.

Organisers: Romanian Society of Pneumonology (SRP); ENSP

Until now, more than 150 healthcare professionals have participated in the hands-on trainings while ENSP is planning to co-organize trainings in Georgia, Albania, Moldova, France and Romania in the next months.

Any partner organisations, interested in hosting a training for healthcare professionals interested in treating tobacco dependence, please contact ENSP Secretariat at:  cornel.radu@ensp.org or  polina.starchenko@ensp.org

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