Challenges for dedicated smoking cessation services in developing countries

This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0. RESEARCH Challenges for dedicated smoking cessation services in developing countries G Y Tadzimirwa,1 MB ChB; C Day,1 MB BCh, Dip HIV Man (SA), MMed (Medicine); A Esmail,1 MD, FCP (SA), Cert Pulmonology (SA); C Cooper,2 Dip Nurs; M Kamkuemah,3 MPH; K Dheda,1,4 MB BCh, FCP (SA), FCCP, FRCP, PhD; R N van Zyl-Smit,1,4 MB ChB, MRCP (UK), Dip HIV Man SA, FCP (SA) MMed, Cert Pulm (SA), PhD Division of Pulmonology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa Division of Nursing, E16 Respiratory Clinic, Groote Schuur Hospital, Cape Town, South Africa 3 Division of Public Health Medicine, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa 4 University of Cape Town Lung Institute, South Africa 1 2 Corresponding author: R N van Zyl-Smit () Background. South Africa, ranked as the world’s second most stressful country to live in, has an estimated 7 million smokers. A dedicated smoking cessation clinic established at Groote Schuur Hospital, Cape Town, provides the only clinical service and training centre in the country. Objectives. To evaluate the smokers attending the clinic, in order to better understand the requirements of smoking cessation services in resource-limited settings. Methods. Demographic and smoking-related data were collected prospectively from all clinic attendees since its inception. Nicotine dependence, depression scores and exhaled carbon monoxide levels were formally evaluated. Consent was provided to review the data collected. Results. Ninety-seven smokers were evaluated. Their mean (standard deviation) age was 50.9 (10.7) years, and 59% (57/97) were male. The median age of smoking initiation was 16 years (interquartile range (IQR) 8 - 28), with a current median daily consumption of 12 cigarettes (IQR 7 - 20). Overall, men smoked more than women, with a median of 20 cigarettes per day (IQR 10 - 20) v. 12 (IQR 5 - 20), respectively (p=0.001). The median Fagerström nicotine dependence score was 5 (IQR 3 - 7), with scores of 6 (IQR 4 - 8) for men and 5 (2 - 7) for women (p=0.06); 50% of smokers had a Fagerström score <6 (low to above-average dependence) and 22% a score ≥8 (extreme dependence). The median Patient Health Questionnnaire-9 (PHQ-9) depression score was 8 (IQR 4 - 11), and 49% of smokers had symptoms of at least minor depression (score ≥10). The clinic could not provide pharmacotherapy. The self-reported quit rate was 28% at median follow-up of 22 months (IQR 14 - 39). Conclusions. In smokers attempting to quit, moderate levels of nicotine dependence coexist with significant depression and anxiety symptoms. These data inform resource allocation and public health strategies, suggesting that in resource-limited smoking cessation services, psychological/behavioural support focusing on depressive symptoms may be a greater priority than simple pharmacotherapy. S Afr Med J 2019;109(6):431-436. DOI:10.7196/SAMJ.2019.v109i6.13631 The detrimental effect of smoking on population health has been apparent since the early 1900s, when a relationship between increased prevalence of smoking and increased incidence of lung cancer, previously uncommon, was identified.[1,2] Since then, numerous studies have highlighted the relationships between smoking and non-communicable diseases including cardiorespiratory disease, autoimmune disease, subfertility, malignancy, cerebrovascular disease and poor fetomaternal outcomes.[2-6] South Africa (SA)’s first burden of disease report in 2000 highlighted the quadruple burden of disease the country faces and the need for a multifaceted approach to improving health that includes managing modifiable risk factors, particularly smoking.[7] It was reported that in SA in 2000, smoking accounted for 8.5% of all deaths (and 13% of deaths in adults aged >35 years) and 3.7 - 4.3% of disability-adjusted life-years due to lung and other cancers, cardiovascular disease, chronic obstructive pulmonary disease (COPD), tuberculosis and other medical conditions.[8] South Africa has an estimated 7.2 million adults living with HIV, 60% of whom are co-infected with TB, with 61% of adults on antiretroviral therapy.[9] In addition, both smoking and TB increase the risk of COPD.[10-13] However, individuals who 431 quit smoking successfully lower their risk with every year after cessation. Furthermore, those who manage to quit before the age of 45 have the same life expectancy as those who have never smoked.[14] Many low- and middle-income countries (LMICs) have made significant efforts to minimise adverse health outcomes due to smoking, with legislation restricting tobacco use, advertising and trade following the World Health Organization (WHO) MPOWER strategy.[15] Formal cessation programmes mainly exist in high-income countries, which equate to ~15% of the world’s population able to access cessation support.[16] Very few data exist on formal cessation programmes provided in low-income settings or on how applicable cessation strategies developed in high-income settings are to low-income countries.[16,17] Furthermore, smoking cessation pharmacotherapy such as nicotine replacement therapy (NRT), although on the WHO essential medicine list, is not always available to smokers.[18,19] This is particularly true in SA, where, although it is classed as a middleincome country, no smoking cessation pharmacotherapy is available to smokers accessing public health services. A combination of behavioural therapy and pharmacological support is regarded as the interventional strategy with the highest June 2019, Vol. 109, No. 6 RESEARCH odds of long-term cessation. There are, however, no data to indicate who will be unsuccessful if pharmacotherapy is not added to behavioural interventions. change with a specific focus on self-motivation, problem solving and strategies for coping with withdrawal symptoms. Objectives Ethics approval to perform this clinical patient database review was granted by the University of Cape Town Faculty of Health Sciences Human Research Ethics Committee (ref. no. 667/205) and GSH administration. At the time of their first visit, all patients provided written informed consent to have their data relevant to the smoking cessation clinic collected as part of the standard evaluation of all patients at the clinic. Participants also provided contact details to allow for telephonic contact to provide support and evaluate outcomes. A dedicated smoking cessation clinic established at Groote Schuur Hospital (GSH) in Cape Town is the only one of its kind in SA. Our objectives were to to assess the sociodemographic and dependency profiles of the smokers who attended this clinic and their short- and long-term outcomes. By understanding the characteristics and needs of smokers in this setting, we hoped to provide relevant data to help guide locally applicable s (...truncated)