Tobacco cessation on prescription : a primary healthcare intervention targeting socioeconomically disadvantaged areas in Stockholm

Sammanfattning: Background: In Sweden, the prevalence of tobacco use is higher among socioeconomically disadvantaged groups. Primary healthcare (PHC) has the main responsibility for tobacco cessation treatment in the Swedish healthcare system but relatively few PHC patients are identified as tobacco users and are offered support to quit. Tobacco Cessation on Prescription (TCP) is a new PHC intervention that may facilitate tobacco cessation treatment but this has previously not been evaluated. Thus, the aim of this thesis was to explore and evaluate TCP as a PHC intervention with a focus on socioeconomically disadvantaged areas in Stockholm. Methods: Study I, III and IV were exploratory qualitative studies based on semi-structured interviews with patients, PHC providers and experts on other lifestyle interventions on prescription that were analysed according to different approaches to qualitative content analysis. Study II was a cluster randomised controlled trial where 18 PHC centres were randomly allocated to provide TCP or standard treatment to their patients. Data was collected through questionnaires and analysed with descriptive statistics and regression models. Results: In Study I, the informants suggested that TCP should consist of a template with information about the patient, options for evidence-based treatments for tobacco cessation, follow-up, other measures for cessation and support for self-management. TCP was perceived to have an emotional meaning for patients and a practical meaning for PHC providers. Perceived challenges with the method were mainly related to the implementation of TCP. Study II showed that more patients managed to quit their tobacco use with TCP (38 out of 108 patients) compared to standard treatment for tobacco cessation at 6 months follow-up (4 out of 31 patients). The odds for this were 5.4 times higher in the intervention group compared to the control group when the odds ratio was adjusted for significant covariates. This association was statistically significant. In Study III, PHC providers perceived TCP to increase self-efficacy to work with tobacco cessation among providers and involvement in the treatment among patients. Perceived barriers to implement TCP included lack of organisational support, resources and differing attitudes among PHC providers to work with tobacco cessation. Long waiting times, costs of treatment and a focus on face-to-face visits limited patients’ access to cessation treatment. In Study IV, patients reported a need for individualised cessation support, taking their individual experiences of tobacco use and cessation into account. They also expressed a need for a supportive environment to quit, including support from the healthcare system, the social environment and other societal structures. The TCP prescription form was perceived as a useful document for PHC providers but counselling from a specialist, an empathetic approach in the counselling and long-term follow-up was considered more important to patients. Conclusions: PHC providers and patients perceived the TCP prescription form as a tool that could facilitate tobacco cessation treatment from the PHC providers’ perspective. TCP may also be effective in decreasing the prevalence of tobacco use among patients in the given setting. It is important that PHC providers adopt an empathetic approach in cessation counselling, taking patients’ individual experiences of tobacco use and cessation into account. However, the possibilities to work with tobacco cessation in PHC need to be strengthened in order to improve current cessation treatment and facilitate the implementation of TCP. Tobacco cessation services in PHC likely needs to be reorganised to improve access to treatment for lower socioeconomic groups. Interventions outside the healthcare system are also needed to further support this target group to quit.