REGULATORY STATUS OF NRT

Nicotine transdermal systems can only be sold in pharmacies with a medical prescription. The same is true for the 4 mg gum, but the 2 mg gum is available OTC in pharmacies . No reimbursement by the health care system is available.
There is currently a debate around both accessibility and reimbursement of the products. Between OTC status and prescription only, an intermediate solution may exist. It should be possible to obtain :
- Reimbursement for prescribed NRT;
- No reimbursement for non-prescribed NRT.
 

IMPLICATION AND OBJECTIVES OF PROFESSIONALS

Objectives of all the professionals concerned with smoking cessation are :
- Amelioration of   access to information, and the measures and structures necessary for taking care of   smokers;
- Optimisation of the means, whatever the level of intervention or the importance of the dependence;
- Support of the smoker.

 General practitioners must be recognised as real actors in public health. In this sense, their role in smoking cessation must be valorised. Smokers’ motivation to quit is encouraged when they  can count on a help from a credible source such as  a GP. The legitimacy of their public health action, and particularly in the domain of smoking cessation, must be reinforced by :
- Initial training and continuing education;
- Availability of appropriate technical support;
- Time, and specific remuneration;
- Possibility of participation in networks.

All other physicians must also :
- Develop a sensitivity to the problem of tobacco smoking;
- Convey clear messages coherent with a tobacco control policy;
- Be open to professional collaborations.

The objectives for the pharmacists are :
- To be an example;
- Respect of smoking ban in pharmacies;
- Underline the risks linked to tobacco smoking;
- Encourage smoking abstinence;
- Counselling, help and follow-up of quitting smokers.

Teachers and social workers have the ability to transmit information on tobacco smoking risks, and to plan actions to encourage consciousness of the problem.

The objectives of smoking cessation centres are various :
- Taking care of heavily dependent smokers, those motivated who have failed previously, but also those with tobacco-related diseases;
- To promote teaching and continuing medical education;
- Set up a network for smoking cessation;
- Develop research in collaboration with other specialised services and general practitioners;
- Participate in policy making for tobacco control.

Education and training

Initial education. Within the framework of medical education, future physicians should be taught how to treat tobacco dependence. Tobaccology Teaching about tobacco and its effects needs to be started early in their education should also be reintroduce at the end of courses, and particularly emphasised in the most  relevant specialisms, with the participation of human sciences specialists as well as field actors. This initial education of the physicians should be accompanied by   similar education for the other health professionals, particularly nurses, dentists, and pharmacists.

Continuing medical education. As in the domain of AIDS and drug abuse, means should be allowed (public or private) to gather all the personnel implicated in smoking cessation in a common programme.  Participation of physicians and other health professionals in health promotion is another alternative, maybe more efficient than continuing medical education.
 

ACTION

Individual intervention. With appropriate training, health professionals can act at two levels :
- First level. Minimal intervention by GP and specialists within the framework of their activity, particularly  of  advice on smoking cessation volunteered without any expressed request. Industrial medicine, schools medical services , other health professionals and social workers are also implicated. At this first level, the GP can evaluate the dependence level, decide which treatment to use, and realise the follow-up of the smoker. A special role needs to be given  to the pharmacist, because whatever the nicotine substitution, it should be distributed through pharmacies.
- The second level is devoted to specialised structures, which apart from their role in education and  research, should be focused on highly dependent smokers. It is the role of the government to provide financial support for  such structures.

Participation of a significant number of GP in smoking cessation efforts implies that the time they spend in continuing education and in consultations, longer than usual, should be correctly remunerated.

Collective information and intervention. The methods for smoking cessation are usually unknown by the general population. It appears necessary to develop a national, but also regional, information policy on all the possibility to achieve tobacco abstinence through GPs and pharmacists.
A barrier to the campaigns mounted up until now , particularly by the Comité Français d'Education à la Santé (CFES, French Committee for Health Education), has been  the lack of interest, but also the lack of education, of health professionals in terms of prevention and hygiene education. They should now be involved at the regional level in the preparation of documents and campaigns.

Within this framework, it also seems important to develop an educational policy oriented toward children in  middle school and high school.
 
 

General conclusions :
Smoking cessation is a major problem for public health. It justifies new policy  initiatives and concerns the whole population; smokers and non-smokers, health professionals, administrative and political authorities, who should collaborate with mutual  respect for a better health for all.