Tobacco cessation on prescription a primary healthcare intervention targeting socioeconomically disadvantaged areas in Stockholm
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 syste m 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 thi s thesis was to explore and evaluate TCP as a PHC intervention with a focus on socioeconomic ally disadvantaged areas in Stockholm. Methods: Study I, III and IV were exploratory qualitative st udies based on semi structured interviews with patients, PHC providers and experts on other lifestyle interventions on prescription that were analysed according to differ ent approaches to qualitative content analysis. Study II was a cluster randomised control led trial where 18 PHC centres were randomly allocated to provide TCP or standard treat m n to their patients. Data was collected through questionnaires and analysed with descriptiv e statistics and regression models. Results: In Study I, the informants suggested that TCP shoul d 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 pra ctical meaning for PHC providers. Perceived challenges with the method were mainly re lated 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 to bacco cessation at 6 months follow up (4 out of 31 patients) The odds for this were 5.4 tim es higher in the intervention group compared to the control group when the odds ratio w as adjusted for significant covariates. This association was statistically significant. In Study III, PHC providers perceived TCP to increa s self efficacy to work with tobacco cessation among providers and involvement in the tr eatment among patients. Perceived barriers to implement TCP included lack of organisa tional support, resources and differing attitudes among PHC providers to work with tobacco essation. Long waiting times, costs of treatment and a focus on face to face visits limite d patients' access to cessation treatment. In Study IV, patients reported a need for individua lised cessation support, taking their individual experiences of tobacco use and cessation int account. They also expressed a need for a supportive environment to quit, including sup port 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 f rom a specialist, an empathetic approach in the counselling and long term follow up was cons idered more important to patients. Conclusions: PHC providers and patients perceived the TCP prescr iption form as a tool that could facilitate tobacco cessation treatment from t he PHC providers' perspective. TCP may also be effective in decreasing the prevalence of t obacco use among patients in the given setting. It is important that PHC providers adopt a n empathetic approach in cessation counselling, taking patients' individual experience s of tobacco use and cessation into account. However, the possibilities to work with tobacco ces sation in PHC need to be strengthened in order to improve current cessation treatment and fa cilitate the implementation of TCP. Tobacco cessation services in PHC likely needs to b e reorganised to improve access to treatment for lower socioeconomic groups. Intervent ions outside the healthcare system are also needed to further support this target group to quit.