Project Quit Tobacco International (QTI)

1. Project Quit Tobacco International (QTI) Mimi Nichter, Ph.D. University of Arizona School of Anthropology

2. Overview • Introduce Project Quit Tobacco International • Provide a brief background on tobacco use and tobacco control in Turkey • Discuss the current QTI project in Turkey

3. Project Quit Tobacco International (QTI) • A decade-long Fogarty NIH project in India & Indonesia to develop evidence–based culturally-sensitive cessation approaches • Conduct formative research to understand perceptions of tobacco harm and patterns of use • Establish relevance of cessation advice by addressing how smoking has contributed to a patient’s existing health problems, and how SHS places others in household at risk • Introduce community-based approaches to tobacco education and develop smoke-free home initiatives

4. QTI: Illness-specific focus • Most patients and the general public have general knowledge that smoking causes lung cancer or COPD but do not associate health conditions such as diabetes or TB with smoking • Raise community consciousness about the harms of tobacco beyond general knowledge • Illness is a teachable moment • Patients may be more willing to quit at this time • Tailoring cessation advice to a patient’s condition and incorporating motivational interviewing enhances the effectiveness of cessation messages

7. For more information on QTI India and Indonesia: www.quittobaccointernational.org *15 module curriculum for medical students *15 videos modeling brief interventions for specific illnesses *educational materials for laypersons *Our publications

8. QTI TURKEY

9. Turkey & Tobacco Control • Turkey was among first countries globally to ratify WHO’s FCTC • Considered a leader in Europe in tobacco control, with comprehensive smoke-free legislation and taxation on tobacco products • In 2013, lauded as the only country in the world to have implemented all of WHO’s six MPOWER tobacco control measures (Monitor, Protect, Offer Help, Warn, Enforce and Raise Taxes) • Tobacco use remains a key public health concern—causes at least 100,000 deaths per year

10. Smoking Prevalence • Turkey is the 8th largest consumer of tobacco in the world • Smoking among men: 41%; Women: 13% • Turks are high level smokers; men smoke about 20 cigarettes per day; women 15 • Perception around Europe of a heavy smoker is one who “smokes like a Turk” • Among health care providers: 24% of general practitioners, 13% of specialists, 20% of nurses and midwives are regular smokers

11. DownwardShiftin SmokingPrevalence Men Total Women

14. Smoking Cessation in Turkey • Although tobacco cessation is a key component of Turkish Health Policy, cessation outcomes are not well documented • In 2011, Turkey opened cessation clinics around the country; 27 were located in government hospitals in Istanbul. • Overall there are 415 cessation clinics in the country which are all very understaffed. The country has 14 million smokers. • Cessation is only carried out by doctors and is highly medicalized –pharmacotherapy (Varenicline &/or Bupropion). When available through the national health care system it was distributed freely, but availability is sporadic. • Notably, medications were purchased by the Ministry of Health in large batches twice—both times around the time of election. • When the medications are depleted, patients can purchase them with a prescription. • Very little behavioral counseling offered in cessation clinics

15. Efficacy of Cessation Clinics • Only one study has evaluated the efficacy of national cessation program (Celik et al., 2015) • Examined one year period (2011); randomly chose 16,500 people who had received free medication (64% varenicline/Champix; 36% Bupropion/Zyban) • 30% of Varenicline users and 25% of Bupropion users had quit and had not relapsed at one year • Those with hypertension, diabetes, and CVD were more likely to have successfully quit Celik et al. Nationwide smoking cessation treatment support program in Turkey, Health Policy 119(2015) 50-56.

16. Increasing need for cessation services • Recent national survey results on quitting: 43% of smokers had tried to quit in past year, and 35% had thought about quitting • The desire to quit is on the rise • There is a need for more information/educationon the harm of tobacco • At present, people have a general sense that smoking is harmful for health and that it can cause lung cancer

17. Project Overview: QTI Turkey • Overall goal is to extend the reach and depth of smoking cessation training within the Turkish healthcare system. • To create a cadre of nurses trained in tobacco cessation who are able to: • perform illness-specific as well as general cessation as part of their routine clinical practice • assist in the training of other nurses in their sub-specialties.

18. Why Nurses? • Recent Cochrane Review of 35 trials found nursing interventions to help smokers quit have been effective in US, UK, Australia, China, and many European countries. • In QTI, goal to make cessation a normative part of curative as well as preventive care • Nurses not involved at present; assumed that doctors had received training

19. Team Effort QTI-Turkey Team • Mark Nichter, Ph.D., MPH, University of Arizona • Prof AygulAkyuz, Koc University, Istanbul We also like to thank: • Assoc. Prof. M. AtillaUysal, Yedikule Research Hospital • Dr. ElifAltug, Amerikan Hospital • Assoc. Prof. TokerErguder, WHO Turkey For their support

20. Thank You!