Protocole National pour le sevrage tabagique

Objectives

The protocol provides a harmonised reference framework for identifying and managing tobacco dependence in Côte d’Ivoire, aligned with international directives and recommendations. It seeks complete and sustained cessation of tobacco use, ultimately without nicotine substitutes, while preventing withdrawal symptoms, relapse and tobacco-related complications.[1][2][3][4]Its intended population is people who consume tobacco, with preventive action also addressing people not yet exposed and groups considered at elevated risk, including adolescents, school populations, manual-handling personnel and prisoners.[1][5]

• Harmonise tobacco-dependence management through identification, clinical care, psychological and social support, preventive counselling, medicines, motivational methods, psychotherapy, dietary measures and physical activity.[1][3]
• Prevent tobacco initiation through primary prevention and targeted public information, particularly for populations at risk.[5]
• Prevent complications among people for whom tobacco is a risk or aggravating factor through secondary prevention, and reduce tobacco-related risks through tertiary prevention.[5]
• Support informed and voluntary cessation decisions, establish an individual therapeutic plan and sustain abstinence through post-treatment follow-up.[6][4]
• Assess and address nicotine dependence, motivation, co-addictions, anxiety or depressive comorbidity, and psychiatric, cardiovascular, respiratory and other tobacco-related complications.[2][7][4][8]
• Integrate cessation support into primary healthcare and comprehensive tobacco-control programmes, while improving affordability and access to nicotine-replacement products and psychological support.[9]

Implementation

The delivery model combines community and health-system identification with stepped, predominantly outpatient cessation care across peripheral, intermediate and central services.[1][4][10][11][12]Care is intended to be empathetic, non-judgemental and patient-centred, with the patient an essential participant: adult patients should initiate treatment requests themselves, while requests for minors should come from a parent or legal guardian.[5][2][7]Tobacco-control non-governmental organisations and community health workers provide reception, listening, information and referral, while health professionals including doctors, pharmacists, dental surgeons, nurses, midwives and traditional medicine practitioners contribute to identification, brief advice and care.[1]Psychiatrists, psychologists, social workers, families and associations may support continuing care.[1]

• Screen routinely for active and passive tobacco exposure, product type, frequency and intention to quit; provide brief, clear advice and information materials; and refer patients through the health-system pyramid when required.[10][11]
• Assess dependence through smoking history, previous quit attempts, patterns of use, co-dependence and the Fagerström test, alongside assessment of motivation, anxiety, depression and other addictions.[2][7]The dependence-assessment tool described in the extract also considers cigarette consumption, time to the first cigarette, smoking early after waking and smoking despite illness or enforced bed rest.[9]
• Deliver specialised tobacco consultations using clinical equipment, consultation forms, self-assessment tools, carbon-monoxide testing, spirometry and an intervention algorithm, with available equipment determined by the service level.[7]Conduct clinical examination and tests selected according to presentation, which may include cotinine testing, exhaled carbon monoxide, full blood count, chest radiography, respiratory-function tests and electrocardiography.[6]
• Prepare patients for cessation by explaining tobacco harms and dependence, correcting misinformation, exploring ambivalence, classifying readiness for change, securing adherence and agreeing a quit date and therapeutic project without coercion.[6]Tailor motivational support to the transtheoretical stages of change, including non-blaming re-engagement following relapse.[4][8]
• Provide treatment mainly on an ambulatory basis, reserving hospitalisation for complications, co-addictions requiring admission or associated conditions.[4]Combine nicotine replacement therapy with psychological and social support, counselling, physical activity, dietary measures, relaxation, self-help groups, family therapy and supportive or cognitive-behavioural psychotherapy as appropriate.[1][3][4]Use bupropion or varenicline as second-line options where nicotine substitutes have not enabled cessation.[3][7]
• Prescribe nicotine-replacement products, where there are no contraindications, in forms including patches, chewing gum, lozenges, tablets and inhalers; permit combinations of forms where appropriate; and use treatment courses of approximately six weeks to six months.[13][11][12]The protocol also identifies over-the-counter availability, affordability-oriented pricing and taxation, insurance reimbursement, and financing of cessation programmes as measures to improve access.[9]
• Operate referral and counter-referral across peripheral, intermediate and central levels. Intermediate services provide screening, dependence assessment, motivational intervention, nicotine replacement, follow-up and referral for severe comorbidity, while central services provide more specialised psychotherapy, investigation and treatment of complications.[11][12]
• Schedule follow-up at day 7, day 14, day 30, and months 2, 3, 6, 9 and 12; monitor adherence, medicines, adverse effects, withdrawal, relapse, motivation, mental health, weight and social or environmental influences; and restart cessation assistance after relapse.[4][11][12]
• Monitor implementation through notification, collection, compilation and analysis of data, supported by supervision through meetings, visits and surveys.[12][14]Use patient files, identification and follow-up forms, registers and activity reports; produce monthly, quarterly and annual reports through the Ministry of Health and the Fight against AIDS data circuit, with copies to the National Programme for the Fight against Tobacco and Addiction.[12][14]
• Track numbers received, followed, referred and counter-referred; comorbidity, relapse and loss-to-follow-up rates; cessation success; service availability by health-system level; knowledge, attitudes and practices; and tobacco-related consultation trends.[14]

Monitoring & Evaluation

Monitoring combines clinical follow-up of tobacco cessation with service-level data collection, reporting and evaluation. Clinical reviews assess treatment effectiveness, adherence, medicine use, adverse effects, dosing, withdrawal symptoms and relapse, while the wider system uses routine notification, compilation, analysis, supervision and evaluation to support service adjustments.[3][4][12][14]

• Assess tobacco use, product type, frequency, passive exposure, quit intentions, previous cessation attempts, co-dependence, circumstances of high consumption and nicotine dependence, including through the Fagerström test and other dependence-scoring approaches.[7][10][9]
• Investigate clinical status, co-addictions and complications through examination and tests selected according to presentation, which may include cotinine testing, exhaled carbon monoxide measurement, full blood count, chest radiography, respiratory-function tests and electrocardiography.[7][6]
• Monitor physical and psychological effects during follow-up, including sleep disturbance, weight gain, anxiety or depressive deterioration, fatigue, irritability, impaired concentration, loss of motivation and social or environmental factors affecting cessation.[7][6][12]
• Schedule follow-up at day 7, day 14, day 30, and months 2, 3, 6, 9 and 12; provide renewed cessation assistance following relapse.[11][12]
• Measure outcomes through numbers of tobacco consumers received, followed, referred and counter-referred; the proportion with co-morbidity; relapse and loss-to-follow-up rates; and cessation success rates.[14]
• Measure service functioning through the number and proportion of health facilities providing cessation support, disaggregated by health-system level and facility type.[14]
• Assess impact through surveys of tobacco-related knowledge, attitudes and practices and trends in consultations associated with tobacco use.[14]
• Record information in patient files, identification and follow-up forms, registers and activity reports; produce monthly, quarterly and annual reports through the Ministry of Health and the Fight against AIDS data circuit, with copies sent to the National Programme for the Fight against Tobacco and Addiction.[14]
• Undertake supervision and evaluation through meetings, facility visits and surveys.[12][14]

The extract identifies healthcare providers, health-pyramid facilities, the Ministry of Health and the Fight against AIDS data circuit, and the National Programme for the Fight against Tobacco and Addiction as operational actors in monitoring and reporting.[12][14]It does not specify numerical targets, reporting templates, data-quality procedures, named accountable officers, enforcement mechanisms or a comprehensive surveillance architecture beyond the stated clinical and routine-reporting arrangements.[3][4][14]

Costing & Financing

Costing is described principally as a theoretical accumulation of expenditure on consultations, paraclinical examinations, medicines and other additional costs.[1][5]No total programme budget, quantified allocation, currency amount, funding gap, expenditure estimate or economic assumption is provided.[1][5][3][4]

• Include consultation, investigation, medicine and other additional expenses when calculating the theoretical cost of cessation care.[1][5]
• Recognise that nicotine-replacement products have limited pharmacy availability, in part because economic factors affect their procurement.[1]
• Support affordability through over-the-counter access to nicotine-replacement products, pricing and taxation policies, and reimbursement by public and private health insurers for cessation products and psychological support.[9]
• Finance smoking-cessation programmes as part of comprehensive tobacco-control programmes and primary healthcare integration.[9]

Nicotine replacement therapy is a central treatment component, while bupropion and varenicline are identified as second-line options for people unable to stop smoking with nicotine substitutes.[2][3][7]However, the source does not specify product prices, patient charges, reimbursement levels, procurement volumes, financing sources, resource-mobilisation responsibilities, or the cost implications of referral, clinical testing, psychological care, dietary support or physical activity.[3][4][11][12][9]