Guide d’aide au sevrage tabagique

Objectives

Establish an integrated tobacco-control and smoking-cessation framework that reduces tobacco-related mortality, morbidity and disease, prevents initiation, protects non-smokers from second-hand smoke, and supports cessation through care adapted to each smoker’s dependence, motivation, behavioural profile and circumstances.[1][2][3]Smoking cessation is presented as beneficial at any point, with earlier cessation offering greater avoidance of tobacco-related risk.[4]

• Prevent tobacco use and tobacco-related diseases, including cancers, while addressing the health, psychological, educational and economic consequences of smoking and passive exposure.[1][2][4][5]
• Integrate cessation consultations into primary health care and enterprise medical-care packages, so that general practitioners, nurses and other health professionals can support smokers who want to quit.[1][2]
• Adapt interventions to the smoker’s pharmacological dependence, personality, readiness to change, social environment and change processes.[3][6][7]
• Support smokers through contemplation, preparation, action and maintenance, strengthen confidence and motivation, reduce withdrawal symptoms, and sustain long-term abstinence.[6][8][9]
• Prevent relapse by helping people recognise and manage cravings, triggers, high-risk situations, smoking-related beliefs and emotional or social pressures.[10][11][9]

The framework recognises nicotine dependence as both pharmacological and behavioural, and therefore combines clinical treatment with behavioural, cognitive and psychosocial support.[4][6][10]It also identifies tobacco harms across multiple body systems and risks from passive smoking, including respiratory illness, cardiovascular disease and adverse effects on children’s growth and respiratory health.[4][12][5]

Implementation

Deliver a structured, individualised cessation programme over several months, preferably led by practitioners trained in tobacco dependence, with regular consultations, clinical assessment, behavioural support, pharmacological treatment where appropriate, and continued follow-up to prevent and manage relapse.[6][9]The supplied material does not set out a comprehensive national governance, financing or accountability framework, but it identifies intersectoral collaboration for smoke-free educational institutions and enterprises.[2][13][14][15]

• Assess smoking history, daily and previous consumption, tobacco-use environment, psychosocial context, co-occurring substance use, sleep, physical activity, current treatment and clinical status before selecting support.[7]
• Assess readiness and dependence with structured tools, including the Fagerström test for nicotine dependence, the Horn Test for behavioural dimensions of dependence, and the Lagrue and Légeron test for motivation to quit.[7][16][17][18]
• Tailor behavioural and cognitive support to readiness for change, without forcing cessation before a smoker is ready, and strengthen preparation through trigger management, behavioural deconditioning, self-control and supportive contacts.[10][11]
• Use practical relapse-prevention measures, including removing tobacco and smoking accessories, avoiding high-risk settings, planning alternative activities, recalling that cravings are temporary, and addressing alcohol use, weight gain, social pressure and exposure to other smokers.[11][9]
• Provide nicotine-replacement therapy in forms suited to the individual, including patches, gum, sublingual tablets, lozenges, inhalers and nasal spray, and adjust dose according to dependence and clinical signs of under- or over-dosing.[8][19][20][13]
• Use combined nicotine-replacement approaches where a single product is insufficient, and permit temporary abstinence or gradual reduction as routes towards complete cessation.[14]
• Offer bupropion or varenicline where clinically appropriate, with attention to contraindications, adverse effects, interactions and prescription requirements; provide vitamin C, magnesium and calcium as symptomatic support during withdrawal where indicated in the guide.[13][14][15]
• Schedule follow-up around days 7, 21 or 28, 60 and 90, then adapt later appointments to the patient; maintain telephone availability, particularly during the first week, and re-engage people who miss appointments.[6][11][9]
• Monitor abstinence, cravings, adverse effects, obstacles, wellbeing and relapse risk through consultation, clinical examination and, where relevant, heart rate, blood pressure, peak expiratory flow, exhaled carbon monoxide, respiratory testing, chest radiography or electrocardiography.[6][7][11][9]
• Respond to relapse without blame by valuing prior abstinence, reducing guilt, identifying lessons and continuing support within a chronic-care approach.[9][21]
• Implement the “Smoke-free Colleges, Secondary Schools and Enterprises” programme through collaboration among the Lalla Salma Association for the Fight Against Cancer, the Ministry of Health, the Ministry of National Education, Training of Educational Staff and Scientific Research, and the Pfizer Foundation.[2]

Training in tobaccoology and use of a practical cessation guide are key delivery mechanisms; the guide covers cessation procedures, follow-up, monitoring and relapse prevention.[2]More than 800 health professionals, including about 600 doctors, had received training, and the programme aimed to extend smoke-free secondary-school coverage from 804 participating establishments to all colleges and secondary schools by the end of 2010.[2]

Clinical follow-up provides the principal monitoring mechanism. Reported outcomes include an approximately 25% one-year cessation rate when the structured programme is combined with pharmacological treatment, while the source also reports relapse as concentrated in the first six months after cessation.[6][9]No routine programme-wide indicator set, reporting process, surveillance arrangement, budget, financing mechanism or resource-mobilisation plan is specified in the supplied material.[2][13][14][15]

Monitoring & Evaluation

Monitoring and evaluation are primarily embedded in individual smoking-cessation care rather than in a programme-wide performance or accountability framework. Follow-up is intended to assess readiness, tobacco dependence, abstinence, cravings, withdrawal, treatment adherence, adverse effects, wellbeing, confidence and risks of relapse, with care adapted to the smoker’s clinical and behavioural circumstances.[6][7][10][11][9]

• Use structured assessment tools to tailor and review care, including the Horn Test for behavioural dimensions of tobacco dependence, the Fagerström test for nicotine dependence, and the Lagrue and Légeron test for motivation to quit.[7][16][17][18]
• Measure tobacco exposure clinically, including through exhaled carbon monoxide measurement; initial or subsequent investigations may also include chest radiography, respiratory-function testing and electrocardiography.[7]
• Schedule consultations during the cessation process, including follow-up at day 7, around days 21 or 28, and around days 60 and 90, before adapting later appointments to the individual.[11][9]
• Review abstinence, cravings and adverse effects during follow-up, and where relevant measure heart rate, blood pressure, peak expiratory flow and exhaled carbon monoxide before adjusting nicotine-substitution treatment.[11]
• Maintain contact during early cessation, including telephone availability during the first week, re-engage people who miss appointments, and progressively space consultations as abstinence stabilises.[6][9]
• Monitor clinical signs of nicotine under-dosing or over-dosing when nicotine-replacement treatment is adjusted, and record and manage adverse effects from cessation medicines.[19][20][13][14][15]
• Address relapse as part of chronic care by identifying obstacles, high-risk situations and triggers, reducing guilt, valuing previous abstinence and using relapse as a learning opportunity.[6][11][9][21]

The source provides several outcome measures and evidence points, but these are reported clinical or illustrative results rather than a unified monitoring indicator set. A cessation programme combined with pharmacological treatment is associated with an approximately 25% cessation rate at one year.[6]Reported cessation rates associated with follow-up duration are 10% at one month, 28% at one to three months, and 38% at three to nine months.[11]Cessation is classified as recent at four to six months, persistent at 12 months and confirmed at 24 months.[11]

• Track relapse risk particularly in the first six months, when 75–80% of relapses are reported to occur, and through the first year, when 40–60% of former smokers are reported to relapse.[9]
• Recognise evidence reported for pharmacological treatment: bupropion abstinence outcomes were 44% versus 19% at treatment end, 27% versus 16% at six months, and 23% versus 12% at one year compared with placebo; varenicline was reported as more effective than placebo and bupropion at three months and one year.[14][15]
• Use the cessation guide’s procedures for follow-up, surveillance after cessation and relapse prevention.[2]

No programme-level monitoring framework, routine indicators, reporting arrangements, population surveillance system, evaluation methodology or formal institutional accountability mechanism is specified in the supplied excerpts.[2][4][12][5][19][13][17][18]

Costing & Financing

Costing and financing information is very limited. The supplied material does not provide a tobacco-control or cessation-programme budget, expenditure allocation, unit cost, financing mechanism, resource-mobilisation plan, funding-gap estimate or wider economic assumption.[2][6][8][19][13][10][9][17]

• Identify the Pfizer Foundation as a collaborator in the “Smoke-free Colleges, Secondary Schools and Enterprises” programme, alongside the Lalla Salma Association for the Fight Against Cancer and relevant Moroccan ministries; no financial contribution, funding terms or allocation is specified.[2]
• Recognise resource inputs described without cost estimates, including trained health professionals, cessation consultations in health centres and enterprise medical-care packages, clinical follow-up, tobacco-dependence assessment tools and nicotine-replacement or other pharmacological treatment.[1][2][6][7][13][14][15]
• Note individual and societal economic benefits associated with smoking cessation, including reduced spending on cigarettes and health care, fewer sickness-absence days and fewer tobacco-related premature deaths.[5]

The only quantified financial information is an illustrative calculation based on smoking one packet per day at a stated price of 30 Moroccan dirhams per packet.[5]This equates in the source to 219,000 Moroccan dirhams over 20 years and 328,500 Moroccan dirhams over 30 years; these figures describe personal cigarette expenditure rather than programme costs, savings, budgets or committed financing.[5]