Global Bridges members discuss…definitions

Global Bridges European team’s scoping exercise had identified (as previous and ongoing studies and other work have also shown) disparity amongst different countries methods for assessing and defining smoking status and treatment outcomes for tobacco dependence treatment programs. This makes it very difficult, even in one region, such as Europe, to compare prevalence, incidence and outcomes between countries.

At all levels (international, regional and national), brief interventions to identify and assist smokers to quit are strategically recommended. Brief interventions (the 5As) and very brief interventions (the 3As) rely on clinicians at all levels identifying smokers – for which they need absolute clarity about what constitutes a smoker.

We sent an email to the listserv participants asking for representatives of different countries to provide the definitions (if used) and rationale behind those definitions (if known) for:

  • Smoker
  • Non-smoker
  • Ex-smoker
  • Treated smoker
  • Quitter

We received 18 different responses from a diverse range of countries across the globe. There was a clearly perceived and stated need for standardized definitions. ‘It is important to have a consensus on the definitions.’ (Western Pacific member) ‘I too feel that we should be working towards one standard definition globally for these items so that we can compare the results of different studies. The age group should also be stated.’ (SE Asia member). ‘I know that we in India always struggle every time we have to use these concepts. It would so good to get a clarity and consensus globally on the definitions.’ (SE Asia member)

Definitions of ‘smoker’

Many respondents split this further into ‘adolescent vs adult’ and ‘occasional vs regular’. Whilst there was a general agreement on these principles (and the need for these further definitions) some countries have a very generalised and loose definition:  ‘usually we refer to them as a person who smokes at least 1cigarrette per day’ (Latin America member); ‘Our country is steering everyone away from these terms. When patients present they are classified either “smoke-free” or “not smoke-free”. ie asked “are you smoke-free?” (Western Pacific member) while others have a very specific definition ‘ Adult Smoker: Any person over the age of 18 years who smoked at least 100 cigarettes in your life and that currently smoke any or all of the days. Adolescent Smoker: frequent smoker : young people who have smoked for at least 20 of the 30 days prior to the survey; ever smokers: young people who have ever smoked (although one or two puffs); occasional smoker: young people who have smoked at least once in the thirty days preceding the survey.’ (Latin America member).

For occasional smoking, a reasonably standard response was ‘smokes, but less than once daily, regardless what kind of tobacco’ (Europe member).

There was a multi respondent discussion suggesting and then refuting the use of the Global Adult Tobacco Survey (GATS) questions developed for the World Health Organisation (WHO) as a measure of smoking status. This was considered by several members to be less useful in clinical practice than as a population level measurement tool, given the complexity of the questions and the amount of training that may be required to accurately collect such data. It was also pointed out that this set of questions were designed for population level surveillance – therefore there was full support for these validated questions to be the questions used in any national survey or population level survey, but NOT for clinical practice.

The members seem to be in agreement that there is a need for standard definitions that are clear, straightforward, and sensible for the following:

  • Adult regular smoker
  • Adult occasional smoker
  • Adolescent/Young regular smoker
  • Adolescent/Young occasional smoker

Definitions of ex-smoker

Definitions of ex-smoker also ranged in complexity and levels of definition from the very general to the more specific. In one case, two definitions are provided for ‘ex-smoker’ – ‘’Quit less than 12 months and greater than 12 months’.   (Western Pacific member); which the member described as being perceived as ‘too complicated’. A more general approach is that described by a member from the SE Asia region; ‘an ‘ex-smoker’ is one who has been an ever smoker but who is not a current smoker.’

Definitions of non-smoker

Respondents wanted a definition for this, since by recording non-smoking status, the time they took to talk to the patient was acknowledged. ‘Our clinical staff report this is demoralizing.  From an audit point of view we are unable to back track the Patient Smoking Status if they are a Never Smoker.  It looks like they were never asked.’ (Western Pacific member).

The stated definitions of a non-smoker, where described, were mainly null descriptors, along the lines of ‘someone who has never smoked a cigarette, or a cigar, or a pipe’(Europe member).

Definitions of treated smoker

Definitions of a treated smoker were rarely described – most respondents said there was no agreed-upon definition of treated smoker in their country. The members of the discussion felt that this definition is necessary to have a sense of the denominator for any service efficacy work.

The definitions that were provided were mostly assumed ‘There is not a definition for this person in our Guides, but we believe that a smoker is in treatment when entering a program of smoking cessation’ (Latin America/US &Canada member). Only one definition is specific and measurable ‘ a treated smoker is a smoker who consents to treatment, undergoes at least one treatment session on or prior to the quit date and sets a firm quit date.’ (Europe member).

Definitions of quitter

There were 3 main definitions of quitter –

  1. Short term (ie. 4 week quitter as used in the Russell Standard) (Europe member)
  2. Medium term ( 3 or 6 months)
  3. Long term (12 months or 12 months plus

In terms of quantifying this, members talked about mainly self-report (i.e. with no biochemical validation) or validated (with expired CO readings). The former was more prevalent in responses than the latter. “Smoke-free” is defined as total abstinence at three months, but best practice also suggests further determination at 12 months. Some cessation services have breathalyzers to determine this, but not all.’(Western Pacific member)

This discussion has highlighted an important role for Tobacco Dependence Treatment advocates. It is clearly felt that there is a need for specific, measurable and sensible definitions of the most commonly used terms in the field that can be agreed upon by clinicians and clinical leaders in the field to support standardization, and therefore comparability between localities, countries and regions.