Creating a TDT training network in Crete

The TiTAN Project  — Tobacco treatment TrAining Network in Crete — involves developing a primary care tobacco dependence treatment (TDT) network in Crete, Greece. The project is one of 19 grants awarded through a partnership between Pfizer Independent Grants for Learning & Change (IGLC) and Global Bridges. The $2.3 million in grant awards are designed to increase tobacco cessation rates through healthcare professional training and advocacy in low- and middle-income countries.

Please share with us an overview of this project:

Currently, Greece has one of the highest smoking prevalence among members of the European Union, estimated at slightly above 38% of the adult population[1] , a staggering percentage of smokers. In 2011, smoking accounted for almost 200,000 hospital admissions (8.9% of the national total), with attributable hospital treatment costs calculated at over 554 million Euro, which represents 10.7% of the national hospital budget.[2]  These are dramatic numbers for a country with a population smaller than that of New York.

Despite this enormous burden to the healthcare system, we know a significant percentage (44%) of tobacco users in Greece are interested in quitting.[3]  Primary health care providers (PHC) are well positioned to deliver tobacco treatment in the course of their daily routines.

Internationally, World Health Organization (MPOWER) has called for smoking cessation to be integrated into primary health care.[4-6] Despite the evidence supporting the efficacy of smoking cessation interventions, our team has documented a practice gap in the rates at which 5As smoking cessation interventions are delivered by primary-care practitioners.[7,8] This gap in clinical practice is especially true in developing countries [9] or in countries under fiscal constraints, such as Greece.[10]

Our goals of the Titan Crete project are to:

  1. Develop a faculty of tobacco treatment experts, primary care providers, who will deliver tobacco treatment training to a network of primary care providers in Crete.
  2. Create and deliver curriculum/training program on tobacco treatment for PHC based on national and international experience and best practice guidelines that is specific to the needs of primary care providers in Crete (language, culture, delivery system).
  3. Adapt and deliver the provider/practice resources to make it easier to deliver tobacco treatment in primary care practices in Crete.
  4. Evaluate impact using a pre-post evaluation comparing providers involved in the program to those in a neighbouring community not involved.

The project addresses the three main pillars of the Global Bridges Program:

  • Expand the number of healthcare professionals committed to treating tobacco dependence: The project will set up the infrastructure to deliver training as well as set-up practice-level supports to address barriers to delivering evidence-based tobacco treatment, with the overall mission to create champions in both tobacco treatment and advocacy.
  • Promote collaborations across multiple countries and across regions: This project will support a new collaboration between the Faculties of Medicine at Universities of Ottawa (Canada), Crete (Greece) and the Harvard School of Public Health (USA) which has been created for the shared purpose of increasing the number of trained health professionals committed to treating tobacco dependence in PHC in Crete.  These entities bring significant expertise and knowledge in tobacco dependence and capacity development to the project.
  • Building on existing infrastructure: The TiTAN-Crete project will be implemented in an existing primary care Practice-Based Research Network (PBRN) in Crete which is affiliated with the Clinic of Social and Family Medicine (CSFM) of the University of Crete. This research network is devoted to promoting the provision of PHC in Crete and augmenting the capacity of PHC providers in addressing issues related to health promotion and is a great place to start this work in Greece.

This project will adapt an evidence-based multi-component intervention program, the Ottawa Model for Smoking Cessation, originally developed and rolled out in primary care practices in Canada for use in Greece. This intervention will be augmented with resources from the Global Bridges forum, so as to ensure existing tools from these two resources that will be contextualized to the PHC setting of Greece.

How would this be different from other efforts in the past, or how would it build upon other efforts?

The intervention program planned will employ known evidence-based strategies for increasing the uptake of tobacco treatment in primary care settings:

  1. Provider training in evidence-based tobacco treatments;
  2. Real-time provider reminders;
  3. Provider performance feedback;
  4. The use of key opinion leaders;
  5. Practice-outreach support.

This project will build on the significant experience of the University of Ottawa Heart Institute in influencing PHC provider behaviors and attitudes related to tobacco control, an approach known as the Ottawa Model for Smoking Cessation[11] . Dr. Sophia Papadakis and Dr. Andrew Pipe from the University of Ottawa Heart Institute are members of the TiTAN Crete project team and this connection to the work in Canada is a central part of the project.

The three A’s (Ask, Advise, Act) model will be used as the clinical framework for integrating tobacco treatment into routine primary care practice for this project. We will emphasize a team-based approach which involves nurses, physicians, and community social workers in the delivery of treatment. Strong evidence shows that multi-component interventions that combine practice-based, provider and patient-level intervention strategies are the most effective method for increasing provider performance in the delivery of smoking cessation treatment and improving cessation rates among patients[12].

Is this something that could be replicated elsewhere? How?

We hope this will be the beginning of the establishment of a longstanding primary care-based tobacco treatment network in Crete and that we will expand over time to make this a national network with strong connections to the Global Bridges network.

We envision that this project could be extended to undergraduate medical/nursing programs in Greece so that they may be channeled into the Global Bridges network and receive the training needed to cultivate a critical mass of clinicians who are champions of tobacco control policy.

We have had an excellent response from local primary care physicians since the launch of this program which demonstrates the interest from providers in addressing tobacco use with their patients.

What would be the ultimate goal of this project?

Our goal is simple… to develop a network of trained primary health care (PHC) providers in Crete, Greece that will integrate treatment of tobacco dependence into daily clinical practice and become champions of tobacco control policy. We are very excited about creating of this new “node” of the Global Bridges network and the creation of a formalized tobacco treatment training program that is specific to primary care providers in Crete.

The expected impact can offer a chance to extrapolate such research in other settings similar to the Greek context, such as in the Mediterranean region. The international collaboration with Global Bridges and the local adaptation of an evidence-based approach successfully applied in Canada provides us with strong foundation to build from.

  1. Lionis C, Vardavas CI, Symvoulakis E, et al. Measuring the burden of herpes zoster and post herpetic neuralgia within primary care in rural Crete, Greece. BMC Family Medicine. 2011; 12:136.
  2. Loukopoulou A, Vardavas CI, Farmakides G,  Rossolymos C, Chrelias C, Tzatzarakis M , Tsatsakis A, Lymberi M, Connolly  GN, Behrakis P. Design and study protocol of the Maternal Smoking Cessation during Pregnancy study, (M-SCOPE). BMC Public Health  2011; 11:903.
  3. Vardavas CI, Symvoulakis EK, Lionis C. Dealing with tobacco use and dependence within primary health care: time for action. TobInduc Dis. 2013 Feb 26;11(1):6.
  4. Alpert HR, Vardavas CI, Chaloupka FJ, Vozikis A, Athanasakis K, Kyriopoulos I, Bertic M, Behrakis PK, Connolly GN. The recent and projected public health and economic benefits of cigarette taxation in Greece. Tob Control. 2013 Mar 6. [Epub ahead of print] PMID: 23467654
  5. Vardavas C, Girvalaki C, Lazuras L, Triantafylli D, Lionis, Connolly G, Behrakis P. Changes in tobacco industry advertising around high schools in Greece following an outdoor advertising ban: a follow up study. Tobacco Control. 2013 In press PMID: 23132812
  6. Vardavas CI, Agaku I, Patelarou E, Anagnostopoulos N, Nakou C, Dramba V, Giourgouli G, Argyropoulou P, Antoniadis A, Gourgoulianis K, Ourda D, Lazuras L, Bertic M, Lionis C, Connolly G, Behrakis P.  Ashtrays and signage as determinants of a smoke-free legislation’s success. PLOS ONE-13-02752
  7. Agaku IT, Vardavas CI, Ayo-Yusuf OA, Alpert HR, Connolly GN. Temporal trends in smokeless tobacco use among US middle and high school students, 2000-2011. JAMA. 2013; 309(19):1992-4.
  8. Schoretsaniti S, Filippidis FT, Vardavas CI, Dimitrakaki C, Behrakis P, Connolly GN, Tountas Y. 5-Year trends in the intention to quit smoking amidst the economic crisis and after recently implemented tobacco control measures in Greece. Addict Behav. 2013 Sep 20. doi:pii: S0306-4603(13)00274-8.
  9. Agaku IT, Ayo-Yusuf OA, Vardavas CI, Alpert HR, Connolly GN. Use of conventional and novel smokeless tobacco products among US adolescents. Pediatrics. 2013 Sep;132(3):e578-86.
  10. Tsalapati K, Vardavas C, Athanasakis K, Thireos E, Vozikis A. Pavi E, Behrakis P, Kyriopoulos I. Going up in ashes? Smoking attributable morbidity, hospital admissions and expenditure in Greece. Eur J Public Health.
  11. Papadakis S, McDonald PW, Pipe AL, Letherdale ST, Reid RD, Brown KS. Effectiveness of telephone-based follow-up support delivered in combination with a multi-component smoking cessation intervention in family practice: A cluster-randomized trial. Prev Med. 2013;56:390-397
  12. Papadakis, S, McDonald, P, Reid, R, Pipe, A, Mullen, K, and K. Skulsky. Strategies to improve the delivery of smoking cessation treatments in primary care: A systematic review and meta-analysis.  PreventiveMedicine 2010; 51: 199-213.