Why People Smoke

US-Russia Civil Society Partnership Program (CSPP)Working Group Public HealthTOBACCO USE CESSATION AND TREATMENT OF TOBACCO DEPENDENCE

EVIDENCE BASED GUIDELINES

Washington, D.C., USA-Moscow, Russian Federation

May 2013

Table of contents

Declaration of interests9 Acknowledgements1013Level of evidence of recommendations

Foreword........................................................................................................................................14World Health Organization Framework Convention on Tobacco Control...15US experience............................................................................................................................18Russian experience....................................................................................................................20EC experience............................................................................................................................25US-Russia Civil Society Partnership Program (CSPP)............................................................2732PART ONE: RECOGNIZING TOBACCO USE AND TOBACCO DEPENDENCE IN GENERAL PRACTICE (Parts 1-3 based on ENSP ESCG, with amendments and additions)

Chapter 1.32Assessment/diagnostic of tobacco use and tobacco dependence

321.1 Tobacco use is a disease

331.2. Definitions, classifications, terms and specific explanations

331.2.1 Tobacco dependence: an acquired disease with tobacco industry as a vector

331.2.2 Mechanism of induction of tobacco dependence

341.2.3 Nicotine is not the only driver of tobacco dependence

341.2.4 Nicotine dependence according to WHO

35Nicotine/tobacco abstinence (smoking cessation)

36Nicotine withdrawal syndrome

36Smoking status

371.3. Smoking is a chronic relapsing disease

371.3.1 Natural history of tobacco dependence

381.3.2 Treatment of tobacco dependence after cessation

381.4. Routine identification of smokers is mandatory in current medical practice

381.5 Assessment/diagnosis of tobacco use and dependence

381.5.1. Clinical diagnosis of tobacco use and dependence

401.5.2 Analysis of previous quit smoking attempts

401.5.3 Motivation to quit smoking

421.5.4 Non-psychiatric patients medical history

421.5.5 Patients anxiety and depression history

421.5.6 Contraception

421.5.7. Laboratory diagnosis of tobacco dependence

42Carbon monoxide (CO)

44Cotinine

44Utility of biomarkers

45References

Chapter 2.46General recommendations for the treatment of tobacco use and tobacco dependence

462.1 Tobacco use

462.2 Tobacco dependence disease

462.3 Smoking cessation

472.3.1 Therapeutic education

472.3.2 Behavioural support (CBT)

472.3.3 Medication available

472.3.4 Tobacco cessation

472.4 Treatment of tobacco dependence after cessation

482.5 Prevention of relapse

Chapter 3.49Brief advice on stopping tobacco use

493.1 General recommendations

493.2 Intervention plan for medical personnel involved in assisting smokers

493.3 Recommendations for general practitioners

503.4 Recommendation for hospitalized patients

503.5 Recommendation for pregnant women

503.6 Recommendation for patients with elective surgery

51References

52PART TWO: TREATMENT OF TOBACCO DEPENDENCE

Chapter 4.52Standard tobacco treatment interventions

524.1. Therapeutic interventions for tobacco use and tobacco dependence: basic landmarks

524.1.1 Standard approach to quitting smoking

52All health professionals are concerned

52Assessment of readiness to quit

53The 5As

53Analyze readiness to quit

54The 5Rs strategy

55Helping non-motivated smokers to quit

55Smoking reduction

56Tobacco users who are recent quitters

56For never tobacco users

56Recommendations

564.1.2 Effectiveness of treatment for tobacco use and dependence

57Medications available

57Efficacy of medicines available

4.1.3 Adherence to treatment5759Recommendations

604.1.4 Health care systems approach for tobacco use and dependence treatments

604.1.5 Criteria for tobacco abstinence for scientific work and clinical research

60Definition for scientific evaluation

61Definitions for clinical practice

61Recommendations

614.1.6 Therapeutic intervention to stop smoking is mandatory

62Recommendations

634.1.7 Types of smoking cessation interventions

634.1.7.1Minimal (brief advice)

634.1.7.2 Treatment of tobacco dependence by GPs or other non-specialized doctors

634.1.7.3 Specialized individual interventions towards stopping smoking

654.1.7.4 Specialized group intervention towards stopping smoking

65References

674.2 Pharmacological treatment of tobacco dependence

674.2.1. Treatment with NRT

674.2.1.1 Mechanism of action

694.2.1.2 Clinical evidence for the efficacy of NRT

69Meta-analysis by the Cochrane Collaboration

69Meta-analysis by Michael C. Fiore

694.2.1.3 NRT in combination with pharmacotherapy

704.2.1.4 Indications

704.2.1.5 Smoking reduction with nicotine replacement

714.2.1.6 Clinical use

71Nicotine substitutes in patch

73Oral nicotine replacement

73Bioavailability of oral nicotine

Nasal spray.....................................................................................................................................75 754.2.1.7 Prescribing instructions

75Choose the initial dose of nicotine replacement therapy

75Association of nicotinic substitutes

75Dose adjustment after 24-72 hours

76Signs of overdose

76Signs of underdose

774.2.1.8 Contra-indications

774.2.1.9 Adverse effects, precautions, warnings, drug interactions

77Risk of dependence on oral substitutes

77Side effects of nicotine replacement therapy

77Adverse effects of treatment as compared to tobacco cessation related symptoms

79Recommendations

794.2.2 Treatment with bupropion SR

79Mechanism of action

79Clinical evidence for the efficacy of bupropion

80Indications

80Clinical use

81Prescribing instructions

81Contra-indications

81Adverse effects, precautions, warnings, drug interactions

81Main adverse events

82Other adverse effects

82Precautions for use

83Indications for interrupting bupropion therapy

83Cost-effectiveness of bupropion treatment

83Recommendation

834.2.3. Treatment with varenicline

834.2.3.1 Mechanism of action

844.2.3.2 Clinical evidence for efficacy of varenicline

84Efficacy in smoker without comorbidity

85Efficacy of prolonged treatment

86Efficacy in patients with COPD

86Efficacy in patients with heart disease

86Efficacy in HIV patients

86Efficacy in patients with psychiatric disorders

86Efficacy to quit smokeless tobacco

874.2.3.3 Varenicline in combination pharmacotherapy

874.2.3.4 Varenicline and counselling

874.2.3.5 Indications

874.2.3.6 Clinical use

884.2.3.7 Precautions imposed by varenicline therapy

88Patients with renal failure

88Vehicle drivers and heavy machinery operators

88Patients with mental illnesses

884.2.3.8 Tolerability and safety

88Nausea

89Insomnia

89Cardiovascular

90Psychiatric disorders

90Other adverse events

91Recommendation

914.2.4. Treatment with clonidine

91Precautions, warnings, contra-indications, adverse effects

91Suggestions for clinical use

92Recommendation

924.2.5. Treatment with nortriptyline

92Clinical use

92Efficacy

92Adverse events

92Dosage

93Practical points for using nortriptyline:

93Recommendation

93References

974.2.6 Recommendations for prolonging treatment duration

97Prolonged nicotine substitution treatment

97Prolonged treatment with varenicline

98Prolonged treatment with bupropion

98References

974.2.7 Combination of pharmacological therapies

994.2.7.1 Individualized therapeutic schemes

994.2.7.2 General principles of combination pharmacotherapy

1004.2.7.3 Combination of nicotine replacement therapy (NRT)

100NRT + paroxetine

100Nicotine patch + nicotine oral

100Nicotine patch + nicotine spray

100Nicotine patch + nicotine inhaler

101Nicotine patch + bupropion

101NRT + bupropion

101Nortriptyline + NRT

101Varenicline + NRT

Recommendations........................................................................................................................102

102Varenicline + bupropion SR

4.2.8 Cytisine104105References

1064.3. Non-pharmacological therapy for tobacco use and dependence

106Recommendations

1074.3.1. Telephone support and self-help materials

1074.3.1.1 Telephone support

107Efficacy of quitlines

1084.3.1.2 Self-help materials

108Example of check list and questions for self-aid material

111Efficacy of patient educational material

1124.3.1.3 Computer/web-based help

References.....................................................................................................................................113

1144.3.2. Motivational interviewing (MI)

114What is motivational interviewing?

114Underlying principles of MI

114Some important features of MI

115Motivational interviewing in clinical practice

116Evidence of efficacy

116Recommendations

116References

1174.3.3. Individual cognitive-behavioural therapy (CBT)

Principles of CBT.........................................................................................................................117

Efficacy of CBT............................................................................................................................117

How to manage behavioral smoking addiction............................................................................118

Recommenations..........................................................................................................................119

References....................................................................................................................................119.

1204.3.4. Psychological support for smoking cessation

122Recommendation

122References

1234.4. Combined counselling and medication treatments

Recommendation..........................................................................................................................123

123References

1244.5. Treatment recommendations in special situations and population groups at risk

1244.5.1. Treatment recommendations for pregnant women

1244.5.2. Treatment recommendations for young people under 18

125Counselling and smoking cessation therapies to people under the age of 18

126Programmes designed specifically for teens

126Telephone counselling

126Pharmacotherapy for teenagers

128Recommendations

1284.5.3. Treatment recommendations for smokers with respiratory, cardiovascular, psychiatric, cancer and other comorbidities

128Cardiovascular disease

129Respiratory disease

129COPD

Recommendation..........................................................................................................................130

130Asthma

Recommendation..........................................................................................................................131

131Tuberculosis

131Cancer disease

132Psychiatric disorders, drug consumers

133HIV infected patients

1334.5.4. Recommendations to approach post-smoking cessation weight gain

134Recommendation

134References

1384.6. Treatment recommendations to prevent relapse to smoking

139References

1414.7. Group smoking cessation counselling

141References

1424.8. Recommendations for smoking reduction approach

142Recommendation

142References

1444.9 Available evidence on other interventions to support tobacco cessation

144Vaccines

144Other drugs

145Non-pharmaceutical interventions

1474.10. E-cigarettes

Chapter 1445. Research and Scientific Recommendations for Evaluating Smoking Cessation

1485.1. Criteria for clinical research in smoking cessation

1485.2 Cost-effectiveness of tobacco dependence therapies

150References

1515.3 Recommendations about implementation of smoking cessation guidelines

151References

1535.4 Recommended Evidence Based Scientific Literature Resources on Smoking Cessation

154PART THREE: STANDARDS FOR ACCREDITATION OF TOBACCO CESSATION SERVICES AND OF TRAINING IN TOBACCO CESSATION

Chapter 1546. Recommendations to train health professional in the treatment of tobacco use and dependence and quality standards for tobacco cessation specialists and tobacco cessation services

1566.1 Recommendations for criteria of standard smoking cessation expertise training

1576.2 Recommendations to develop smoking cessation curricula for medical university graduates

157Rationale

157Content of training programme

157Training methods

References.....................................................................................................................................159

1606.3 Recommendations to develop smoking cessation curricula for medical university postgraduates Certificate Programme

160Rationale

160Aims of training programme

160Training methods

160Details of the face-to-face training programme:

161Evaluation

161Training programme for chest physicians

References.....................................................................................................................................161

1626.4 Recommendations to develop smoking cessation curricula for other categories of professionals involved in delivering smoking cessation: psychologists, nurses, health policy-makers

162Recommendations

162References

1636.5. Training standards for tobacco cessation clinicians

163Background

163Content of training

163Mandatory content of training curriculum

163Content of basic training (days 1 and 2)

164Content of follow up (day 3)

164Evaluation of training

164Material to use in the training:

165Authorization to conduct training courses for tobacco cessation

165Remarks

References.....................................................................................................................................165

1666.6 Quality standards in tobacco dependence treatment

166Definition

166Role and responsibilities of the Tobacco Dependence Treatment Specialist

166Tobacco dependence knowledge and education

167Counselling skills

167Assessment interview

167Treatment planning

168Pharmacotherapy

168Relapse prevention

168Approaching difficult/special categories of smokers

169Documentation and evaluation

169Professional resources

169Law and ethics

169Professional development

References.....................................................................................................................................169

1706.7 Requirements for accreditation of specialized tobacco cessation service

1706.7.1 Three levels of tobacco cessation services2

170Specialized tobacco cessation units (STCU)

170Tobacco cessation specialists practice (TCSP)

171Tobacco cessation counselling centre (TCCC)

1716.7.2 Accreditation of specialized tobacco cessation units

171Human resources

172Material resources

172Categories of tobacco users that should be referred to tobacco cessation services

172High-risk tobacco user

173All tobacco users

173Specific public

173Healthcare activities

174Teaching activities

175Research activities

175Role of tobacco cessation services in health promotion

175Recommendation:

References.....................................................................................................................................175Appendix 1.A bakerss dozen years of tobacco legislation in Russia. Author Andrey K. Demin, Russian Public Health Association, March 2013.........................................................................177Appendix 2.Beyond Ratification. The Future for U.S. Engagement on International Tobacco Control. A Report of the CSIS Global Health Policy Center. Author Thomas J. Bollyky. CSIS, November 2010. 21 p.191

Declaration of interests

Members of the Working Group "Public Health":

Elena Viktorovna Dmitrieva, co-chair, Doctor of Sociological Science, Director of Foundation, "Health and Development", Moscow dmitrieva.ev@gmail.comJudith Twigg, co-chair, Professor, School of Government. Douglas Wilder, Virginia Commonwealth University, Director of the Partnership between the University of the Commonwealth of Virginia State University and SPGU jtwigg@vcu.eduAndrey Konstantinovich Demin, MD, Doctor of Political Science, President of Russian Public Health Association, Professor at I.M. Sechenov First Moscow State Medical University and N.I. Pirogov National Medical Surgical Center, and physician at Medical and Rehabilitation Centre under Ministry of Health of the Russian Federation kukuv@icloud.comSandra G. Hassink, MD, Director of the Nemours Pediatric Obesity Initiative at A.I. Dupont Hospital for Children in Wilmington, DE; Chairperson of the Ethics Committee and a member of the Institutional Review Board for duPont Hospital for Children; Assistant Professor of Pediatrics for Jefferson Medical College, Thomas Jefferson University; member of the National Association of Childrens Hospitals and Related Institutions and serves on a focus group on Obesity; member of the Board of Directors of the American Academy of Pediatrics; Pediatric Consultant for the Delaware Office of Disability and a member of the Committee on Environmental and Public Health for the Medical Society of Delaware shassink@nemours.orgVasiliy Viktorovich Vlasov, MD, Doctor of Medical Science, Professor, president of Russian Society of Evidence Based Medicine, Professor at I.M. Sechenov First Moscow State Medical University and Moscow Higher School of Economics, member of Moscow society for development of public health care, formular committee under Presidium of Russian Academy of Medical Sciemnces, Health Technology Assessment International, Society for Epidemiologic Research, USA, International Epidemiological Association vlassov@cochrane.ruDonald W. Zeigler, PhD, Adjunct Associate Clinical Professor, School of Public Health, University of Illinois at Chicago and Assistant Professor, Community and Social Medicine, Department of Preventive Medicine,Rush University Medical Center, Chicago, IL.Retired Director, Prevention and Healthy Lifestyles, American Medical Association. He is an active member of the American Public Health Association's Alcohol, Tobacco and Other Drug Section and the Trade and Health Forum zeiglerdw@aol.comdeclare that they have no conflict of interest with any pharmaceutical or tobacco company.Acknowledgements

This project was supported by CSPP and Eurasia Foundation grant of $22,000 USD, and in-kind contributions of U.S. and Russian NGOs, CSPP participants. Members of the CSPP WG Public Health wish to thank:

The European Network for Smoking and Tobacco Prevention (www.ensp.org), ENSP-ESCG Editorial Board and Board of Revisors for developing European Smoking Cessation Guidelines, which were used as core document for this project. US and Russian organizations and experts taking part in review of guidelines.Partners of the United States: American Academy of Pediatrics www.aap.orgAssociation for treatment of tobacco use and tobacco (ATTUD) www.attud.orgAmerican Public Health Association www.apha.orgPartners in Russia: Russian Public Health Association www.raoz.ruRussian Society of Evidence-Based Medicine www.osdm.orgFoundation "Health and Development" www.fzr.ruReviewers and contributors:

Viktoriya Viktorovna Arshinova, Candidate of Psychological Sciences,Senior researcher of laboratory MedicalSocial Rehabilitation

Moscow State Psychological and Pedagogical UniversityVkt.arshinova@gmail.comViktoria Vasilyevna Bartsalkina, Candidate of Psychological Sciences, head of laboratory MedicalSocial Rehabilitation Moscow State Psychological and Pedagogical UniversityBartsalkina50@mail.ruMatthew P. Bars, MS , CTTS

Director- Fire Dept of the City of NY Tobacco Treatment Program, World Trade Center Medical Monitoring & Treatment Program

Jersey City Medical Center IQuit Smoking Center of Excellence

CEO-IntelliQuit

Chairman-ATTUD Policy & Government Affairs Committee

Member-Editorial Board of the Journal of Smoking Cessation

163 Indian Hollow Court

Mahwah, New Jersey 07430 USA

mbars@Libertyhcs.orgmatt.bars@yahoo.com

Michael C. Fiore, MD, MPH, MBA

Professor, Medicine University of Wisconsin-MadisonDirector, UW Center for Tobacco Research and Intervention1930 Monroe Street, Suite 200Madison, WI 53711 USAmcf@ctri.wisc.eduTom Houston, MD, FAAFP, FACPM

McConnell Heart Health Center

Clinical Professor, Department of Family Medicine and College of Public Health

The Ohio State University

3773 Olentangy River Road

Columbus, Ohio 43214

thouston@ohiohealth.comDiakon Ioann Klimenko (Ivan Petrovich Klimenko), Candidate of Chemical Sciences

Responsible secretary of All-Russian Ioanno-Predtechenskoe brotherhood Sobriety of the Russian Orthodox Church

o.ioann.klimenko@gmail.comOleg Talgatovich Kutushev, Candidate of Medical Sciences head of Centre for prevention and treatment of tobacco and non-chemical dependencies under Moscow Scientific and Practical centre of narcolody under Department of Health of Moscow City kutushev@mail.ruVladimir Filippovich Levshin, Doctor of Medical SciencesProfessor of Chair of public health care and preventive medicine, I.M. Sechenov First Moscow State Medical University, head of department of assessment of effectiveness and implementation of techniques of cancer prevention, N.N. Blokhin Russian Cancer Centre lev@crc.umos.ruAleksandr Nikolaevich Mayurov, professor, corresponding member of Petrovskaya academy of sciences and art, academican of Academy of social technologies, academician of International academy of forecasting, academician of International academy of sobriety, president of International academy of sobriety, Nizhny NovgorodMayurov3@gmail.comRadjab Davronovich Safaev, Doctor of Medical SciencesMunicipal health care institution Ramenskaya Central Rayon Hospital, Moskovskaya Oblast, Ramenskjye, Professor of Chair of surgery of Moscow Institute for Advanced training of physicians, member of New York Academy of sciences Safaev_r@mail.ruSteven A. Schroeder, M.D.Distinguished Professor of Health and Health CareDirector, Smoking Cessation Leadership CenterUniversity of California , San Francisco

3333 California Street, Suite 430 , San Francisco , CA 94143

Schroeder@medicine.ucsf.eduChristine Sheffer, Ph.D.Associate Medical ProfessorCommunity Health and Social MedicineSchool of Biomedical Education

City College of New York

Harris Hall Suite 400, 160 Convent Ave

New York, NY 10033USA

csheffer@med.cuny.eduAnaloliy Sergeevich Shidlovskiy, Doctor of Medical Sciences, academician of Academy of Medical and Technical Sciences of the Russian Federation

Professor of Chair of Anaesthesiology and ReanimatologyDepartment for advanced training of physiciansNizhegorodskaya State Medical Academy

Shi-an@list.ruAleksandr Sergeevich Shprykov, Doctor of Medical Sciences

Associate Professor of Chair of Tuberculosis Nizhegorodskaya State Medical Academy,

Chairman of Nizhegorodskaya Oblast chapter of Russian Society of Phthysiatry, member of European Respiratory Society

olgachpr@aport.ruMichael Steinberg, MD, MPH, FACP

President, Association for the Treatment of Tobacco Use and Dependence

University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School

Tobacco Dependence Program, Division of General Internal Medicine125 Paterson Street, Suite 2300, New Brunswick, NJ 08903 USA

steinbmb@umdnj.eduOlga Anatolyevna Sukhovskaya, Doctor of Biological Sciences, head of All-Russia consultative telephone centre for help in tobacco use cessationFGBU Saint Petersburg research institute of phthysiopulmonology under Ministry of Health of Russian Federation sukhovskaia@mail.rufor reviewing the project materials and valuable contributions. Representatives of the Ministry of Health of the Russian Federation, the key centers/institutes, U.S. Department of Health and Human Services, care providers in the two countries, and WHO were informed and invited to participate in the project. Level of evidence of recommendations in the guidelines

Table 1:The current guidelines stratify the evidence into three categories, judging by the type, quality and quantity of the referred studies.

Foreword

Tobacco use and dependence in any form is a difficult to attain remission, relapsing and deadly disease. Today addiction theory and practice can lead only a small portion of tobacco dependent individuals to a sustained remission lasting a year.

In U.S., Russia, the EU, as in most countries of the world, the problem of cessation of tobacco use and adequate treatment for tobacco dependence has a high social and economic importance. According to the World Health Organization (WHO), the tobacco epidemic is one of the major public health threats, the world has ever faced, as it kills nearly six million people a year.In U.S., 19.0% of adults smoke (43.8 million). Smoking causes about 20% of deaths. It is estimated that smoking causes 443.000 deaths each year, including deaths from second-hand smoke.

Domestic and international studies have confirmed that in Russia number of tobacco consumers exceeds 50 million, more than a third of total population. In the Russian Federation only adult smokers number 43.9 million, 60.2% of men and 21.7% women smoke. Tobacco use in Russia is one of the key factors causing recent declines in life expectancy in that nation. Now Russia is at the top of the world in prevalence of smoking. Annual number of premature deaths caused by products of tobacco companies reached 415,000 by 2008.

According to the Eurobarometer survey published in 2012, more than one in every four citizens smokes (28%) and 37% of the 25 to 39 age group are smokers. Tobacco kills 50% of its regular users, i.e. 500,000 Europeans every year.

These alarming statistics urge nations to take measures for tobacco use cessation and treatment of tobacco dependence. It has been proved that tobacco use and dependence is a chronic disease, and therefore, it must be diagnosed and treated in the same way as other chronic diseases.A few individuals manage to ensure tobacco use cessation and freedom from tobacco dependence without help.A multimillion army of individuals dependent on products of globalized tobacco industry is used to protect the tobacco industrys parasitic interests. Attempts to effectively overcome the tobacco epidemic so far in some countries, including Russia, are resisted with manipulative arguments, including invented economic and political risks.

Interventions aimed at cessation of tobacco use, have a medium-term effect on the number of deaths and, therefore, should be encouraged. As estimated in the World Bank report Curbing the epidemic: Governments and the economics of tobacco control, at the example of the EU, if starting smoking is reduced by 50% by 2020, the number of deaths from tobacco will decline from 520 to about 500 million in 2050. On the other hand, if half of current smokers will stop tobacco use by 2020, the number of deaths from smoking would be reduced from 520 to 340 million in 2050 .Large-scale liberation of the population of any country from tobacco dependence requires that at least two basic issues be resolved. First of all, effective, safe, affordable and acceptable techniques of tobacco use cessation and treatment of tobacco dependence should be developed. The second issue is payment for cessation of tobacco use and treatment of tobacco dependence. Due to the enormous social and economic costs of tobacco use, these interventions should be included in the program of State guarantees, provided at no cost for patients. Thus the cost of respective marketed interventions, should also be minimal. Obvious is the need to optimize the care which is provided currently. Approaches that have not been so confirmed in domestic and international theory and practice, have not passed the test of evidence and significance, should not be applied until relevant proof is ensured. Moreover, the institutions and specialists who provide appropriate care, must comply with the approved procedures for licensing and certification. Training of specialists is also a key area for success.

Figure 1:Unless current smokers quit tobacco deaths will rise dramatically in the next 50 years. Estimated cumulative deaths 1950-2000 with different intervention strategies (example of EU). (Source: The World Bank)

Health professionals and patients alike need to benefit from the newest and safest methods of diagnosis, developed in recent studies of tobacco dependence and the consequences and adverse effects of tobacco use, and from the most successful strategies and treatments to combat the disease. One successful strategy is to establish smoke-free environments, which will reduce the financial burden on health systems around the world.In addition, targeted actions should be taken aimed at young people, to convince them to avoid the use of tobacco products, thus preventing addiction. This is extremely important due to the fact that consumption in adolescence turns into tobacco addiction towards the end of youth. Previously used strategies had an impact, but, given the alarming statistics, it is clear that there is a need for a more direct and well-adapted instrument to resolve the problem of tobacco use. We must recognize that tobacco use is a chronic disease, and develop our strategies accordingly.

It is also clear that tobacco cessation interventions should be accompanied by population-level policy initiatives in tobacco control, including increased prices (tax), comprehensive smokefree indoor air regulations, restrictions on advertising and promotion, and other policy changes as outlined in the Framework Convention on Tobacco Control. World Health Organization Framework Convention on Tobacco ControlA key characteristic of the growing international community's efforts to overcome the global tobacco epidemic, is integration on the basis of the international law of the UN system - WHO Framework Convention on Tobacco Control (WHO FCTC). Convention was adopted by most countries, including the United States, Russia and European countries, in 2003. Now the number of countries- parties to the Convention is 176 out of 192 countries-members of the WHO. The Convention covers about 90% of the global population. Tobacco corporations have been undermining WHO FCTC process massively from the very start, however the Convention contains definite language on cessation of tobacco use and tobacco dependence treatment:Article 14.Demand reduction measures concerning tobacco dependence and cessation

1.Each Party shall develop and disseminate appropriate, comprehensive and integrated guidelines based on scientific evidence and best practices, taking into account national circumstances and priorities, and shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence.

2.Towards this end, each Party shall endeavour to:

(a)design and implement effective programmes aimed at promoting the cessation of tobacco use, in such locations as educational institutions, health care facilities, workplaces and sporting environments;

(b)include diagnosis and treatment of tobacco dependence and counselling services on cessation of tobacco use in national health and education programmes, plans and strategies, with the participation of health workers, community workers and social workers as appropriate;

(c)establish in health care facilities and rehabilitation centres programmes for diagnosing, counselling, preventing and treating tobacco dependence; and

(d)collaborate with other Parties to facilitate accessibility and affordability for treatment of tobacco dependence including pharmaceutical products pursuant to Article 22. Such products and their constituents may include medicines, products used to administer medicines and diagnostics when appropriate."

At its fourth session in November 2010, the Conference of the Parties (COP) adopted guidelines for implementation of Article 14 of the WHO FCTC on Article 14.Demand reduction measures concerning tobacco dependence and cessation (decision FCTC/COP4 (8).

Purpose

4.The purpose of these guidelines is to assist Parties in meeting their obligations under Article 14 of the WHO FCTC, consistent with their obligations under other provisions of the Convention

and with the intentions of the Conference of the Parties, on the basis of the best available scientific evidence and taking into account national circumstances and priorities.

5.To this end the guidelines:

(i)encourage Parties to strengthen or create a sustainable infrastructure which motivates attempts to quit, ensures wide access to support for tobacco users who wish to quit, and provides sustainable resources to ensure that such support is available;

(ii)identify the key, effective measures needed to promote tobacco cessation and incorporate tobacco dependence treatment into national tobacco control programmes and health-care systems;

(iii)urge Parties to share experiences and collaborate in order to facilitate the development or strengthening of support for tobacco cessation and tobacco dependence treatment

17.Certain infrastructure elements will be needed to promote tobacco cessation and provide effective tobacco dependence treatment. Much of this infrastructure (such as a primary health care system) already exists in many countries. In order to promote tobacco cessation and develop tobacco dependence treatment as rapidly as possible and at as low a cost as possible, Parties should use existing resources and infrastructure as much as they can, and ensure that tobacco users at least receive brief advice. Once this has been achieved, other mechanisms for providing tobacco dependence treatment, including more specialist approaches (see Developing cessation support: a stepwise approach below), can be put in place.

18.Professional associations and other groups with relevant expertise in this area should be involved at an early stage in the design and development of the necessary infrastructure, but with the process protected from all actual and potential conflicts of interest

23.Parties should develop and disseminate comprehensive tobacco dependence treatment guidelines based on the best available scientific evidence and best practices, taking into account national circumstances and priorities. These guidelines should include two major components: (1)a national cessation strategy, to promote tobacco cessation and provide tobacco dependence treatment, aimed principally at those responsible for funding and implementing policies and programmes; and

(2)national treatment guidelines aimed principally at those who will develop, manage and provide cessation support to tobacco users.

24.A national cessation strategy and national tobacco dependence treatment guidelines should have the following key characteristics:

they should be evidence based;

their development should be protected from all actual and potential conflicts of interest;

they should be developed in collaboration with key stakeholders, including but not limited to health scientists, health professional organizations, health-care workers, educators, youth workers and nongovernmental organizations with relevant expertise in this area;

they should be commissioned or led by government, but in active partnership and consultation with other stakeholders; however, if other organizations initiate the treatment guidelines development process, they should do so in active collaboration with government;

they should include a dissemination and implementation plan, should highlight the importance of all service providers (within or outside the health-care sector) setting an example by not using tobacco, and should be periodically reviewed and updated, in the light of developing scientific evidence, and in accordance with the obligations established by Article 5.1 of the WHO FCTC.

25.Additional key characteristics of national treatment guidelines:

they should be widely endorsed at national level, including by health professional organizations and/or associations;

they should include as broad a range of interventions as possible, such as systematic identification of people who use tobacco, provision of brief advice, quitlines, face-to-face behavioural support provided by workers trained to deliver it, systems to make medications accessible and free or at an affordable cost, and systems to support the key steps involved in helping people to quit tobacco use, including reporting tobacco use status in all medical notes;

they should cover all settings and all providers, both within and outside the health-care sector.

In accordance with the FCTC/COP4 (8), Convention Secretariat makes available a database of sources of information related to these guidelines, based on the information presented by the Parties through their implementation reports and other international sources, as appropriate. This list recommends key resources which are global, periodically updated, easily accessible, and directly related to Article 14. From these sites Parties will be able to find resources or links to resources that will help them implement Article 14, including the experiences of other Parties, examples of national guidelines, information about monitoring and evaluation, and a direct link with to the WHO FCTC itself.

Text of the WHO Framework Convention on Tobacco Control, www.who.int/fctc/text_downloadConvention Secretariat, WHO Framework Convention on Tobacco Control http://www.who.int/fctc

WHO Tobacco Free Initiative http://www.who.int/tobaccoCochrane reviews on tobacco cessation http://www.cochrane.org/reviews/en/topics/94_reviews.htmCochrane reviews are prepared by an international network of researchers to help healthcare providers, policy makers and patients make well-informed decisions about health care. The Cochrane Tobacco Addiction Group, based at Oxford University, reviews the evidence base for individual treatments, community level interventions and public policies that aid smoking cessation and prevent tobacco use initiation.

SRNT's cessation/treatment website treatobacco.net www.treatobacco.netTreatobacco.net is a periodically updated, independent website which summarizes the scientific evidence on tobacco dependence treatment and has a resource library which includes national treatment guidelines.

Individual countries have accumulated considerable experience in development and implementation of measures aimed at tobacco use cessation and tobacco dependence treatment.Recent cross-sectional study of national tobacco dependence treatment guidelines in 173 countries - Parties to WHO FCTC (163 countries participated), found that of 121 countries which responded, 53 (44%) had guidelines, and the Russian Federation does not. Major part of national guidelines included dissemination strategy, stated funding source and had professional endorsement. Guidelines adopted in the USA, UK and New Zealand are most frequent reference in the national guidelines reviewed.

U.S. experienceTobacco use is the single most preventable cause of death and disease in the United States. Each year, approximately 443,000 Americans die from tobacco-related illnesses. For every person who dies from tobacco use, 20 more people suffer with at least 1 serious tobacco-related illness. In addition, tobacco use costs the U.S. $193 billion annually in direct medical expenses and lost productivity.

From 1965 to 2010, the prevalence of cigarette smoking among adults in the United States decreased from 42.4% to 19.3%, in part because of an increase in the number who quit smoking. Since 2002, the number of former U.S. smokers has exceeded the number of current smokers.

The prevalence of quit attempts in the U.S. increased during 2001--2010 among smokers aged 25--64 years, but not among other age groups. In 2010, 68.8% of adult smokers wanted to stop smoking, 52.4% had made a quit attempt in the past year, 6.2% had recently quit, and 31.7% had used counseling and/or medications when they tried to quit. Moreover, 68.3% of the smokers who tried to quit did so without using evidence-based cessation counseling or medication.

A large number of well-known research and practical developments on tobacco use cessation and treatment of tobacco dependence have been achieved in the U.S.A., even though the country belongs to a small number of countries in the world which have signed but not yet ratified the WHO Framework Convention on Tobacco Control.

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. The Task Force also recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke. Such services will now be included in all health insurance and carried out with no co-payments or deductible along with other preventive services under the national health reform, the 2010 Affordable Care Act.

The key national cessation guideline, the U.S. Public Health Service Clinical Practice Guideline on Treating Tobacco Use and Dependence (2008 update),concludes that counseling and medication are each effective alone in increasing the prevalence of smoking cessation and are even more effective when used together. Individual, group, and telephone counseling are effective in helping smokers quit, and the seven Food and Drug Administration (FDA)-approved first-line cessation medications reliably increase long-term smoking abstinence rates.

There are both behavioral and pharmacological treatments available that have been demonstrated to increase the ability of smokers to quit and to benefit both individuals and society. Behavioral interventions include face-to-face counseling by health care providers, telephone quit lines, and printed materials. Pharmacological interventions include nicotine replacement therapy (NRT) (gum, lozenges, patches), the atypical antidepressant bupropion, and varenicline. Programs often combine behavioral and pharmacological treatments and provide counseling in combination with NRT, bupropion, or varenicline. According to a 2010 report, use of medications for cessation was approximately five times more common than use of counseling, which might be influenced, in part, by the widespread availability of over-the-counter cessation medications (e.g., nicotine patch, gum, and lozenge).

In the U.S. smoking cessation programs hold the potential of a favorable cost-benefit ratio from a state-based societal perspective. For every dollar the United States spends on providing tobacco cessation treatments, it has an average potential return on investment of $1.26. Despite relatively high prices for cigarettes in the U.S., the real cost to society is 3.27 times higher per pack. Even though advice from a health professional increases quit attempts and increases use of effective medications which can nearly double to triple rates of successful cessation, in 2010, only 48.3% of those who had visited a health-care provider in the past year reported receiving advice to quit smoking.

Actively involved in cessation activities include the Association for the Treatment of Tobacco Use and Tobacco Dependence (ATTUD), the National Tobacco Cessation Collaborative (NTCC), medical specialties, major university and health centers, and voluntary health organizations along with the federal and local governments.

The U.S. Department of Health and Human Services released Healthy People 2020, the nations 10-year goals and objectives for health promotion and disease prevention, with a goal to reduce illness, disability, and death related to tobacco use and secondhand smoke exposure. One of the key areas in Healthy People 2020s tobacco use objectives is health system changes: adopting policies and strategies to increase access, affordability, and use of smoking cessation services and treatments.

Based on more than 45 years of evidence, it is clear that the toll tobacco use can be significantly reduced. The Community Preventive Services Task Force, established by the U.S. Department of Health and Human Services, identifies evidence-based population health interventions to help inform the decision making of government, health care providers, researchers and communities. Its Guide to Community Preventives Services recommendations related to cessation include:

Assessment of workers health risks and provide feedback, incentives and competitions to change employees health and to increase smoking cessation;

Workplace and other public area smoke-free policies;

Increasing the unit price for tobacco products;

Mass media interventions that use brief, recurring messages to inform and motivate tobacco users to quit;

Reducing smokers out-of-pocket costs for cessation therapies; and

Multi-component interventions that include telephone support

Quitlines are telephone-based tobacco cessation services that help tobacco users quit by providing support, a tailored quit plan and other services. Quitlines reach out to smokers through mass media, print ads, and referral networks with health care providers and community organizations. Residents in all 50 U.S. states, Puerto Rico, Guam, and the District of Columbia have access to quitline services accessible through a national toll-free number (1-800-QUIT NOW). Quitlines are a referral source for health-care providers who might not have the time or staff to provide all of the steps in the recommended "5A" cessation counseling model: ask about tobacco use, advise to quit, assess willingness to make a quit attempt, assist in quit attempt, and arrange follow-up. The North American Quitline Consortium (NAQC) promotes evidence-based quitline services across diverse communities in North America. While the US has placed a priority on reducing tobacco use, many challenges remain, including persistent industry interference, to reduce tobacco use to the point that it is no longer a public health problem for the nation.

Russian experience The Russian Federation also accumulated an important theoretical and practical potential on cessation of tobacco use and tobacco dependence treatment. The Russian Federation joined the WHO FCTC in 2008.The President of the Russian Federation Vladimir Putin signed the Federal law of the Russian Federation of February 23, 2013 N 15-FZ "On protection of health of citizens from impact of ambient tobacco smoke and the consequences of consumption of tobacco."

In the book "Russia: Deal is tobacco. Investigation of mass killing" published in 2012, there is an analysis of how internal legislation and process of Framework Convention were undermined, how foreign tobacco companies took dominant role, and captured almost completely local tobacco market. Tobacco impact on health and life of Russians, as well as all aspects of tobacco industry in Russia, including organization, economics, human resources, tobacco promotion, penetration in Governmental regulating bodies, business and expert communities, civil society, are reviewed for the first time, suggesting what should be done with socially dangerous businesses in the national interest.

After penetration of foreign tobacco companies into Russia in 1991, production of cigarettes was increased from 140 billion per year in 1995 to 413 billion in 2008. Industry interests representative boasts that tobacco factories built in Russia are capable to produce 700 billion cigarettes annually. Number of deaths caused by tobacco increased from 275,000 in 1990, to 415,000 in 2008. Prevalence of tobacco use increased sharply among women and children, heavily targeted by the industry. According to GATS (2009) prevalence of smoking among men is the highest among 25-44 olds close to 70%, and among women close to 40% - among 19-24 olds. Prevalence of tobacco use among health professionals is close to that among general population.Value of annually produced cigarettes in Russia is $13 billion, and actual supply exceeded 446 billion cigarettes in 2008. Spending on tobacco promotion exceeds $ 1 billion per year. After paying negligible excise tax, profits are exported abroad, and the damage is not compensated at all. The main countries-recipients of mammoth tobacco generated profit flows from Russia are Japan (in 2009, 37.5% of Russian market belonged to JTI), USA (26.4% - PMI), UK (BAT 19.6% and IT8.5%), and South Korea (KT&G0.9%). Population spends on tobacco amount of money, close to the Federal expenditure on education, or health, physical culture and sports. Russian paradox is that the higher education level is, the higher the probability of being a smoker is.Foreign tobacco companies advise national authorities, hire leading experts, carefully select human resources among Russian talented young people. Scary "merits" of tobacco bosses are solemnly acknowledged by high official awards.

For a few key subjects of the Federation, including Saint Petersburg - the Russian tobacco capital and the forge of the ruling elite, factories of foreign tobacco companies, hastily constructed, the largest in the world, became vitally important for incomes of local budgets.

Russia has turned into a tobacco superpower, one of a few global centers of tobacco evil, key logistics, production, sales, human resources and management platform of the largest five tobacco companies in the world, employing innovative technologies, backed up by pressure from the leading nations. The above mentioned facts explain the difficulties of adequate countering of the tobacco epidemic in Russia's national interest, including effective legal regulation. Things have gone so poorly, that protection of the country from tobacco threat, might require political process and agreements similar to concerted international action on weapons of mass destruction.

Tobacco issue in Russia is at the crossroads. Devastating impact of tobacco use has been well documented and awareness is on the rise, that tobacco control can resolve basic demographic challenges of the nation. At the same time, there are politicians, who are reluctant to pursue strong tobacco measures, being concerned with industry rhetoric on presumable political risks of control of dependence involving 50+ millions of citizens. Tobacco control development will define the future of healthy lifestyles policy and practice in Russia. Thus tobacco control has turned into a burning domestic and foreign relations political issue of the nation. Federal law of the Russian Federation of February 23, 2013 N 15-FZ "On protection of health of citizens from impact of ambient tobacco smoke and the consequences of consumption of tobacco," contains important provisions related to tobacco use cessation and treatment of tobacco dependence:Article 17 "Providing medical care to citizens, aimed at stopping consumption of tobacco, treatment of tobacco dependence and impacts of consumption of tobacco" envisages

1.Individuals who use tobacco and contacted medical organizations, are provided with medical care, aimed at cessation of tobacco use, treatment of tobacco dependence and the effects of tobacco use.2.Provision of medical care to citizens, aimed at cessation of tobacco use, including prevention, diagnosis and treatment of tobacco dependence and impact of consumption of tobacco, by medical organizations of State health care system, municipal health care system and private health care system, is performed in correspondence with program of State guarantees of free provision of medical care to citizens.

3.Medical care aimed at cessation of tobacco use, treatment of tobacco dependence and consequences of consumption of tobacco, is provided on the basis of standards of medical care and in accordance with the order of provision of medical care. 4.Attending physician must provide the patient, who contacted medical organization for medical care, regardless of reasons for such contact, with recommendation on cessation of tobacco use, and with necessary information about medical care, which can be provided."However, neither abovementioned standards nor orders of care of the Ministry of Health of the Russian Federation have been agreed and approved, even for adults, as well as for dependent minors.

One of the obvious difficulties in these developments in Russia is the relatively high cost of quality care for cessation of tobacco use, combined with numbers of dependent individuals reaching half a hundred of millions.

At the same time there exists a national network of centers of medical prevention, recently complemented with a national network of health centers, and since 2007 healthy lifestyles, including tobacco cessation, are an official policy priority. On 17 November 2011 All-Russia free telephone line of help in tobacco use cessation was started in accordance with Concept of implementation of State policy of counteracting tobacco consumption for 2010-2015, approved by ordinance of the Government of the Russian Federation from 23 September 2010 . 1563-.

Thus structural prerequisites for a large scale national tobacco cessation program are taking place in Russia.

An overview of available numerous domestic guidelines and recommendations on this issue since 1988, shows that they have been developed in Russia by representatives of various medical specialties, mostly-psychiatrists, oncologists, cardiologists, TB specialists, pulmonologists, medical psychologists, representatives of preventive medicine, military doctors and others; interaction between representatives of different professions has been limited.Table 2:Available guidelines and recommendations for smoking cessation and treatment of tobacco dependence in Russia (since 1988, in chronological order, all in Russian)1.Medical care in case of tobacco smoking in practical health care. Methodological guidelines. Compiled by Tseshkovskiy M.S., Milievskaya I.L., edited by Smirnov V.K. Ministry of Health of USSR. Moscow, 1988.2.Smirnov V.K., Chudnovsky V.A., Boldyreva T.A. On provision of medical-psychological care to individuals, seeking smoking tobacco cessation. Methodological guidelines for physician. ., 1993.

3.Smirnov V.K. Scheme of recording patient history in case of tobacco dependence. M., 1996.4.Levshin V.F. Help in cases of tobacco smoking in practical health care. Methodological guidelines for medical professionals. M., 1998.

5.Chuchalin A.G., Sakharova G.M. Diseases of lungs of smoking individual//Disease prevention and health promotion. -1999 -4. pp.3-10.6.Smirnov V.K., Yermolova O.I., Sharahov Yu.A., Garnitskaya A.S. Differentiated approaches to the diagnosis, clinic and treatment of tobacco dependence in individuals with borderline mental disorders. Methodological guidelines. M., 2000.

7.Smirnov V.K. Clinic and treatment of tobacco dependence. Guide for physicians. M., 2000. - 96 p.

8.Ishekov N.S., Solovyov A.G., Ishekova N.I., Kirpich I.A. Edited by P.I.Sidorov. Treatment of tobacco dependence (tabakizm). Methodological guidelines. Department of Health under Administration of the Arkhangelsk Oblast. Northern Scientific Center of the North-Western Branch of RAMS. Northern State Medical University. Arkhangelsk, 2001. - 14 p.

9.Chuchalin A.G., Sakharova G.M., Novikov K.Yu. Practical guidance on treatment of tobacco dependence. M. Russian Medical Journal, 2001: pp. 904-912.

10.Shprykov A.S., Zhadnov V.Z., Shkarin A.V. Tobacco smoking and pulmonary tuberculosis: Clinical and experimental aspects. Teachingmethodological aid. NGMA Publishing house, Nizhny Novgorod, 2002. 52 p.

11.Chuchalin A.G., Sakharova G.M., Antonov N.S., Zaitseva O.Yu., Novikov K.Yu. Comprehensive treatment of tobacco dependence and prevention of chronic obstructive lung disease caused by tobacco smoking. Methodological guidelines. Ministry of Health and Social Development of the Russian Federation. - 2003, 2002/154. - 48 p.

12.Levshin V.F. Technique of group sessions to provide medical care for smoking cessation. M.: Russian Public Health Association.-2003.-32 p.

13.Oganov R.G., Kalinina A.M., Shalnova S.A., Maksimov M.A., Popovic M.V., Gambaryan M.G., Priezzheva O.N., Vihireva O.V. Organization of care to individuals seeking smoking cessation. Organizational-methodological letter. Moscow, 2003.

14.Medical treatment in smoking cessation (a collection of organizationalmethodological materials). Compiled by Oganov R.G., Kalinina A.M., Shalnova S.A. et al. M.- 2004.

15.Lukina Yu.V., Marcevich S.Yu., Kutishenko N.P., Shalnova S.A., Vikhireva O.V. Changes of function of external respiration in treatment with beta-adrenoblockers in smoking and non-smoking patients with stable angina of tension // Russian cardiological journal. -2004. - 2(46). - pp.41-4416.Ministry of Defence of the Russian Federation, Chief military-medical directorate of the Ministry of Defence of the Russian Federation, State institute for advanced training of physicians under Ministry of defence of the Russian Federation, Academician N.N. Burdenko Chief military clinical hospital. Diagnostic and clinical approaches to treatment of smoking as a disease in the armed forces of the Russian Federation. Based on materials of Research program of Academician N.N. Burdenko Chief military clinical hospital and conference Tobacco smoking as a problem of 21 century. Methodological guidelines. Approved by Chief of military-medical directorate of the Ministry of Defence of the Russian Federation. Authors Bryusov P.G., Ardashev V.N., Safayev R.D. Moscow, 2004. - 39 p.17.Muradov A.B., Shidlovskiy A.S., Skopcov E.A., Hudenko T.V., Frolov A.Yu., Satina O.V., Kuznetsova O.V., Kavrelishvili T.Yu. Antismoking new addition to standards and protocols in anaesthesiology and reanimatology // Vestnik intensivnoy terapii. 2005. - 5. - pp.13-14.18.Muradov A.B., Shidlovskiy A.S., Romanov I.N., Frolov A.Yu., Satina O.V. Inhalations of furocemid in pre-surgery preparation of smoking patients // Vestnik intensivnoy terapii. 2006. - 7. - pp.39 -40. 19.Vikhireva O.V. Smoking cessation./Cardiology: national guide/Edited by Yu.N.Belenkov, R.G.Oganov, - .: GEOTAR-Media, 2007. -pp. 267-277.

20.The role and place of acupuncture in treating individuals with tobacco addiction. Methodological guidelines 99. Compiled by Kharenko V.N., Kutushev O.T., Yermolova O.I., Brun E.A., Mikhailova V.A. The Moscow City Government, Department of Health. Moscow, 2008.-15 p.

21.Prevention of smoking among young men of conscript and preconscript ages. Methodological guidelines 46. Compiled by Kutushev O.T., Lykov V.I., Stolyarov G.B. The Moscow City Government, Department of Health. Moscow, 2010. - 23 p.

22.Antonov N.S., Sakharova G.M., Savchenko L.M., Astanina S.Yu. Medical care for tobacco use cessation and treatment of smoker. Curriculum for additional vocational training (advanced training) of faculty of Ministry of Health and Social Development of the Russian Federation. FGOU IPK FMBA, GOU DPO RMAPO. Moscow,2010.30 p.

23.Ordinance of Ministry of Health and Social Development of the Russian Federation 222H from April 7, 2010 "On approval of the order of provision of medical care to patients with broncho-pulmonary disease of pulmonological profile." www.minzdravsoc.ru24.Technique of biofeedback in comprehensive treatment of tobacco dependence. Methodological guidelines. Compiled by Kutushev O.T., Smirnov V.K., Speranskaya O.I., Yermolova O.I., Dyshlenko L.G., Soboleva A.D., Knyazeva N.A. The Moscow City Government, Department of Health, Moscow, 2010.19 p.

25.Sakharova G.M., Antonov N.S. Providing care for tobacco use cessation in medical therapy practice. Teaching aid. Ministry of Health and Social Development of the Russian Federation. Moscow, 2010. 58 p. http://new.med-prof.ru/_files/metod_saxarova.pdf26.Gambaryan M.G. How to quit smoking? Moscow, GEOTAR-Media, 2010. 23 p.

27.Speranskaya O.I. Tobacco dependence: research perspectives for diagnosis, treatment. "Library of physician specialist." M., 2011.

28.Levshin V.F. Tabakizm: pathogenesis, diagnosis, treatment. M., 2012.

29.Smyshlyaev A.V. Toplicality of the development of standards for providing specialized medical care for patients with mental and behavioral disorders due to use of tobacco.//Topical issues of treatment of tobacco dependence. Materials of XII Moscow scientific-practical conference. M., 2012.pp. 93-100.30.Boytsov S.A., Vylegzhanin S.V., Gambaryan M.G., Gulin A.N., Eganyan R.A., Zubkova I.I., Ipatov P.V., Kalinina A.M., Ponomareva E.G., Solovyova S.B. Organization of implementation of dispensarization and preventive medical examinations of adult population. Methodological guidelines. Approved by Chief specialist on preventive medicine of the Ministry of Health of the Russian Federation S.A. Boytsov. Ministry of Health of the Russian Federation. FGBU State scientific-research centre of preventive medicine under Ministry of Health of the Russian Federation. Moscow, 2013. 87 p. This peculiarity determines differences in methodological approaches, diagnosis, treatment and prevention of smoking, used in the existing guidelines and recommendations. Issues of evidence based recommendations, standards and accreditation of this care are underdeveloped, as well as links with achievements of foreign centers and specialists.

Single, officially approved guidelines for tobacco use cessation and treatment of tobacco dependence, developed jointly by relevant various medical specialists and covering various forms of tobacco use, which occur in the country, do not exist in Russia. Standards of quality of care for tobacco cessation and treatment of tobacco dependence, and procedures for accreditation of this care have not been developed.

Thus, the challenge is to develop and apply standards and orders of care in accordance with the program of State guarantees, in accordance with the law. This can be facilitated by integration of existing approaches, developed and applied in Russia, taking into account principles of evidence based and international experience. There is also a need for development of quality standards and certification procedures for this care and training of medical professionals.

According to GATS in Russia (2009), tobacco cessation activity of Russian tobacco users is very low and should be encouraged:

-Less than one third of Russian smokers (32.1%) attempted smoking cessation during the previous year.

-The largest number of those who attempted cessation is among smokers aged 15-18 years (46.2%).

-60.3% of smokers express willingness to quit, more women (70,7%), compared to men (55,8%).

-Only 3.6% plan to attempt smoking cessation during the next month, and only 10.8% during the next year.

-One fifth of those (20.1%), who attempted smoking cessation, used pharmaceuticals, helping to treat nicotine dependence;

-Much smaller proportion of smokers, who attempted cessation, used psychological counselling (3.5%) or non-pharmaceutical techniques (3.7%). Less than one third of smokers (31.8%), which contacted medical professional during recent 12 month prior to poll, said that they received advice to quit from medical professional who they visited.

In Russia there are numerous activities aimed at raising awareness on tobacco use prevention and cessation among the military, health care and education systems professionals, students. For example, in 2002 there was established Antismoking committee, and in 2008 smoking cessation center in Nizhegorodskaya medical academy. There is a need to extend tobacco use cessation and treatment of tobacco dependence to second and third hand smoking.

Experts in psychology point to the need to develop contents and requirements related to involvement of population, provide psychological and rehabilitation support to tobacco users, emphasize issue of tobacco use among minors. Risk groups should be identified according to age, social status, cultural traditions, etc. in treatment and prevention of tobacco use. Successes of various social institutes such as health care, education culture, law enforcement in prevention and treatment of tobacco dependence should be compared.

At the same time there is a grassroot public movement for tobacco cessation, not linked to the official health care. Advocates of this movement claim that advanced techniques are applied that have been developed by such practitioners as Shichko, Grinchenko, Grigoryev, Hudolin, Lindeman, Ryazantsev and many others.

EC experienceArticle 168 of the EC Treaty provides:"A high level of human health protection shall be ensured in the definition and implementation of all Union policies and activities. The European Parliament and the Council, acting in accordance with the ordinary legislative procedure and after consulting the Economic and Social Committee and the Committee of the Regions, may also adopt incentive measures designed to protect and improve human health and in particular to combat the major cross-border health scourges, measures concerning monitoring, early warning of and combating serious cross-border threats to health, and measures which have as their direct objective the protection of public health regarding tobacco and the abuse of alcohol, excluding any harmonization of the laws and regulations of the Member States.

The EC's important role in health policy has been reaffirmed in the Reform Treaty which was agreed by EU Heads of State and Government in Lisbon on 19 October 2007 and which proposes to reinforce the political importance of health. A new overall aim on supporting citizens' well-being is expected, as well as an encouragement of co-operation amongst Member States on health and health services. Work on health at Community level adds value to Member States' actions, particularly in the area of prevention of illness, including work on tackling smoking, .

The EQUIPP report and the e.SCCAN 2010 report provide the baseline for the current smoking cessation service level in different European countries. In addition, the ENSP Secretariat in Brussels collected other relevant data using a survey among ENSPs members.

Virtually every country in Europe has developed recommendations on the issue. In this context should be mentioned "European Smoking Cessation Guidelines: The authoritative guide to a comprehensive understanding of the implications and implementation of treatments and strategies to treat tobacco dependence. Revised 1st edition. October 2012. ISBN: 978-2-9600708-1-1," based on WHO FCTC, global experience, including the EU, individual European countries, the U.S.A. and Russia, recently published by the European Network for Smoking Prevention and Tobacco Control (European Network for Smoking and Tobacco Prevention aisbl). Responsible publisher: Panagiotis K. Behrakis, president of the ENSP. Presentation of the document took place on October 3, 2012 at a special meeting of interested European organizations in the European Parliament, Brussels, Belgium.

The event, held by MEP Elena Oana Antonescu, was devoted to the presentation and discussion of European guidelines, a volume of 228 pages, prepared during 2011-2012 by Board of Editors including internationally recognized experts: Panagiotis K. Behrakis, MD, PhD (McGill), FCCP, President of ENSP, is Associate Professor of Respiratory Physiology at Athens University and Adjunct Professor at Harvard University;

Nazmi Bilir, Professor of Public Health, Hacettepe University, Faculty of Medicine, Department of Public Health, Ankara, Turkey;

Luke Clancy, BSc, MB, MD, PhD, FRCPI, FRCP (Edin), FCCP, FFOM, respiratory physician and Director General, TobaccoFree Research Institute Ireland (TFRI);

Bertrand Dautzenberg, Professor of Chest Medicine at Piti-Salptrire hospital, Paris and Chair of Office franais de prvention du tabagisme (OFT), Paris, France;

Andrey Konstantinovich Demin, M.D., D.Polit.Sci., is a physician at the Medical and Rehabilitation Centre under the Ministry of Health of the Russian Federation, Professor of Public Health at I.M. Sechenov 1st Moscow State Medical University and N.I. Pirogov National Medical Surgical Centre, and President of Russian Public Health Association, Moscow, Russia;

Hans Gilljam, MD, Professor of Public Health, Karolinska Institute, Stockholm, Sweden;

Antigona Trofor, M.D. Ph.D., Associate Professor of Pulmonology at the University of Medicine and Pharmacy Gr. T. Popa, Iai and Respiratory Physician at the Clinic of Pulmonary Diseases, Iai, Romania.

The Board of Revisors of European guidelines included:

Sofia Cattaruzza, head of UNITAB, Sapienza University, Rome, Italy;

Florin Dumitru Mihlan, Professor of Pneumology, M.Nasta National Institute of Pneumology, President of the Romanian Society of Pneumology, Bucharest, Romania;

Manfred Neuberger, O. Univ.-Prof. M.D., Vienna, Austria;

Biagio Tinghino, President of the Societ Italiana di Tabaccologia (SITAB), co-ordinator of the working group on SITAB Guidelines, head of the Smoking Cessation Centre, ASL Monza e Brianza, Italy;

Paulo D. Vitria, Psychologist, PhD, Professor of Preventive Medicine at Faculdade de Cincias da Sade Universidade da Beira Interior, member of the co-ordination team at Portuguese Quitline, member of the Steering Board at Portuguese Society of Tabacology (SPT), Portugal;

Vincenzo Zag, editor-in-chief of Tabaccologia, Societ Italiana di Tabaccologia (SITAB), Bologna, Italy;

Witold A. Zatoski, Professor, M.D., PhD., Director Division of Epidemiology and Cancer Prevention, Director WHO Collaborating Centre, Warsaw, Poland.

The project was initiated and managed by Cornel Radu-Loghin, Director of Policy and Strategy at the ENSP Secretariat. ESCG publication was co-ordinated, compiled, edited and revised by Michael Forrest, Communications Officer at the ENSP Secretariat.

Romanian Smokers Assistance and Smoking Cessation Guidelines (RSASCG www.srp.ro) developed by Romanian Society of Pulmonologists and the Board of Editors and published in 2010, was used as a background document by ENSP-ESCG Editorial Board.

The project to develop European Guidelines has received financial support from the European Commission in the framework of the EU Public Health Programme, 2008-2013. Neither ENSP nor the European Commission nor any person acing on their behalf can be held responsible for any use that may be made of the information contained in this document. The production of this report has been supported by unrestricted educational grants from Pfizer Limited and Servier Pharma. This report does not necessarily reflect the views or either Pfizer Limited or Servier Pharma, and the content and recommendations are those of the ENSP Editorial Board and not the supporting pharmaceutical companies.

ENSPs Vision - is a future where our fellow Europeans will not suffer the distress of ill health and early death due to tobacco. We want children and young people to be able to grow up without being targeted with messages that seek to lure them into a lifetime of addiction. We want all Europeans to be able to breathe clean air unpolluted by tobacco smoke. We want to help smokers escape from a fatal trap. We want to put an end to the tobacco epidemic.ENSP has thus set itself the ambitious target of making Europe totally tobacco-free by 2040. It is important to set a date and it is likewise important to repeat this aim at every opportunity in order to make this target a reality in our life-time.

We continue to invest our efforts to support the WHO Framework Convention on Tobacco Control (WHO FCTC) which, we are convinced, is the most efficient tool to reach our objectives. Because we aim to create greater coherence among smoking prevention activities and to promote comprehensive tobacco control policies at both national and European levels, it is thus logical and in accordance with FCTC Article 14 to reinforce ENSPs commitment to helping smokers quit by developing these European Smoking Cessation Guidelines."

US-Russia Civil Society Partnership Program (CSPP)

The US-Russia Civil Society Partnership Program (CSPP) was launched in May of 2011. The program is implemented by Eurasia Foundation (USA) in partnership with the New Eurasia Foundation. The program will run through May of 2013.

CSPP is the follow-on to the two US-Russia Civil Society Summits held in 2009 and 2010, during which Russian and US civil society organizations recognized the need for greater collaboration across a broad array of thematic topics.

Through dynamic and unfettered dialog, the program participants will design concrete and innovative policy recommendations to accelerate progress in such areas as anti-corruption, local community development, environmental protection, education, migration, child protection, youth, gender equity, independent mass media and freedom of information, public health, and human rights.

The ultimate goal is to create sustainable mechanisms for the development and delivery of recommendations from citizens to policymakers, leading to greater cooperation and meaningful improvement in the lives of the citizens of both countries.

The program will include a series of activities, including three conferences of the civil society leaders from the two countries (two of which will be held in Moscow and one in Washington), a small grants competition designed to support the implementation of collaborative projects, and online meetings of the 11 working groups. CSPP also features an Internet resource platform that enables participants to exchange information about their activities, update work plans in a timely fashion, and publish news and event announcements.

The first US-Russia Civil Society Partnership Program conference "Institutions of civil society in Russia and the U.S.: expanding partnership" took place place on November 14 15, 2011 in Moscow. Representatives of 70 NGO from the USA and Russia, and the leading experts discussed successes, problems and prospects of collaboration in two countries.

WG Public Health priorities:

-Prevention of non-communicable diseases among children and adolescents (tobacco, alcohol, obesity, legal and illegal drugs): intersectoral approach, involvement of family, impact of negative factors;

-Development of transparent health care system: involvement of NGOs, rating system, interaction between professionals and public, involvement of media;

-Health of migrants and providing health care for migrants: experience of the U.S. and Russia. On 15-16 November 2012, more than 70 U.S. and Russian civil society experts gathered in Washington, DC, at the second annual conference on "CSPP: Forward Together". The main purpose of the conference was to discuss the progress and future opportunities in the Russian-American civil cooperation. At the opening of a number of officials from Russia and the United States emphasized the importance of citizen diplomacy for Russian-American relations. Among the speakers were representatives of the Russian Embassy in the United States, the U.S. State Department and the U.S. Agency for International Development.

At the second conference, members of the working group on public health have decided to promote development of recommendations for tobacco cessation and treatment of tobacco dependence.

The project of the working group "Development and distribution of the joint U.S.Russian guidelines on cessation of tobacco use in support of promoting healthy lifestyles in both countries and in the world" makes a direct contribution to the advancement of the two priority areas of the Working Group on Health of the Bilateral Presidential Commission Russia-USA:mother and child health, and control of noncommunicable diseases. Tobacco use is the leading risk factor in both areas.

These guidelines will include specific sections to help to stop tobacco use among women, pregnant women, and children.

In addition, the project will contribute to the development of the first combined prevention of tobacco and alcohol during pregnancy project, presented on the website of the U.S.-Russia Bilateral Presidential Commission.

It is expected that the project will be beneficial to improving public health in the two countries, will allow interested organizations and experts to learn from experiences of the two countries, and will contribute to the global process of the WHO FCTC.

This project aims to support tobacco cessation and tobacco dependence treatment activities and strengthen their impact by:-providing health professionals with a template of tobacco cessation and tobacco dependence treatment, and guidelines and best practice;

-providing tobacco control community with tools for monitoring and accreditation.The planning and execution of the project takes into account standards of gender aspects.The project will last from 18 February to 15 May 2013, with technical and financial ($22.000 USD) support from CSPP.

As a basis for the work of experts in Russia and in the United States in was decided to use the recent European guidelines on smoking cessation (ENSP-ESCG), published by European network for Smoking and Tobacco Prevention in 2012. ESCG were prepared with extensive use of experience of Russia and the USA. Also, one of members of CSPP WG on public health (Andrey K. Demin), participated in ESCG preparation as a member of Board of Editors. It is expected that as a result of the CSPP project, guidelines will be reviewed by Russian and U.S. experts and organizations, will be prepared in Russian and in English, supplemented by relevant materials, and will provide opportunities for all interested specialists and organizations of the two countries to make their contribution in this joint work of high social, economic and political importance.

All interested experts and organizations on tobacco cessation and treatment of tobacco dependence, were invited to review the guidelines.

Guidelines were presented on May 1, 2013 in Washington, DC, USA, and on 14 May 2013 in Moscow, Russia, and widely disseminated.

The project will promote public awareness that tobacco use and tobacco dependence-disease that needs treatment; cessation of tobacco use and tobacco dependence treatment is essential and possible, facilitated by international cooperation.

Civil society organizations and experts involved in this project, will submit the results to interested governments of Russia and the U.S., including intergovernmental cooperation in public health.

In particular, it should be noted that some influential experts in developed countries currently consider plant alkaloid cytisine (Tabex) as a promising means for cessation of tobacco use in large-scale government programs on criteria of safety, effectiveness, efficiency and availability. This pharmaceutical was developed and widely applied in former Socialist countries, including former Soviet Union, and is approved and used in the Russian Federation, price of month long treatment course is less than $9. Thus Russian experience can benefit internal and global needs. For example, randomized controlled trials and review of statistics of cytizine use in Russia could deserve attention.

On the other hand, government representatives and experts of the Russian Federation will be able to use the experience of the United States and other countries, despite differences in the methods used.

Two papers are attached to the guidelines, which are aimed at promotion of FCTC process in two countries and globally:1.A bakerss dozen years of tobacco legislation in Russia. Author Andrey K. Demin, Russian Public Health Association, March 2013. 2.Beyond Ratification. The Future for U.S. Engagement on International Tobacco Control. A Report of the CSIS Global Health Policy Center. Author Thomas J. Bollyky. CSIS, November 2010. 21 p.

A perspective of global policy and governance is also discussed in McGrady, Benn. Confronting the Tobacco Epidemic in a New Era of Trade and Investment Liberalization. Geneva: World Health Organization, 2012.

It is expected that guidelines will be beneficial not only for specialists in Russia and the U.S., but in many other countries, including the CIS, and will contribute to progress in this vital area. This effort will also promote the role of physicians and other health professionals in acting as role models for their patients and in society generally, by not smoking and by advocating in favor of tobacco control policy and practice changes. This aspect still needs to be developed further. Physicians who smoke send mixed messages about the harms of tobacco use, and counsel their patients about smoking significantly less than physicians who do not smoke, for example. In Eastern Europe, physicians still smoke in great numbers, unlike their counterparts in the UK, Australia/New Zealand, and the US. Individual physicians and the medical societies to which they belong are key in creating social changes as outlined in these guidelines, and adopting personal health changes as well as official policy statements that support tobacco control objectives such as these are crucial. These guidelines take the opportunity to emphasize the role of individual physicians and organized medicine in tobacco control.

On the way to tobacco free planet Earth there are many obstacles. These guidelines are a step in the right direction, and a basis for a comprehensive and holistic approach to tobacco cessation and treatment of tobacco dependence.

Health professionals and tobacco users now have a comprehensive set of tools to support tobacco use cessation and treatment of tobacco dependence, and there is a hope that more smokers lives will be saved on this basis.References

PART ONE: RECOGNIZING TOBACCO USE AND TOBACCO DEPENDENCE IN GENERAL PRACTICE.Chapter 1.Assessment/diagnostic of tobacco use XE "Tobacco use" and tobacco dependence XE "Tobacco dependence" 1.1 Tobacco use XE "Tobacco use" is a disease

Smoking and smokeless tobacco XE "smokeless tobacco" products use are a major cause of illness, incapacity and death XE "death" worldwide (according to the FCTC XE "FCTC" ). It is a known fact that a smokers life expectancy is ten years shorter than that of a non-smoker: half of smokers lose 20 years of healthy life before dying from a tobacco-related disease. The condition under discussion needs to be framed correctly: smoking and tobacco use. Smoking was marketed by the tobacco industry XE "tobacco industry" as a freedom and life-style choice, but smoking is a disease and an addiction XE "addiction" . Tobacco dependence XE "Tobacco dependence" is the disease which drives the vast majority of tobacco use among adults. Tobacco dependence is associated with the long-term, daily use of tobacco-based products (cigarettes XE "cigarettes" , pipes, cigars, bidis, hookahs, chewing tobacco XE "chewing tobacco" etc.). Most smokers are unable to stop smoking at will. In medical terms chronic smoking is defined as: tobacco dependence XE "Tobacco dependence" , nicotine XE "nicotine" dependence, tobacco addiction or nicotine addiction.

Doctors and health professionals XE "health professional" must therefore take into account that tobacco dependence XE "Tobacco dependence" is a medical condition and not a habit, vice, pleasure, freedom or life-style, as described by tobacco industry XE "tobacco industry" manipulations.

The main etiological factor of tobacco dependence XE "Tobacco dependence" disease is nicotine XE "nicotine" . Nicotine is a highly addictive drug which is contained in tobacco and which determines dependence in those who use tobacco products chronically. Any tobacco use gesture is detrimental to health. Even though, depending on the intensity, duration of use and type of tobacco product used, not all tobacco users follow the same risk pattern, the response of health professionals to tobacco use must be one: to identify and treat smokers tobacco dependence without delay.

Tobacco dependence is a chronic, relapsing disease, not a lifestyle choice. Tobacco dependence must be diagnosed and treated in the same way as other chronic diseases. A health professional XE "health professional" has the duty to intervene and initiate tobacco cessation. Prompt initiation of treatment for tobacco dependence is a good practice for doctors and health professionals, as tobacco consumption is mainly driven by tobacco dependence: only in very exceptional cases is tobacco smoking driven by a smokers free choice of life-style. It is bad practice XE "bad practice" not to treat or arrange for treatment of tobacco-dependent patients. A minimum intervention is minimal counselling XE "counselling" which is a neutral practice (preventing bad practice) (Figure 2).Once tobacco use and dependence are correctly perceived as a disease, tobacco-dependent smokers have greater success in achieving abstinence when tobacco cessation assistance is offered by a health professional XE "health professional" in order to quit XE "quit" , which is provided through tobacco dependence XE "Tobacco dependence" treatment XE "Tobacco dependence treatment" . This medical aid consists of diagnosing chronic tobacco use and tobacco dependence, followed by regular treatment for remission of tobacco consumption and treatment of chronic tobacco dependence, as with any other disease.

By way of conclusion, by smoking tobacco individuals not only introduce nicotine XE "nicotine" into their own bodies and maintain or increase tobacco dependence XE "Tobacco dependence" , but also expose themselves to numerous severe illnesses, many of which are fatal, caused by the toxins contained in tobacco. The earlier tobacco dependence is treated, the earlier the patient quits smoking or using oral tobacco and tobacco smoke and the higher the health benefit for the patient. Tobacco dependence XE "Tobacco dependence" has to be treated without delay in all smokers until remission of tobacco use.

Figure 2: Good, neutral and bad practices in assisting smokers with quitting

1.2. Definitions, classifications, terms and specific explanations

1.2.1 Tobacco XE "Tobacco dependence" dependence: an acquired disease with tobacco industry as a vectorTobacco dependence XE "Tobacco dependence" is an addiction XE "addiction" to tobacco caused by the drug nicotine XE "nicotine" . The smoker suffering from tobacco dependence XE "Tobacco dependence" cannot stop using the substance despite the fact that it causes him/her harm. While the nicotine contained in tobacco causes the nicotine dependence, the toxic effects are mainly due to other substances contained in the tobacco smoke.

The reason why persons who use tobacco on a daily basis for at least several weeks cannot quit XE "quit" smoking easily is the dependence mainly due to the nicotine XE "nicotine" contained in tobacco. Inhaled nicotine is known as a drug able to induce an addiction XE "addiction" at least as strong as that of heroin or cocaine.

Tobacco users who took up smoking as teenagers are usually more addicted than those who took up tobacco use as adults. Nicotine, a substance with psycho-active properties, creates the cravings XE "cravings" for cigarettes XE "ciga