Doctors should advise patients to quit smoking

Smoking cessation: smokers can't do it alone

Germany is a developing country when it comes to professional, medically supported addiction therapy for smokers. For outpatient as well as inpatient measures, the health insurance companies persistently refuse to reimburse the costs. Supportive pharmaceuticals are wrongly regarded as lifestyle medication.

Of the around 20 million smokers in Germany, many would like to finally quit. But most of them have little chance of remaining permanently abstinent without support. Photo: Stepan Popov / stock.adobe.com

More than 70% of those who want to quit smoking try it alone at first, but only 3–7% are abstinent after a year (1). With professional support, the success rate can be increased to up to 40%.

However, if you want to take advantage of this in this country, it is difficult. It is true that the providers of quitting courses on Google make full-bodied promises: "All health insurances pay" (2). However, if you look at the small print, in the end most of it sticks to the patient.

Not only statutory health insurances refuse to cover the costs for drugs or nicotine replacement products, private ones are also restrictive. Although they pride themselves on paying for acupuncture and hypnosis to quit smoking, these are precisely what the current guidelines do not recommend (3).

It is also scientifically proven that smoking cessation in Germany is neglected by the cost bearers (4). This contradicts all evidence; a Cochrane Review recently confirmed that reimbursement is of great importance for the effectiveness of smoking cessation (5). Local doctors are slowed down in two ways: Neither inpatient nor outpatient smoking cessation is part of the range of services offered by the health insurance companies.

This is why the German Society for Pneumology (DGP) launched the OPS "Tobacco Weaning" (6). Such an operation and procedure key is necessary in order to be able to bill in the case flat rate system (DRG). The OPS 9-501 is intended to enable cost reimbursement in the future when clinics begin smoking cessation using a standardized procedure during an inpatient stay and then transfer the patient to outpatient structures (box). This applies to all inpatient smokers, whether they have been admitted for COPD, a heart attack or a joint operation.

Start smoking cessation in the clinic

"We know that patients in the clinic are very receptive to quitting smoking," says Prof. Dr. med. Stefan Andreas, chief physician at the Immenhausen lung clinic. Especially if the motivational interview (box) is carried out by a doctor (7).

"We sometimes have the paradoxical situation that we carry out complex and cost-intensive therapies for smokers - such as creating vascular bypasses - but that we miss the 'teachable moment' to encourage weaning during this time in the clinic," criticizes the pulmonologist. In particular, patients being treated for a smoking-related illness are a worthwhile target group. But in principle all smokers are covered by the program.

Depending on the clinic, this could be up to 40% of the inpatients treated. Estimates suggest that the multimodal program would cost around EUR 400 per case (8). Several pneumological clinics and specialist practices have worked with the German Institute for Medical Documentation and Information (DIMDI) for around a decade towards implementation. Initial observations after trial phases show that the procedure is practicable and achieves good weaning rates.

However, if OPS 9-501 is implemented, the financing of the subsequent weaning therapy in outpatient practice has still not been resolved.

According to the relevant guidelines, the evidence suggests a combination of behavioral therapy and drug support (9, 1). Neither is paid for. For example, those affected have to pay for pharmaceuticals to help them wean themselves: These are primarily the various nicotine replacement therapies (NRT as nicotine patches, chewing gums, tablets, mouth sprays and inhalers), then varenicline as a partial agonist of the nicotine acetylcholine receptor α4β2 and finally the antidepressant bupropion.

Sue for withdrawal therapy

These drugs are wrongly belittled by the legislator as lifestyle medication and are thus excluded from reimbursement by the health insurances, criticize the "pulmonologists on the net" (10). All 3 pharmacological approaches are effective, a combination of several application forms can increase the effectiveness of NRT as well as their combination with varenicline or bupropion.

Smoking cessation is also seen as a crucial aid in the treatment of patients with COPD, lung cancer, asthma and tuberculosis (11). For example, quitting smoking lowers the complication rate after pulmonary resections, improves the prognosis and improves the response to chemotherapy (12). And better than statins, beta blockers, or ACE inhibitors, this lowers coronary heart disease mortality (13).

"For this reason we launched a lawsuit years ago to treat tobacco addiction as an addictive disease", explains Prof. Dr. med. Anil Batra, head of the addiction medicine and addiction research section at the Psychiatric University Clinic in Tübingen and chairman of the Scientific Action Group on Tobacco Weaning (WAT). The limitation of reimbursement services to low-cost prevention offers (Section 20 SGBV) must be urgently lifted (14).

This lawsuit is currently on hold because proceedings with the same goal are pending before the Federal Constitutional Court. In Germany, smokers are therefore forced to go to the Federal Constitutional Court for reimbursement of their therapy.

Although smoking e-cigarettes is believed to have less potential for harm to the individual smoker than tobacco smoke, it is not a means of smoking cessation as is currently being promoted. Andreas clearly rejects such approaches. A recent study from 28 European countries showed that reaching for an e-cigarette may even hinder smoking cessation (15). “The patients then often smoke both at the same time,” says Andreas. The study also shows that in the end the population smoked more rather than less.

Recently, Prof. Dr. Paul Aveyard of Oxford University even suggested prescribing e-cigarettes as well as nicotine replacement therapy. Prof. Dr. Kenneth C. Johnson from the University of Ottawa, on the other hand, argued that in a long-term observation of 11–18 year old schoolchildren who started using the e-cigarette had twelve-fold the risk of ending up smoking tobacco (16).

He also pointed out that almost half of all smoking-related deaths are from heart disease. The vessels would still be damaged by nicotine. E-cigarette consumption would therefore also be associated with a considerable cardiac and cerebral risk of infarction. To recommend it as a weaning aid is "irresponsible", summarizes Johnson.

Dr. med. Martina Lenzen-Schulte

Literature on the Internet:
www.aerzteblatt.de/lit3118
or via QR code.

Multimodal inpatient therapy for smoking cessation

  • Standardized recording of the smoking history with a detailed questionnaire and standardized recording of nicotine dependence (Fagerström test)
  • Implementation and documentation of motivational talks to end tobacco consumption for a total of at least 60 minutes by a doctor who is qualified to quit smoking (the prerequisite is a certified ability to quit smoking, e.g. via the curriculum of the German Medical Association of the DGP and BDP)
  • Implementation and documentation of motivational interviews individually or in groups of at least 120 minutes in total by staff qualified to quit smoking (psychologists, pedagogues, social pedagogues, social scientists, health scientists, nurses or medical assistants)
  • Education about the use and mode of action of nicotine-containing preparations and other medicinal aids for smoking cessation
  • At least 2 carbon monoxide determinations in the exhaled air or in the blood (CO-Hb value in the blood gas analysis) for documentation of the progress
  • Documented registration (signed by the reporting hospital and the reported patient) for an outpatient tobacco cessation program recognized by health insurance companies
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