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Quality improvement and accountability in the treatment of tobacco dependence: the need for a national training and certification programme

Healthcare programmes, services, and practitioners in the USA and many other western countries are being held increasingly accountable for quality, safety, and cost effectiveness. Performance measurement—a first step toward assuring quality—is being integrated into all aspects of healthcare. Government agencies, large employers, and other institutions that pay for medical care are insisting on accountability, in response to the growing demand for medical services; the introduction of new, expensive technologies and pharmaceuticals; studies showing that medical practice often does not conform to evidence based guidelines; geographic variations in the utilisation of medical services; and the high incidence of serious medical errors.1-3 

Curiously, the treatment of tobacco dependence has not been part of this picture. Evidence based guidelines for smoking cessation treatment exist,4-7 and recommended interventions are extremely cost effective.8 But there is little effort to ensure compliance with guidelines among programmes and providers being paid to help smokers quit.

The need for quality control in the treatment of tobacco use and dependence is compelling for several reasons. Firstly, the number of effective treatment options is increasing, and consumers should have assurance that they are being offered assistance that is of known benefit. Secondly, some of the newly recommended first line and second line medications6—such as bupropion, clonidine, and nortriptyline—have more serious risk profiles than nicotine replacement products, and require careful ascertainment of contraindications, side effects, and drug interactions. Thirdly, the use of combination therapy involving more than one medication increases the complexity of treatment. Fourthly, few physicians are adequately trained to use these medications, in part because tobacco dependence treatment is not a uniform component of medical school education.9 

A fifth reason is that more funding is being made available in the USA, the UK, New Zealand, and perhaps in a few other western countries, …