Guidelines on the Implementation of Unified and Standardized Tobacco Cessation Services at All Levels of Care

April 5, 2021

DOH ADMINISTRATIVE ORDER NO. 2021-0031

 

I. RATIONALE

Tobacco use remains the leading cause of preventable premature morbidity and mortality worldwide. Globally, it is known to cause more than 8 million deaths every year due to direct use of tobacco products and exposure to secondhand smoke (WHO Tobacco Fact Sheet, 2020).

In the Philippines, the Global Adult Tobacco Survey (2015) found that 23.8% of the adult population in the country, equivalent to 16.6 million individuals, uses tobacco in any form. While 76.7% of current tobacco users have expressed interest in tobacco cessation, only 52.2% have made a quit attempt in the past 12 months. Specifically, only 4% of these have successfully quit.

Under the FOURmula ONE Plus for Health (F1+ for Health) "Boosting Universal Health Care," the Department of Health's flagship program, efforts are directed toward ensuring "better health outcomes, a more responsive health system, and a more equitable health care financing," with an overall vision of "Filipinos as among the healthiest people in Southeast Asia by 2022, and in Asia by 2040." With the passing of Republic Act No. 11223, or the Universal Health Care Act of 2019, the role of primary health care is recognized as an invaluable component of the health system in ensuring that all Filipinos are provided with "a comprehensive set of quality and cost-effective, promotive, preventive, curative, rehabilitative and palliative health services." The United Nations Sustainable Development Goal (SDG) target 3.a "strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control (FCTC) in all countries" underscores the importance of tobacco prevention and control measures in obtaining SDG 3: Ensure healthy lives and promote well-being for all at all ages. Particularly, FCTC Article 14 requires that the treatment of tobacco dependence be incorporated into the health care system.

Studies have shown that tobacco cessation is the sole intervention found to have the potential to decrease tobacco-related mortality in the short- and medium-term, thereby conferring protection to the population from non-communicable and communicable diseases caused by the consumption of tobacco and tobacco-related products, exposure to tobacco smoke, and addiction to nicotine. In line with the thrusts of the Universal Health Care Act, this Order is being issued to standardize the approach to the diagnosis and treatment of tobacco use and dependence.

II. OBJECTIVES

General Objective: This Order aims to provide guidelines on the implementation of unified and standardized tobacco cessation services.

Specific Objectives:

1. Identify tobacco cessation services that shall be provided at different levels of service delivery;

2. Determine referral guidelines for the provision of tobacco cessation services; and

3. Delineate the roles of different government agencies and partners in the implementation of this policy.

III. SCOPE

This Order shall apply to all entities promoting and providing tobacco cessation services, such as, but not limited to, DOH Central Office, Centers for Health Development, Ministry of Health-Bangsamoro Autonomous Region in Muslim Mindanao (MOH-BARMM) subject to the applicable provisions of Republic Act No. 11054 of the "Bangsamoro Organic Act" and subsequent rules and policies issued by the Bangsamoro government; Hospitals, Specialty hospitals, Treatment and Rehabilitation Centers, Local Government Units, public and private health facilities including other government offices/agencies; workplace; academe, school/university clinics and health professional societies; non-governmental organizations (NGOs)/Civil Society Organizations (CSOs); and other stakeholders.

IV. DEFINITION OF TERMS

1. Brief tobacco intervention (BTI) refers to the short (3 to 10 minutes), personalized interaction with or counseling of every client, regardless of age, who is a current tobacco user, or is a non-tobacco user but is exposed to tobacco smoke, using the "5-A" approach, namely:

Ask about tobacco use

Advise to quit through personalized messages

Assess willingness to quit

Assist with quitting

Arrange follow-up care and support

2. Current tobacco user refers to an individual who uses any tobacco product whether daily or occasionally;

3. DOH Quitline refers to the phone- or mobile-centered support service under the Lung Center of the Philippines that offers intensive tobacco cessation counseling requiring multiple sessions to help tobacco users quit;

4. Electronic Nicotine Delivery System/Electronic Non Nicotine Delivery System (ENDS/ENNDS) refer to the combination of (i) a liquid solution or gel, that transforms into aerosol without combustion through the employment of a mechanical or electronic heating element, battery or circuit that can be used to heat such solution or gel and includes but not limited to (ii) a cartridge, (iii) a tank, and (iv) the device without the cartridge or tank;

5. Fagerström Test for Nicotine Dependence (FTND) refers to a screening tool for physical nicotine dependence;

6. Former tobacco user refers to an individual who previously used any tobacco product whether daily or occasionally;

7. Heated Tobacco Products (HTPs) refer to tobacco products that may be consumed through heating tobacco, either electrically or through other means sufficiently to release an aerosol that can be inhaled without burning or combustion of the tobacco. HTPs include liquid solutions and gels that are part of the product and are heated to generate an aerosol;

8. Never/Non-tobacco user refers to an individual who has never used any tobacco product;

9. Novel Tobacco Products refer to all substances, devices, and innovations entirely or partly made of tobacco leaf as raw material, already existing or to be developed in the future, intended to be used as substitutes for cigarettes, conventional tobacco products, ENDS/ENNDS or HTPs;

10. Intensive tobacco cessation counseling refers to an advanced level of intervention utilizing motivational interviewing or behavioral counseling requiring multiple sessions, with each session lasting for 30 minutes or more. This intervention may or may not require pharmacotherapy;

11. Tobacco Cessation Aid refers to a pharmacological aid to tobacco cessation approved by the Food and Drug Administration (FDA) for such purpose, as an adjunct to intensive tobacco cessation counseling and/or various forms of behavioral support;

12. Tobacco Cessation Service refers to evidence-based health care services provided to assist tobacco users to stop using tobacco or to continue abstinence from using tobacco, such as but not limited to, Brief Tobacco Intervention, Intensive Counseling, Pharmacologic Treatment, Quitline, which can be delivered face-to-face, or through other modes of delivery or technologies including but not limited to digital applications and chat services; and

13. Tobacco Industry Interference refers to a broad array of tactics and strategies used by the tobacco industry to interfere with the setting and implementing of tobacco prevention and control measures.

V. GENERAL GUIDELINES

A. Tobacco cessation services shall be integrated into the existing and future treatment protocols of relevant health programs including but not limited to: pre-natal care, child health and immunization, adolescent health, men's and women's reproductive health, dental health, mental health, non-communicable diseases, Tuberculosis, and HIV.

B. Tobacco cessation services shall follow the current guidelines on the Diagnosis and Treatment of Tobacco Use and Dependence adopted by the DOH, and shall adhere to current infection prevention and control guidelines on Corona Virus disease 2019 (COVID-19) and other infectious diseases that might affect service delivery.

C. Electronic Nicotine/Non-Nicotine Delivery Systems, Heated Tobacco Products and Novel Tobacco Products shall NOT be recommended as tobacco cessation aids, unless otherwise approved by the FDA for such purpose. Clients shall be advised on the health effects of these products.

D. New health technologies for tobacco cessation to be funded by the DOH and PhilHealth shall undergo health technology assessment in accordance to Administrative Order No. 2020-0041 "The New Implementing Guidelines on Health Technology Assessment to Guide Funding Allocation and Coverage Decisions in support of Universal Health Care." In addition, FDA approval shall be required for medicines that will be used as tobacco cessation aids.

E. Tobacco cessation services provided through digital technologies shall adhere to current guidelines on electronic health issued by the DOH and the Department of Information and Communications Technology (DICT).

F. Appropriate capacity building of health care providers on tobacco cessation services, including promotion, shall be made an essential part of tobacco cessation implementation.

G. Monitoring and evaluation systems shall be put in place to determine implementation gaps and challenges. These shall serve as the basis for regular review and evaluation by technical experts to determine more cost-effective diagnosis and management approaches as well as areas that require technical assistance.

H. Health care providers and health facilities shall adhere to the Civil Service Commission (CSC)-DOH Joint Memorandum Circular No. 2010-01 or the Protection of the Bureaucracy Against Tobacco Industry Interference, particularly prohibitions on unnecessary interaction with the tobacco industry, preferential treatment to tobacco industry, accepting gifts, donations and sponsorships, any financial or material interest in any transactions, accepting other favors, and engaging in an occupational activity within the tobacco industry. A notarized declaration of no conflict of interest shall be required from any partners, sponsors and/or donors from the private sector prior to engagement. The template provided in AO 2021-0011, entitled "Implementing Guidelines of Section 35 of the Republic Act No. 11223, otherwise known as the "Universal Health Care Act," on Standards on Receipt, Assessment, and Management of Conflict of Interest," shall be used for this purpose (Annex A).

VI. SPECIFIC GUIDELINES

A. Tobacco Cessation Service

1. Tobacco cessation services shall be provided to ALL tobacco and non-tobacco users regardless of reason for consultation/visit. These shall follow existing evidence-based guidelines on the Diagnosis and Treatment of Tobacco Use and Dependence adopted by the DOH.

2. Every trained health care provider shall document the status of tobacco use, level of nicotine addiction using the Fagerström Test for Nicotine Dependence (FTND), and/or exposure to tobacco smoke shall be checked and updated at the initial and succeeding visits thereafter. Tobacco use status may be used as a sixth (6th) vital sign in ALL patients during visits at the outpatient and emergency room departments ("Do you smoke or do you use any tobacco product?" and "Is there anyone in the household who smokes?").

3. Non-tobacco users exposed to tobacco smoke shall be provided advice and educational materials on the health effects of exposure to tobacco smoke. Promotion of smoke-free environments shall also be done.

4. Tobacco users shall be advised to quit in a clear, strong and personalized manner, provided information on the health effects of tobacco use, and assessed for readiness to quit. Clients who are ready to quit shall be given the appropriate assistance as detailed in Annex B: Tobacco Cessation Algorithm.

5. Pharmacotherapy shall be prescribed only after detailed assessment of the provider to a client who has moderate to high level of nicotine dependence (FTND score of > 4) and shall ALWAYS be accompanied by intensive counseling in accordance to existing evidence-based guidelines on the Diagnosis and Treatment of Tobacco Use and Dependence adopted by the DOH.

6. Tobacco cessation services shall be provided in the following levels of health care:

a. Primary level: Barangay health stations, rural health units, primary care clinics, school/university and workplace clinics, and outpatient departments of Levels 1, 2 and 3 hospitals and outpatient departments of Drug Abuse Treatment and Rehabilitation Centers part of the health care provider networks (HCPN) shall provide screening for tobacco use status, assessment of nicotine dependence using the Fagerström Questionnaire, BTI and referral to the next level of care, as necessary, including follow-up and monitoring in the community. See Annex C. Primary care facilities may offer intensive tobacco cessation counseling and pharmacotherapy: Provided, that they have personnel who received appropriate training from the DOH or any DOH-recognized training institutions: Provided further, that these facilities will not manage special populations beyond their service capacity.

b. Secondary and Tertiary level: Outpatient/inpatient departments of Levels 1, 2, and 3 hospitals, specialty centers, and Drug Abuse Treatment and Rehabilitation Centers part of the HCPN shall provide intensive counseling, pharmacologic treatment for tobacco or nicotine dependence, and laboratory services such as carbon monoxide monitoring and urine cotinine (if available), as prescribed by current evidence-based guidelines adopted by the DOH. Level 3 hospitals shall also provide management and care of special populations, e.g., youth and pregnant/lactating tobacco users, persons with mental health disorders and other forms of substance abuse disorders, and individuals with other co-morbidities and complications.

B. Tobacco Cessation Referral

1. Referral to the appropriate level of care as enumerated under VI.6 shall be done if the patient:

a. Shall be started on pharmacotherapy;

b. Has moderate to high level of nicotine dependence (FTND score of > 4); and

c. Belongs to special populations of tobacco users such as adolescents, pregnant/lactating women, and those with co-morbidities and complications.

2. The Tobacco Cessation Referral Form shall be used for this purpose. See Annex D.

3. Health care providers shall refer clients to the DOH-Quitline, if necessary or preferred by the client for provision of BTI and intensive counseling only.

4. Health facilities/health care providers providing higher levels of care shall refer clients back to the referring primary health care provider to facilitate continuity of care and monitoring in the community, as necessary.

C. Capacity Building

1. All relevant Health Care Providers shall undergo appropriate training and re-training on tobacco cessation as needed, through the DOH training program or any DOH-recognized training institutions.

2. Other modes of learning, including but not limited to, distant and blended modes of learning, shall be utilized to minimize travel and mass gatherings in accordance to current infection prevention and control guidelines.

D. Monitoring and Evaluation

1. Data on service and outcome indicators shall be annually collected for monitoring and evaluation of program implementation and guide the evidence-based research and policy making.

VII. ROLES AND RESPONSIBILITIES

A. Department of Health

1. The Disease Prevention and Control Bureau (DPCB) shall:

a. Oversee the dissemination and implementation of these guidelines;

b. Establish standards for tobacco cessation services and ensure their quality through monitoring, in collaboration with Philippine Health Insurance Corporation or PhilHealth;

c. Provide technical assistance to the Centers for Health Development, MOH-BARMM and other stakeholders on tobacco cessation services in collaboration with professional and civil societies;

d. Coordinate with PhilHealth for the development and implementation of benefit packages for tobacco cessation services;

e. Facilitate the establishment and sustainability of pool of trainers and health care providers who will provide tobacco cessation services that meet CPG standards, in collaboration with the Lung Center of the Philippines, other DOH hospitals and professional societies;

f. Develop and disseminate a standard reporting tool for the monitoring and evaluation of health care providers, tobacco cessation services and outcome indicators;

g. Monitor and evaluate the implementation of tobacco cessation services, and outcome indicators; and

h. Coordinate with the Health Policy Development and Planning Bureau in the review and/or update of this policy.

2. The Health Promotion Bureau (HPB) shall:

a. Develop health promotion and communication plans on the health effects of tobacco use including effects of second-hand and third-hand smoke, and health effects of ENDS/ENNDS, heated tobacco products and novel tobacco products;

b. Conduct awareness building and promotion of tobacco cessation services, including the DOH-Quitline; and

c. Evaluate effectiveness of the health promotion and communication strategies in promoting tobacco cessation-seeking behavior to guide evidence-based research and policy making.

3. The Health Policy Development and Planning Bureau (HPDPB) shall facilitate evidence generation mechanisms to support tobacco cessation interventions for program planning and policy.

4. The Epidemiology Bureau (EB) shall:

a. Sustain the conduct of Global Tobacco Surveillance System and disseminate results to relevant stakeholders; and

b. Provide technical support for the conduct of sub-national population-based surveys on tobacco and tobacco cessation.

5. The Health Human Resource Development Bureau (HHRDB) shall provide technical assistance in identifying appropriate curriculum, learning design and module for health professionals in primary health care facilities and hospitals providing tobacco cessation services.

6. The Health Facilities Development Bureau (HFDB) shall:

a. Develop standards and policies to ensure the availability and accessibility of quality tobacco cessation services; and

b. Include tobacco cessation services into the standards for health care facilities.

7. The Knowledge Management and Information Technology Service (KMITS) shall:

a. Provide guidance on existing sources for tobacco cessation-related data under a vetted data governance and management framework;

b. Assist in data visualization/analytics to improve data use among stakeholders; and

c. Provide advice on appropriate technologies for deployment in health facilities.

8. The Philippine Health Insurance Corporation (PhilHealth) shall develop and implement benefit packages for out-patient and in-patient tobacco cessation services in all levels of care and establish appropriate payment mechanisms.

9. The Lung Center of the Philippines (LCP) shall:

a. Sustain and expand DOH-Quitline services to provide tobacco cessation services nationwide; and

b. Provide technical support to DOH and collaborate with the DOH in the development of training standards and certification of health care providers on tobacco cessation.

B. The Secondary and Tertiary DOHHospitals shall:

1. Provide accessible and quality intensive tobacco cessation counseling among outpatients and admitted patients, including pharmacologic treatment utilizing medicines approved by the FDA and aligned with current evidence-based clinical guidelines adopted by the DOH;

2. Mobilize resources for the implementation of this policy; and

3. Monitor and evaluate the implementation of tobacco cessation services within their scope.

C. The DOH Centers for Health Development and the Ministry of Health-BARMM shall:

1. Orient concerned stakeholders on the policy and advocate for its adoption and implementation;

2. Provide technical assistance to Local Government Units and other partners on tobacco cessation services;

3. Promote tobacco cessation services within their areas of influence;

4. Submit timely quarterly reports on brief tobacco intervention services and outcome indicators to DPCB using the prescribed tool (Annex F: Brief Tobacco Intervention Register); and

5. Monitor the implementation of the policy by both public and private health care providers in their respective regions.

D. Local Government Units, including Provincial and District Hospitals, are enjoined to:

1. Provide accessible and quality tobacco cessation services, including pharmacologic treatment utilizing medicines approved by the FDA and aligned with current evidence-based clinical guidelines adopted by the DOH in all levels of care;

2. Mobilize resources for the implementation of the policy;

3. Establish HCPNs within their areas of responsibility that will provide tobacco cessation services in all levels of care in accordance to Administrative Order No. 2020-0021 "Guidelines on Integration of the Local Health Systems into Province-wide and City-wide Health Systems (P/CHWHS)"; and

4. Monitor and evaluate the implementation of tobacco cessation services within their territorial jurisdiction.

E. Other government agencies, health professional societies, non-government organizations, private sector, the academe, and civil society organizations shall support the implementation of this policy and disseminate it to their areas of influence.

VIII. PENALTY CLAUSE

Any violation of the CSC-DOH JMC No. 2010-01 "Protection of the Bureaucracy Against Tobacco Industry Interference" pertaining to the tobacco industry interference shall be considered a ground for administrative disciplinary action pursuant to Rule XIV (Discipline) of the Omnibus Rules Implementing Book V of Executive Order No. 292, without prejudice to the filing of criminal as well as civil actions under existing laws, rules and regulations.

IX. REPEALING CLAUSE

DOH AO No. 122, Series of 2003, or A Smoking Cessation Program to support the National Tobacco Control and Healthy Lifestyle Program, specifically Parts VI on Program Components letter D on Smoking Cessation Services, VII on Roles and Responsibilities, and VIII on Funding are hereby repealed. The provisions of DOH AO No. 2012-0029 entitled Implementing Guidelines on the Institutionalization of Philippine Package of Essential NCD Interventions (PHILPEN) on the Integrated Management of Hypertension and Diabetes for Primary Health Care Facilities, are modified or repealed insofar as they are inconsistent with this Administrative Order.

All orders and issuances inconsistent with this Administrative Order are also hereby repealed and modified accordingly.

X. SEPARABILITY CLAUSE

If any clause, sentence, or provision of this Order shall be declared invalid or unconstitutional, the other provisions not affected thereby shall remain valid and effective.

XI. EFFECTIVITY CLAUSE

This Order shall take effect fifteen (15) days following its publication in a newspaper of general circulation and upon filing three (3) certified copies to the University of the Philippines Law Center.

(SGD.) FRANCISCO T. DUQUE III, MD, MScSecretary

ANNEX A

Declaration of No Conflict of Interest Sample Template Taken fromDepartment Memorandum No. 2019-0349

ANNEX B

Tobacco Cessation Algorithm

ANNEX C

Fagerström Test for Nicotine Dependence

 

Encircle the appropriate answer to assess the patient's nicotine/cigarette dependence score.

Question	Points
1. How many cigarettes do you smoke per day?
a. 10 or less	0
b. 11-20	1
c. 21-30	2
d. 31 or more	3
2. How soon after you wake up do you smoke your first cigarette?
a. 0-5 minutes	3
b. 30 minutes	2
c. 31-60 minutes	1
d. After 60 minutes	0
3. Do you find it difficult to refrain from smoking in places where smoking is not allowed (e.g., hospitals, government offices, cinemas, libraries, etc.)?
a. Yes	1
b. No	0
4. Do you smoke during the first hours after waking than during the rest of the day?
a. Yes	1
b. No	0
5. Which cigarette would you be the most unwilling to give up?
a. First in the morning	1
b. Any of the others	0
6. Do you smoke even if you are very ill?
a. Yes	1
b. No	0

 

TOTAL SCORE	LEVEL OF DEPENDENCE
0 to 3 points	Low
4 to 6 points	Medium
7 to 10 points	High

Source: Toolkit for delivering the 5A's and 5R's Brief Tobacco Intervention in primary care. WHO, 2004.

 

IMPORTANT:

• Key questions are Item 1 (the number of cigarettes smoked daily) and Item 2 (the time of the first cigarette after waking up in the morning). All health workers should ask these 2 questions during consultation, which can then constitute the short version test, scored from 0 to 6, with the same score values as the FTND.

• The higher the score means the higher the nicotine dependence of an individual. A score of 4 or higher indicates the need to administer pharmacological treatment, and predicts a severe withdrawal syndrome.

ANNEX D

Tobacco Cessation Referral Form

ANNEX E

Tobacco Cessation Services at Different Levels of Care

 

Level of Health Care	Health care Facilities	Services to be Provided	Clients	Training Required	Equipment/	Supplies/
Primary Level	BHS, RHUs Health Centers, Infirmaries, Primary care clinics, school/	• Screening of tobacco use status & assessment of nicotine dependence • Brief Tobacco Intervention • Referral • Ff up & monitoring in the community • Intensive counseling provided that the criteria and under section VI.A.5.a. are met	All clients	Brief Tobacco Intervention	Clinic space for consultation	BTI Register/   Karl Fagerström Nicotine Tolerance Questionnaire   Tobacco cessation referral form
Secondary level	Levels 1, 2 and 3 Hospitals, Treatment and Rehabilitation Centers, Quitline	ABOVE Plus: • Pharmacologic Management, except for Quitline • Intensive counseling • Referral for complications or other related diseases • Laboratory services (optional): CO, cotinine	• Those with moderate to high level of nicotine dependence (FTND score of > 4)	Brief Tobacco Intervention, Intensive Counseling, and Pharmacologic management of tobacco/nicotine dependence	Clinic space for consultation   Ward for those requiring admission   Laboratory equipment (if available)	BTI Register/   Karl Fagerström Nicotine Tolerance Questionnaire   Medicines (Nicotine Replacement Therapy (NRT) and non-NRT, if available)   Tobacco cessation referral form
Tertiary Level	Level 3 Hospitals, Treatment and Rehabilitation Centers	ABOVE Plus: • Management of special populations, complications and co-morbidities	ABOVE Plus: • Special population such as 1) youth tobacco users, 2) pregnant/	Brief Tobacco Intervention, Intensive Counseling, Pharmacologic management of tobacco dependence, and management of complications, co-morbidities and special populations.	Clinic space for consultation   Ward for those requiring admission   Laboratory equipment (if available)	BTI Register/   Karl Fagerström Nicotine Tolerance Questionnaire   Medicines (NRT and non-NRT, if available)   Tobacco cessation referral form

 

ANNEX F

Brief Tobacco Intervention Register