Dear Editor,

In 2005, Sweden ratified the WHO Framework Convention on Tobacco Control (FCTC). Article 14 highlights the importance of tobacco cessation. In 2005, a national standard for certification of tobacco cessation practitioners was adopted in Sweden and six years later a similar standard, the Gold Standard Program (GSP) was introduced. In 2018 there were 18 approved education centers in Sweden and one GSP-training program.

Results from Swedish and Danish cessation counselors have shown optimistic results regarding tobacco quit rates1,2. Others have identified barriers for tobacco cessation in various health-care personnel, including a shortage of tobacco cessation experts to refer the patient to3, as well as perceived lack of time for counseling4 and training in tobacco cessation5. To our knowledge, no previous study has explored the characteristics of Swedish tobacco cessation counselors.

An electronic survey was distributed in April 2018 to those who had been certified from 2006 to April 2018 (n=902). The survey involved multiple-choice questions regarding sex, education, current employment, working conditions, and time spent on smoking cessation. The survey was anonymous, and did not involve any patients or sensitive material.

There were 586 (65%) responders. As shown in Table 1, the overwhelming majority (93.9%) were women. The dominating occupation was nurse/midwife and 76% stated being active in tobacco cessation. The majority of respondents (75.5%) reported that they spent 0.5–2 hours per week on tobacco cessation and considered the overall possibilities to conduct tobacco cessation as ‘moderate’. Most responders saw 0–2 new patients per month in predominantly individual sessions.

Table 1

Characteristics of tobacco cessation counselors (Total N=586)

Characteristicsn (%)
Sex (n=586) 
Male36 (6.1)
Female550 (93.9)
Education (n=586) 
Nurse, midwife415 (70.8)
Psychologist1 (0.2)
Dental hygienist31 (5.3)
Dentist0 (0)
Public health practicioner23 (3.9)
Physician2 (0.3)
Other114 (19.5)
Current position (n=584) 
Nurse, midwife386 (66.1)
Psychologist1 (0.2)
Dental hygienist31 (5.3)
Dentist0 (0.0)
Mainly cessation counselor36 (6.2)
Physician2 (0.3)
Other128 (21.9)
Work place (n=585) 
Primary care public285 (48.6)
Primary care private106 (18.1)
Hospital85 (14.5)
Occupational health care19 (3.2)
Other health care center37 (6.3)
Other53 (9.0)
Type of cessation education (n=586) 
Diploma D486 (82.9)
GSP36 (6.1)
Diploma D + GSP18 (3.1)
Other46 (7.8)
Year of diploma training (n=586) 
Before 200525 (4.3)
2005–200845 (7.7)
2009–201292 (15.7)
2013–2016269 (45.9)
2017–2018155 (26.5)
Active in cessation (n=571) 
Yes, active434 (76.0)
No demand38 (6.7)
No, new job48 (8.4)
No, service stopped13 (2.2)
No, other reason36 (6.3)
Retired2 (0.3)
Doctor’s readiness to prescribea (n=484) 
Easy354 (73.1)
Varies between different physicians109 (22.5)
Resistance21 (4.3)
Hours per week spent on cessation (n=458) 
0.5–2346 (75.5)
2.5–574 (16.1)
5.5–1018 (3.9)
>10.520 (4.4)
New patients per month (n=462) 
0–2288 (62.3)
3–4111 (24.0)
5–635 (7.6)
7–1011 (2.4)
>1017 (3.7)
Group vs individual cessation (n=467) 
Individual435 (93.1)
Group32 (6.9)
Follow-up (n=468) 
Face-to-face208 (44.4)
Telephone223 (47.6)
No system14 (3.0)
Other23 (4.9)
Cessation in workplace (n=483) 
I work alone261 (54.0)
I work in a team222 (46.0)
Management of patient information (n=473) 
Registering in the clinic´s own system450 (95.1)
Registering in own computerized system11 (2.3)
Registering on paper12 (2.5)
Referal routines (n=452) 
I get written referrals and replies195 (43.1)
No routines for referrals or replies257 (56.9)
Support from manager (n=558) 
Very good234 (41.9)
Moderate215 (38.5)
Small/none56 (10.0)
Bad53 (9.5)
Support from administrative personnel (n=554) 
Very good172 (31.0)
Moderate227 (40.9)
Small/none104 (18.8)
Bad51 (9.2)
Possibilities to affect work environment (n=558) 
Very good132 (23.7)
Moderate243 (43.5)
Small/none35 (6.3)
Bad148 (26.5)
Possibilities to spend time on cessation (n=551) 
Very good82 (14.9)
Moderate215 (39.0)
Small/none76 (13.8)
Bad178 (32.3)
Possibilities for continuing cessation education (n=553) 
Very good82 (14.8)
Moderate254 (45.9)
Small/none50 (9.0)
Bad167 (30.2)
Overall possibilities to conduct cessation (n=549) 
Very good117 (21.3)
Moderate301 (54.8)
Small/none36 (6.6)
Bad95 (17.3)
Knowledge about guidelines (n=518) 
Yes, we adhere to guidelines279 (53.9)
Known, but not always practiced157 (30.3)
Known only by the cessationers38 (7.3)
Mostly unknown44 (8.5)
Where do your patients come from? (n=471) 
Many different caregivers (hospital, primary care, other)137 (29.1)
Only or almost only from own caregiver334 (70.9)
Is it important for you that the survey is anonymous? (n=586) 
No230 (39.2)
Yes166 (28.3)
No opinion190 (32.4)

a Prescription of replacement therapy, varenicline and bupropion.

The replies to questions dealing with various aspects of support in the work place ranged from moderate to very good for different variables. Although little time was spent on tobacco cessation, the possibilities to spend time on tobacco cessation was stated as moderate by 39% of the respondents; thus, there seems to be no major hindering factor for conducting tobacco cessation, as opposed to what has been reported4.

In contrast to what has been reported from the tobacco cessation database in Denmark, where most tobacco cessation was conducted in a group setting2 according to the GSP program, our respondents reported mostly individual cessation sessions. When stratifying by type of cessation education, all those with solely GSP education (n=36) reported individual cessation sessions, even though group-based interventions are more cost-effective than individual consultations6. A reason for the dominance of individual cessation sessions could be a low inflow of patients from primary care, possibly due to the deprioritizing of smoking-related diseases such as chronic obstructive pulmonary disorder7.

Our results show that most consultations with Swedish cessation counselors are on an individual basis. We also found that little time is spent on tobacco cessation, despite that more than 50% consider their ‘overall possibilities to conduct tobacco cessation’ as moderate. Further studies are warranted to examine the reasons behind the short time spent on tobacco cessation and how more patients in need could benefit from this treatment.