FEEDBACK LOOP DR. PETER SELBY USES PATIENT-CENTRED APPROACH AND CONTINUOUS LEARNING TO ENHANCE TREATMENT FOR TOBACCO ADDICTION

By Elaine Smith

Dr. Peter Selby has big goals: helping people to stop smoking successfully and continuously improving the system that makes this possible. Even bigger is the news that he’s succeeding.

Dr. Selby, the Vice-Chair, Research, for the Department of Family and Community Medicine at the University of Toronto, is a psychiatrist at the Centre for Addiction and Mental Health (CAMH) and the principal investigator and director of its Nicotine Dependence Service, a project that first began in 2005–2006. He is also the driving force and principal investigator behind its Nicotine Dependence Clinic (NDC), Ontario’s STOP (Smoking Treatment for Ontario Patients) program and the TEACH (Training Enhancement in Applied Counselling and Health) program.

The TEACH program offers continuing education and is aimed at capacity-building by training health care providers to support their patients with tobacco addiction and cessation, and address e-cigarette use or vaping. Taken together, these components also form the basis for the Learning Health System that informs the treatments used by both clinic and STOP practitioners.

“Many family medicine problems had common causes, including smoking,” Dr. Selby says. “About four million Canadians smoke and it’s killing about 45,000 every year. However, when treating patients for other conditions, such as COPD (chronic obstructive pulmonary disease), high cholesterol or blood pressure, the benefits are wiped out if the person continues to smoke. In addition to preventing numerous chronic diseases, ongoing smoking harms almost all of them. As family physicians we also see the harms of smoking in pregnancy and the effects of second-hand smoke on children in our practice. Governments were also waking up to see smoking’s connection with other illnesses, but there were no leaders to take this on using this approach.”

Dr. Selby has become that leader.

“We needed to research and create a separate system, since no single treatment seemed to work,” he says. We’ve created a system to look at who smokers are and treat them based on the context of their lives. With data, we could see that many smokers are also dealing with poverty, mental health conditions, drinking to excess, or other conditions. We looked at what we could add as additional interventions and supports.”

The result has been the provincewide STOP program, in addition to the CAMH Nicotine Dependence Clinic. The CAMH program is site-specific and focused on the hospital’s outpatient population, creating individual treatment plans and offering individual and/or group counselling supports. STOP, meanwhile, is a provincewide tobacco cessation treatment program funded by the Ontario Ministry of Health, and delivered either through local Ontario-based healthcare providers, or online via the STOP on the Net program. Smokers or vapers who qualify receive nicotine replacement therapy like gum and patches, and counselling supports.

“We created a system that we could scale up across the province,” says Dr. Selby.

STOP is available at more than 300 sites provincewide through collaborations with family health teams, community health centres, Aboriginal health centres, nurse practitioner-led clinics and addiction and mental health agencies. As of January 2023, STOP has treated 346,000 people across Ontario. People who participate in STOP are eight times more likely to quit than if they attempt to stop using tobacco unassisted.

Given the challenges of in-person interactions during the COVID-19 pandemic, Dr. Selby and his team initiated STOP on the Net, an online version of the program that is now a permanent option, given its popularity and effectiveness.

“We pivoted to provide services that people could access safely and virtually and the enrolment numbers continue to grow,” says Eva Huang, a CAMH knowledge translation specialist.

Adds Dr. Selby, “We created STOP on the Net to assist a workforce under strain. Since it is delivered directly to the smoker [or vaper], they can enrol themselves and reduce pressure on health-care providers. It’s all about improving population health by empowering people to take action.”

STOP has a small footprint, he notes, needing little space of its own. Dr. Selby and his team explore the needs of the setting and create training programs tailored to their populations. These include initiatives targeting women and youth and efforts targeting homeless shelters or Indigenous communities.

STOP sites and the NDC provide Dr. Selby and his team with data about the success or failure of various interventions, as well as patient demographics; they form the basis for a learning health system. It is a system that relies upon continuous cycles of research, analysis, development and implementation of improvements to achieve better health for individuals and improved performance for health care systems.

“As I did traditional research, I recognized that making changes to frontline services took years,” says Dr. Selby. “We needed to take the current problems our patients are facing and rapidly develop solutions that we could simultaneously study and deploy in real-world settings.

“This is an adaptive learning system. We learn what works, create and adapt. The research setting is often different than the real-world setting. We look at the real-world settings and see what’s required to get the outcomes a site needs and make sure what is offered fits with their DNA. We offer intelligent research and support to do it.”

Nadia Minian, PhD, is an implementation scientist with the Nicotine Dependence Service and an assistant professor at DFCM. She is heavily involved in its learning health system and knowledge translation.

“These are evidence-based smoking cessation programs,” Dr. Minian says. “We collect data to see how well the programs are working, then make adjustments. Every time a participant enrols, we collect baseline data to match with treatments and look for trends and gaps. Everything is evidence-based.

“We either identify gaps in the literature and data or hear from our own partners. If we need to develop specific resources, there is also TEACH training and tools to assist patients.” TEACH is also led by another member of DFCM, Rosa Dragonetti. It is an award-winning program with a community of practice that has demonstrated the impact of this training model on patient level outcomes.

Dr. Selby says that a sound learning health system can help planners make health care service decisions. He and his team are currently collaborating with Diabetes Action Canada to determine how the model can provide integrated mental and physical health care to people with diabetes.

“A good learning health system that is designed for the patients and clinicians should make a difference in health system planning and evaluation,” he notes. “It connects various siloes and gets them to work together on an alignment of purpose, and family medicine should be at the centre of a good learning health system, since family physicians co-ordinate whatever patients need.”