Building Evidence-Based Tobacco Treatment in the Eastern Mediterranean Region: Lessons Learned by the Syrian Center for Tobacco Studies

Abstract

The tobacco epidemic in Syria is characterized by high rates of cigarettes smoking in men and dramatic reemergence of waterpipe smoking, especially among youths and women. The Syrian Center for Tobacco Studies (SCTS), an NIH-funded pioneer research and capacity building institution, has developed a research infrastructure and conducted three randomized clinical trials to develop and rigorously test culturally-appropriate tobacco treatment programs integrated into primary healthcare (PHC) centers. This review aimed to discuss challenges and lessons learned from the Syrian experience. Addressing these challenges may inform future cessation research activities in Syria and other developing countries. To develop a research infrastructure, the SCTS has established Syria’s first IRB and trained physicians/medical students in both tobacco treatment and research methods. Main challenges to conduct the cessation trials were difficulties of coordination between the local and international collaborators; high Smoking Rates among PHC providers; lack of pharmacological agents used in tobacco treatment; and difficulties of conducting research in a politically volatile region. Strategies to overcome these challenges were ensuring an active and regular involvement of all investigator; and advocating for a national smoking-cessation plan that involves training health care providers in smoking cessation treatment and make pharmacological agents used in smoking cessation available.

The impact and relevance of tobacco control research in low-and middle-income countries globally and to the US

“…For example, the Syrian Center for Tobacco Studies and the American University of Beirut have made valuable contributions to the literature regarding the epidemiology of waterpipe use, how to structure surveillance measures for waterpipe smoking based on its unique use patterns, its toxic and addictive properties, measurement methods for assessing waterpipe smoking topography, and recommendations on policies and regulations. (Al Ali, Rastam, Ibrahim, et al, 2015; Asfar, Ward, Al-Ali, & Maziak, 2016; Salloum, Asfar, & Maziak, 2016; Shihadeh, Antonios, & Azar, 2005; World Health Organization, 2015b; World Health Organization, 2018a; World Health Organization, 2018b). These prior research efforts advanced the science regarding waterpipe smoking, guiding other countries such as the US in how to respond to the waterpipe epidemic.…”

Tobacco intervention research in low- and middle-income countries: lessons learned and future directions

“…Ever-improving technology makes global communication easier, and lowers the cost of training interventionists and intervention researchers. Global Bridges has created a multilingual website and virtual community (www.globalbridges.org), and this and other systems are being used to remotely train, supervise, and mentor tobacco interventionists (Asfar, Ward, Al-Ali, & Maziak, 2016; Selby et al, 2015). Another web-based resource, www.treatobacco.net, sponsored by the Society for Research on Nicotine and Tobacco and the Society for the Study of Addiction, is likewise building treatment capacity by sharing evidence-based treatment approaches.…”

“…Even with state-of-the art technological support, a continuing challenge is that evidence-based interventions developed in high-income countries are often not appropriate in LMIC settings without substantial adaptation (Asfar et al, 2016; Dogar et al, 2016). Asfar et al, 2016 describe how empirically supported behavioural cessation strategies developed and widely used in the US and UK, such as self-monitoring, nicotine fading, and social support enhancement, are not acceptable or useful in Syria.…”

“…Asfar et al, 2016 describe how empirically supported behavioural cessation strategies developed and widely used in the US and UK, such as self-monitoring, nicotine fading, and social support enhancement, are not acceptable or useful in Syria. Likewise, studies from Pakistan and Syria suggest that adding pharmacotherapy to behavioural support in “real world” healthcare settings may not boost cessation rates beyond what is achievable by behavioural support alone (Asfar et al, 2016; Dogar et al, 2016). …”

Promoting Tobacco Cessation in Low- and Middle-Income Countries

“…Much of the content is encouraging and even inspiring, while still acknowledging major challenges. The success of the Syrian Center for Tobacco Studies in developing the infrastructure to conduct smoking cessation research and to conduct randomised controlled trials is truly remarkable in the context of ongoing political upheaval (Asfar et al, 2016). Work in the Dominican Republic has led to significant successes in a country that has not been generally supportive of tobacco control (Ossip et al, 2016).…”