Challenges of Integrating Tobacco Cessation Interventions in TB Programmes: Case Studies from Nepal and Pakistan

Abstract

I ntroduction: Offering tobacco cessation interventions to TB patients is highly desirable due to the interaction between TB and tobacco use and the potential benefits of quitting. However, implementing such interventions in TB programmes remains a challenge and an under-researched area. Using two initiatives to implement tobacco cessation within TB programmes in Nepal and Pakistan as case studies, we describe these challenges and highlight lessons learnt in the process. Methods: We first conducted a documentary review of all published and unpublished reports of the two initiatives including relevant qualitative and quantitative data and its' analyses. We then analysed this information using the Consolidated Framework for Implementation Research (CFIR) under the five domains of implementation: intervention characteristics, outer settings, inner settings, participant characteristics and the process of implementation. Findings: We faced a number of challenges in implementing tobacco cessation within TB programmes both in Nepal and in Pakistan. These included: doubts about the contextual relevance of the intervention, environments conducive to smoking and political inertia for a cultural shift, service providers' workload, priorities, and their motivation and capacity to deliver tobacco cessation, and inadequate training and support during implementation. We learned that by adapting intervention to the local context, securing mandate from higher authorities, aligning tasks to service providers' roles and receptivity, building capacity through adequate training and providing support, monitoring and feedback during implementation can help in integrating tobacco cessation within TB programmes. Conclusions: Lessons from existing studies can help TB programmes in implementing tobacco cessation interventions and enable greater integration and sustainability of cessation services within routine TB care.

Tobacco cessation in low‐ and middle‐income countries: some challenges and opportunities

“…The implementation, efficacy and cost-effectiveness of culturally relevant tobacco cessation interventions using lower-level health-care workers or community leaders, and their integration into other health-care programmes, will need careful evaluation [7,10,13]. Skinner and colleagues emphasize the need for 'a programme of research' 'to provide vital information about what approaches work most effectively' [1].…”

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

“…The problem is multi-layered: many LMICs have high rates of tobacco use by physicians and other healthcare providers (Abdullah, Qiming, Pun, Stillman, & Samet, 2013, Abdullah et al, 2014; Asfar, Al-Ali, Ward, Vander Weg, & Maziak, 2011), which make them reluctant to champion their patients’ quit attempts. Beyond this motivational issue, many physicians are skeptical that patients want their advice to quit smoking (Ossip et al, 2016; Prucha et al, 2015), do not view cessation as part of their jobs (Dozier et al, 2009; Tee, & Hairi, & Hairi, 2012), and misunderstand the harms of tobacco (Abdullah & Husten, 2004; Asfar et al, 2011; Dogar, Elsey, Khanal, & Siddiqi, 2016; Lando, 2016). …”

“…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

“…There is a huge unmet need to provide tobacco dependence treatment to medically compromised tobacco users. Action to Stop Smoking in Suspected Tuberculosis (ASSIST) is an excellent example of an effective program for smokers with symptoms of TB that has been integrated into the national tuberculosis program of Pakistan (Dogar et al, 2016). Even in low-income countries, provision of specialised treatment to medically compromised tobacco users should be a priority.…”