Health worker and patient views on implementation of smoking cessation in routine tuberculosis care

Abstract

Smoking worsens tuberculosis (TB) outcomes. Persons with TB who smoke can benefit from smoking cessation. We report findings of a multi-country qualitative process evaluation assessing barriers and facilitators to implementation of smoking cessation behaviour support in TB clinics in Bangladesh and Pakistan. We conducted semi-structured qualitative interviews at five case study clinics with 35 patients and 8 health workers over a period of 11 months (2017–2018) at different time points during the intervention implementation phase. Interviews were conducted by trained researchers in the native languages, audio-recorded, transcribed into English and analysed using a combined deductive–inductive approach guided by the Consolidated Framework for Implementation Research and Theoretical Domains Framework. All patients report willingness to quit smoking and recent quit attempts. Individuals’ main motivations to quit are their health and the need to financially provide for a family. Behavioural regulation such as avoiding exposure to cigarettes and social influences from friends, family and colleagues are main themes of the interviews. Most male patients do not feel shy admitting to smoking, for the sole female patient interviewee stigma was an issue. Health workers report structural characteristics such as high workload and limited time per patient as primary barriers to offering behavioural support. Self-efficacy to discuss tobacco use with women varies by health worker. Systemic barriers to implementation such as staff workload and socio-cultural barriers to cessation like gender relations, stigma or social influences should be dealt with creatively to optimize the behaviour support for sustainability and scale-up.

A narrative review of facilitators and barriers to smoking cessation and tobacco-dependence treatment in patients with tuberculosis in low- and middle-income countries

“…• Structural (institutional) factors -lack of impact of health education sessions, lack of extramural activities when on hospital admission, lack of access to smoking cessation interventions (unaware of any available aids to stop smoking or NRT), easy access to cigarettes within a hospital setting (from staff, peers, visitors, shops close to hospital, hospital café) 44 • Non-addiction-related personal barriers -lack of knowledge about quit strategies, lack of willpower to quit, psychosocial stress, peer smokers' influence Barriers for HW to provide BSS: institutional lack of resources (insufficient space, high patient load, no reporting/recording of tobacco, overwork) and an absence of professional support through monitoring and evaluation 48 Possible barriers to smoking cessation/TDT -patients'/staff's knowledge, attitudes Lack of resources (human, financial), low level of education of health providers on smoking cessation 21 Beliefs that smoking is fun, calms nerves, relieves all life stresses 23 Stigma (especially in women to admit using tobacco) 26,48 Tolerance of smoking or snuff dipping at a health centre by medical assistants providing SCI, smoking staff 30 Not considering low-to-moderate level smokers to be real smokers, particularly those who have reduced their smoking from one to two packs a day to just a few sticks 41 Less knowledge that smoking increases risk of stroke and heart attack 36…”

“…Socio-cultural influences (i.e. family/friends smokers) 26 Brief advice focused only on smoking could lead to a higher rate of SLT relapse seen as a form of harm reduction 29 Receiving a disease-specific cessation message -associated with a lower likelihood of smoking relapse 40 Perception of low-moderate level smoking as harmless 41 Period of follow-up: increase in relapses within the 6 months of treatment and within the 3-6 months following treatment [40][41][42] Several barriers were connected to the healthcare system itself: limited space and privacy at the clinics 37 , lack of coordination between the TB treatment programme and tobacco cessation 39,43 , lack of resources (human, financial), low level of education of health providers on smoking cessation 21 , tolerance of smoking or snuff dipping at a health centre by medical assistants providing SCI, and smoking staff 30 .…”

“…Another important barrier is mentioned in the Boeckmann et al 26 and Warsi et al 48 studies -asking about tobacco use was perceived a sensitive issue, especially among women who may not admit to tobacco use. Table 4 shows factors associated with smoking relapse among TB patients in LMICs.…”

“…Empathic intervention increases the probability that the majority of patients will admit smoking. A potential gender barrier should also be taken into account 26 .…”

Factores de riesgo en pacientes con tuberculosis pulmonar y extrapulmonar en un hospital de concentración de la Ciudad de México

“…El tabaquismo se relaciona con riesgo de 2 a 3 veces de padecer TB y es proporcional al número de cigarrillos fumados. 3 Se encontró como factor de riesgo para pacientes que desarrollaron TB extrapulmonar en 30% (RM: 2.6).…”