Challenges to implementing the WHO Framework Convention on Tobacco Control guidelines on tobacco cessation treatment: a qualitative analysis

Portfolio analysis of global tobacco control research funding at the National Cancer Institute, 2000-2019

INTRODUCTION

Research in low- and middle-income countries (LMICs), where the majority of global tobacco users reside, is critical to addressing the global tobacco epidemic. This analysis describes the global tobacco control research portfolio funded by the National Cancer Institute from fiscal years 2000 to 2019.

METHODS

We used the National Institutes of Health Query, View, Report database to identify extramural grants relevant to global tobacco control research. Abstracts were analyzed to describe grant characteristics, including topic areas, tobacco products, countries, and regions of focus. Bibliometric and co-authorship network analyses were performed for publications associated with relevant grants.

RESULTS

Of the 93 relevant grants with foreign (non-US) involvement, the majority (83.9%) supported research in upper and lower middle-income countries. The majority of grants (86.0%) focused on cigarettes, with a small subset of grants addressing smokeless tobacco, waterpipe use, or other non-cigarette products. Most grants focused on at least one of the six tobacco control policy measures in the World Health Organization MPOWER package; almost half (48.4%) focused on monitoring tobacco use and around one-third (32.3%) focused on offering tobacco cessation treatment, while other MPOWER measures received less attention in the research portfolio. While most of these grants, and the funding initiatives that supported them, emphasized research in low- and middle-income countries (LMICs), only 3 of 93 grants were awarded directly to LMIC-based institutions.

CONCLUSIONS

There is a critical need for research to develop and test strategies to adapt, implement, and scale up evidence-based interventions across diverse LMIC settings. This study identified gaps in research activity that should be addressed to strengthen global tobacco control research capacity.

Experiences and Beliefs on Tobacco Use, Cessation in India: A Qualitative Study

Background

Almost 80% of global tobacco usage is concentrated in low- and-middle-income countries (LMICs) like India. Added to this, there is dearth of dedicated tobacco cessation specialist services in healthcare settings in these regions. Identification of challenges in the delivery of cessation interventions and understanding the experiences of tobacco users will aid in formulating successful quit strategies.

Objectives

This qualitative study in India aimed to understand the perspectives of tobacco-using patients in healthcare facilities regarding tobacco use and cessation.

Methods

This qualitative study was conducted in urban and rural areas of four study sites, two each in the North and South India. Using purposive sampling, patients who were tobacco users were selected from healthcare facilities. The interviews were transcribed, coded and organised into themes. Analysis was done using NVivo 10 software.

Results

A total of 22 in-depth interviews were conducted on participants aged 23 to 80 years who were either current or past tobacco users. A majority of the participants were aware of their increased health risks associated with tobacco consumption and had attempted quitting; however, barriers such as peer influence, formed habit, certain cultural barriers and the addictive nature of nicotine prevented them from successfully quitting. Familial and peer support, the government's role in spreading public awareness, and limiting the sale of tobacco were stated as facilitators for tobacco cessation.

Conclusions

The findings of this study point out that despite awareness of the perils of tobacco among smokers, there are various barriers and beliefs related to tobacco use and cessation. These findings would prove advantageous for policy-makers to implement and promote addiction treatment programmes for successful tobacco cessation efforts. In order to optimise strategies, policies must be well informed by ongoing dialogue between the public, service providers and policy-makers.

Could international human rights obligations motivate countries to implement tobacco cessation support?

BACKGROUND AND AIMS

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) seeks to realize the right to health through national tobacco control policies. However, few states have met their obligations under Article 14 of the FCTC to develop evidence-based policies to support tobacco cessation. This article examines how human rights obligations could provide a legal and moral basis for states to implement greater support for individuals to overcome their addiction to tobacco.

ANALYSIS

The United Nations (UN) has a well-established legal framework for promoting human rights, looking to the right to health to realize health autonomy. Where addiction undermines autonomy, it is widely acknowledged that addiction presents a significant barrier to cessation for individuals who use tobacco, undermining the right to health. The UN human rights system could, therefore, provide a complementary basis for monitoring state obligations under Article 14 of the FCTC, identifying challenges to FCTC implementation and motivating states to support tobacco cessation.

CONCLUSIONS

The United Nations' human rights system offers a mechanism that could be used to monitor Framework Convention on Tobacco Control implementation in national policy, facilitating accountability for the progressive realization of cessation support.

How do tobacco control policies work in low-income and middle-income countries? A realist synthesis

BACKGROUND

The burden of tobacco use is disproportionately high in low- and middle-income countries (LMICs). There is scarce theorisation on what works with respect to implementation of tobacco control policies in these settings. Given the complex nature of tobacco control policy implementation, diversity in outcomes of widely implemented policies and the defining role of the context, we conducted a realist synthesis to examine tobacco control policy implementation in LMICs.

METHODS

We conducted a systematic realist literature review to test an initial programme theory developed by the research team. We searched EBSCOHost and Web of Science, containing 19 databases. We included studies on implementation of government tobacco control policies in LMICs.

RESULTS

We included 47 studies that described several contextual factors, mechanisms and outcomes related to implementing tobacco control policies to varying depth. Our initial programme theory identified three overarching strategies: awareness, enforcement, and review systems involved in implementation. The refined programme theory identifies the plausible mechanisms through which these strategies could work. We found 30 mechanisms that could lead to varying implementation outcomes including normalisation of smoking in public places, stigmatisation of the smoker, citizen participation in the programme, fear of public opposition, feeling of kinship among violators and the rest of the community, empowerment of authorised officials, friction among different agencies, group identity among staff, shared learning, manipulation, intimidation and feeling left out in the policy-making process.

CONCLUSIONS

The synthesis provides an overview of the interplay of several contextual factors and mechanisms leading to varied implementation outcomes in LMICs. Decision-makers and other actors may benefit from examining the role of one or more of these mechanisms in their particular contexts to improve programme implementation. Further research into specific tobacco control policies and testing particular mechanisms will help deepen our understanding of tobacco control implementation in LMICs.

PROSPERO REGISTRATION NUMBER

CRD42020191541.

Role of Local Evidence in Transferring Evidence-Based Interventions to Low- and Middle-Income Country Settings: Application to Global Cancer Prevention and Control

PURPOSE

Although the global burden of cancer falls increasingly on low- and middle-income countries (LMICs), much of the evidence for cancer prevention and control comes from high-income countries and may not be directly applicable to LMIC settings. In this paper, we focus on the following question: When the majority of the evidence supporting an evidence-based intervention or implementation strategy comes from high-income countries, what local, contextual evidence is needed when transferring and adapting an intervention or strategy to a specific LMIC setting?

METHODS

We draw on an existing framework (the Population, Intervention, Environment, Transfer-T process model) for assessing transferability of interventions between distinct settings and apply the model to two case studies as learning examples involving implementation of tobacco use treatment guidelines and self sampling for human papillomavirus DNA in cervical cancer screening.

RESULTS

These two case studies illustrate how researchers, policymakers, practitioners, and consumers may approach the need for local evidence from different perspectives and with different priorities. As uses and expectations around local evidence may be different for different groups, aligning these priorities through multistakeholder engagement in which all parties participate in defining the questions and cocreating the solutions is critical, along with promoting standardized reporting of contextual factors.

CONCLUSION

Local, contextual evidence can be important for both researchers and practitioners, and its absence may hinder translation of research and implementation efforts across different settings. However, it is essential for researchers, practitioners, and other stakeholders to be able to clearly articulate the type of data needed and why it is important. In particular, where resources are limited, evidence generation should be prioritized to address real needs and gaps in knowledge.

Colliding Epidemics: Research Gaps and Implementation Science Opportunities for Tobacco Use and HIV/AIDS in Low- and Middle-Income Countries

Introduction

Tobacco use is a leading cause of cancer death among people living with HIV (PLWH) worldwide, and smoking prevalence tends to be higher among PLWH. The burden of both HIV/AIDS and tobacco use is increasingly concentrated in low- and middle-income countries (LMICs), where resources to address these challenges are often limited. However, there has been limited effort to date to integrate tobacco cessation into HIV programs in LMICs.

Methods

We searched the literature (searching was conducted between October 1 and December 31, 2020) using PubMed including search terms “tobacco” and “HIV” and “cessation” over the past ten years (searching for articles published between December 1, 2010, and December 1, 2020) to identify original research studies on tobacco cessation interventions conducted in LMICs for PLWH. We also conducted an analysis of NCI-funded research grants on tobacco cessation and HIV awarded during fiscal years 2010 to 2020. Results and Discussion. Existing evidence suggests that conventional tobacco cessation treatments may be less effective among PLWH. Moreover, while substantial evidence exists to support a range of cessation interventions, most of this evidence comes from HICs and is only partly applicable to the evolving social, economic, and cultural climate of many LMICs. There is an urgent need to develop, adapt, and implement effective tobacco control and cessation interventions targeted to PLWH in LMICs, as well as to generate evidence from these settings. Implementation science provides tools develop and test strategies to overcome barriers and to integrate and scale up cessation services within existing HIV treatment settings.

Conclusion

There is a unique opportunity to address HIV and tobacco use in a coordinated way in LMICs by integrating evidence-based tobacco cessation into HIV programs.

Effectiveness of a multicomponent strategy for implementing guidelines for treating tobacco use in Vietnam Commune Health Centers

INTRODUCTION

Strategies are needed to increase implementation of evidence-based tobacco dependence treatment (TDT) in health care systems in low-and middle-income countries (LMICs).

METHODS

We conducted a two-arm cluster randomized controlled trial to compare the effectiveness of two strategies for implementing TDT guidelines in community health centers (n=26) in Vietnam. Arm 1 included training and a tool kit (e.g., reminder system) to promote and support delivery of the 4As (Ask about tobacco use, Advise to quit, Assess readiness, Assist with brief counseling) (Arm 1). Arm 2 included Arm 1 components plus a system to refer smokers to a community health worker (CHW) for more intensive counseling (4As+R). Provider surveys were conducted at baseline, six- and 12-months to assess the hypothesized effect of the strategies on provider and organizational-level factors. The primary outcome was provider adoption of the 4As.

RESULTS

Adoption of the 4As increased significantly across both study arms (all p<.001). Perceived organizational priority for TDT, compatibility with current workflow, and provider attitudes, norms and self-efficacy related to TDT also improved significantly across both arms. In Arm 2 sites, 41% of smokers were referred to a CHW for additional counseling.

CONCLUSION

The study demonstrated the effectiveness of a multicomponent and multilevel strategy (i.e., provider and system) for implementing evidence-based TDT in the Vietnam public health system. Combining provider-delivered brief counseling with opportunities for more in-depth counseling offered by a trained CHW may optimize outcomes and offers a potentially scalable model for increasing access to TDT in health care systems like Vietnam.

IMPLICATIONS

Improving implementation of evidence-based tobacco dependence treatment (TDT) guidelines is a necessary step towards reducing the growing burden of non-communicable disease (NCDs) and premature death in LMICs. The findings provide new evidence on the effectiveness of multilevel strategies for adapting and implementing TDT into routine care in Vietnam, and offers a potentially scalable model for meeting FCTC Article 14 goals in other LMICs with comparable public health systems. The study also demonstrates that combining provider-delivered brief counseling with referral to a community health worker for more in-depth counseling and support can optimize access to evidence-based treatment for tobacco use.

Smokeless Tobacco Initiation, Use, and Cessation in South Asia: A Qualitative Assessment

Introduction

Smokeless tobacco (ST) is a significant South Asian public health problem. This paper reports a qualitative study of a sample of South Asian ST users.

Methods

Interviews, using a piloted topic guide, with 33 consenting, urban dwelling adult ST users explored their ST initiation, continued use, and cessation attempts. Framework data analysis was used to analyze country specific data before a thematic cross-country synthesis was completed.

Results

Participants reported long-term ST use and high dependency. All reported strong cessation motivation and multiple failed attempts because of ease of purchasing ST, tobacco dependency, and lack of institutional support.

Conclusions

Interventions to support cessation attempts among consumers of South Asian ST products should address the multiple challenges of developing an integrated ST policy, including cessation services.

Implications

This study provides detailed understanding of the barriers and drivers to ST initiation, use, and cessation for users in Bangladesh, India, and Pakistan. It is the first study to directly compare these three countries. The insight was then used to adapt an existing behavioral support intervention for ST cessation for testing in these countries.

A qualitative assessment of factors influencing implementation and sustainability of evidence-based tobacco use treatment in Vietnam health centers

Background

Effective strategies are needed to increase implementation and sustainability of evidence-based tobacco dependence treatment (TDT) in public health systems in low- and middle-income countries (LMICs). Our two-arm cluster randomized controlled trial (VQuit) found that a multicomponent implementation strategy was effective in increasing provider adherence to TDT guidelines in commune health center (CHCs) in Vietnam. In this paper, we present findings from a post-implementation qualitative assessment of factors influencing effective implementation and program sustainability.

Methods

We conducted semi-structured qualitative interviews (n = 52) with 13 CHC medical directors (i.e., physicians), 25 CHC health care providers (e.g., nurses), and 14 village health workers (VHWs) in 13 study sites. Interviews were transcribed and translated into English. Two qualitative researchers used both deductive (guided by the Consolidated Framework for Implementation Research) and inductive approaches to analysis.

Results

Facilitators of effective implementing of TDT included training and point-of-service tools (e.g., desktop chart with prompts for offering brief counseling) that increased knowledge and self-efficacy, patient demand for TDT, and a referral system, available in arm 2, which reduced the provider burden by shifting more intensive cessation counseling to a trained VHW. The primary challenges to sustainability were competing priorities that are driven by the Ministry of Health and may result in fewer resources for TDT compared with other health programs. However, providers and VHWs suggested several options for adapting the intervention and implementation strategies to address challenges and increasing engagement of local government committees and other sectors to sustain gains.

Conclusion

Our findings offer insights into how a multicomponent implementation strategy influenced changes in the delivery of evidence-based TDT. In addition, the results illustrate the dynamic interplay between barriers and facilitators for sustaining TDT at the policy and community/practice level, particularly in the context of centralized public health systems like Vietnam’s. Sustaining gains in practice improvement and clinical outcomes will require strategies that include ongoing engagement with policymakers and other stakeholders at the national and local level, and planning for adaptations and subsequent resource allocations in order to meet the World Health Organization’s goals promoting access to effective treatment for all tobacco users.

Trial registration

NCT02564653, registered September 2015