Supporting economically disadvantaged tobacco users to help them stop: time to review priorities?

Measuring fidelity to behavioural support delivery for smoking cessation and its association with outcomes

BACKGROUND AND AIMS

Behavioural support increases smoking cessation in clinical settings, but effect sizes differ among providers, due possibly to variations in delivery. This study evaluates a measure ('fidelity index') intended to capture fidelity to delivery of content- and interaction-based items of a behavioural support (BS) for smoking cessation and the association of fidelity with quit rates.

METHODS

A fidelity index for scoring the adherence and quality domains of a specific BS intervention, '5As for quit', was developed by classifying the intervention components using the taxonomy of behaviour change techniques. The index was applied to code 154 BS sessions audiotaped among 18 chest clinics in Pakistan to assess their fidelity and explore reliability of coding. The association between intervention fidelity and successful quit achieved by the same providers in a previous study was explored using regression analysis.

RESULTS

The index represented two domains: adherence to delivery of content-based activities of 5As (37 items) and quality of interaction-based activities (eight items). The intercoder reliability was good for content-based (average Krippendorff's α = 0.80) and moderate for interaction-based (average Krippendorff's α = 0.66) items. Approximately 70% (intraclass correlation coefficient: adherence scores = 0.72, quality scores = 0.71) of variation in BS delivery was contributed by providers, which increased to 97% (g-coefficient: adherence scores = 0.973, quality scores = 0.974) after accounting for other sources of variation. Higher quit rates were positively associated with average quality scores [risk ratio = 2.15; 95% confidence interval (CI) = 1.43-3.24], but negatively associated with average adherence scores (risk ratio = 0.55; 95% CI = 0.40-0.77) within services.

CONCLUSIONS

The fidelity index is a reliable measure for quantifying intervention fidelity of delivering smoking cessation behavioural support. Recommended revisions of the fidelity index include incorporation of additional interaction-based items, such as the relational techniques used in motivational interviewing.

The safety, effectiveness and cost-effectiveness of cytisine in achieving six-month continuous smoking abstinence in tuberculosis patients-protocol for a double-blind, placebo-controlled randomized trial

BACKGROUND AND AIMS

Tuberculosis (TB) patients who quit smoking have much better disease outcomes than those who continue to smoke. In general populations, behavioural support combined with pharmacotherapy is the most effective strategy in helping people to quit. However, there is no evidence for the effectiveness of this strategy in TB patients who smoke. We will assess the safety, effectiveness and cost-effectiveness of cytisine-a low-cost plant-derived nicotine substitute-for smoking cessation in TB patients compared with placebo, over and above brief behavioural support.

DESIGN

Two-arm, parallel, double-blind, placebo-controlled, multi-centre (30 sites in Bangladesh and Pakistan), individually randomized trial.

SETTING

TB treatment centres integrated into public health care systems in Bangladesh and Pakistan.

PARTICIPANTS

Newly diagnosed (in the last 4 weeks) adult pulmonary TB patients who are daily smokers (with or without dual smokeless tobacco use) and are interested in quitting (n = 2388).

MEASUREMENTS

The primary outcome measure is biochemically verified continuous abstinence from smoking at 6 months post-randomization, assessed using Russell Standard criteria. The secondary outcome measures include continuous abstinence at 12 months, lapses and relapses; clinical TB outcomes; nicotine dependency and withdrawal; and adverse events.

COMMENTS

This is the first smoking cessation trial of cytisine in low- and middle-income countries evaluating both cessation and TB outcomes. If found effective, cytisine could become the most affordable cessation intervention to help TB patients who smoke.

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

Introduction: 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.