Introduction
Many countries are enacting tobacco treatment guidelines and policies in order to fulfil the Framework Convention on Tobacco Control (FCTC), a treaty enacted by the World Health Organization to reduce the health consequences of tobacco use (World Health Organization (WHO), 2016). Article 14 of the treaty requires parties to support tobacco use cessation. Guidelines for implementing the article encouraged countries to create a national coordinating mechanism for tobacco treatment efforts, develop and disseminate treatment guidelines, train providers, ensure access to treatment, mandate recording of tobacco use in medical records, encourage collaboration and establish funding for cessation assistance (WHO, 2010; WHO, 2016).
A number of surveys have evaluated progress on implementing tobacco treatment systems and training programs. In 2005, a pilot study across 10 countries found that health professional training in treating tobacco was very poor, with only 5%–37% of students had received any formal training on how to conduct cessation counselling (Centers for Disease Control, 2005). A survey conducted in 2008 among key informants from 48 countries, stratified by geographic region and income level, identified 61 tobacco treatment programs in 37 countries (Rigotti et al., Reference Rigotti, Bitton, Richards, Reyen, Wassum and Raw2009). These programs trained an estimated 14,194 individuals in 2007, predominantly physicians and nurses. Programs were less prevalent in low-income countries, and securing funding for the training programs was found to be a major challenge. In 2012, a survey of 121 countries party to the FCTC found the glass half full–44% had treatment guidelines, 49% had a government official responsible for treatment and 44% had an official treatment strategy. One in three (36%) had any form of quitline services and, as in earlier surveys, low- and middle-income countries had less infrastructure and offered fewer services (Piné-Abata et al., Reference Piné-Abata, McNeill, Murray, Bitton, Rigotti and Raw2013).
A 2013 survey of 122 experts in 84 countries reported similar findings: 21% of countries—predominantly low- and middle-income countries—reported having no training program. Half (54%) reported that lack of funding was a barrier to providing training; funding for training tended to come from government sources in higher-income countries and non-governmental organizations (NGOs) for lower income countries (Kruse et al., Reference Kruse, Rigotti, Raw, McNeill, Murray and Piné-Abata2016).
Frontline provider perspectives may assist governments and NGOs in pinpointing the strengths, weaknesses and areas for improvement of existing infrastructure and training. To better identify how to assist treatment providers outside of the U.S., the International Committee of the Association for the Treatment of Tobacco Use and Dependence (ATTUD; www.attud.org) surveyed its international members. They were asked to identify barriers/opportunities for training and recommend resources to support tobacco dependence treatment. This study analysed participant perspectives to identify challenges in treating tobacco dependence and recommendations for improvement. Two organizations partnered with ATTUD to recruit participants: Global Bridges Healthcare Alliance for Tobacco Dependence Treatment (www.globalbridges.org) and the Global Network for Tobacco Free Healthcare Services (Formerly the European Network of SmokeFree Healthcare Services–ENSH; http://www.tobaccofreehealthcare.org/).
Methods
Sample
Our purpose was to collect a broad range of perspectives from international tobacco treatment providers. We defined “international” as any provider living most of their time outside of the United States, the home country of ATTUD. We used branching logic to immediately route U.S. residents who lived most of the time in the U.S. to the end of the survey, without asking further questions. We distributed invitations to complete the survey via member listservs (ATTUD; ENSH Global; Global Bridges) and word-of-mouth. The ATTUD listserv consists of members who pay an annual fee of $90 ($45 for members from countries with low income economies, as classified by the World Bank); some listserv members may be in their free 6-month introductory membership. At the time the survey was posted, there were 518 ATTUD members, all of whom were enrolled in the list serve when they joined the organization. In an effort to gather front-line perspectives, we encouraged listserv members and respondents to forward the survey to other tobacco treatment providers in their countries. This research was approved by the University of Kansas Human Subjects Committee (FWA#00003411).
Measures
Demographic items (such as the respondent discipline and treatment setting) were adapted from existing surveys evaluating tobacco treatment resources (Raw, Regan, Rigotti, & McNeill, Reference Raw, Regan, Rigotti and McNeill2009a; Raw, Regan, Rigotti, & McNeill, Reference Raw, Regan, Rigotti and McNeill2009b). Closed-ended questions included multiple-choice items on the respondent's profession, country, how they learned to treat tobacco dependence, activities they currently perform, and the type of certification (if any) provided in their country for tobacco dependence treatment providers. Respondents were also asked to rate the quality of and access to training activities, and suggest languages that training should be provided in.
Open-ended question wording is provided verbatim in (Table 1). Briefly, these asked respondents to reflect on barriers to treatment, resources needed for treatment, what they ‘liked’/‘didn't like’ about their countries’ treatment guidelines, changes to improve their countries guidelines, and how ATTUD could better serve their needs and interests. A question with branching logic administered items regarding country guidelines solely to participants reporting they had tobacco treatment guidelines in their countries.
Participant perspectives about tobacco treatment training and guidelines
Procedures
The survey was designed to be readily adapted/replicated. All study technology was open source or freeware, included Enketo Smart Paper for the form (Enketo, 2012), Formhub for data collection Modi Research Group (2016), and R for quantitative analysis (R Core Team, 2015). The survey was created in English and translated into Spanish by a native Spanish-speaking volunteer and Portuguese by the authors, who are native speakers of Portuguese (Gomide, Martins, and Cruvinel). As the project was implemented without funding, no other translators were readily identified who could reliably translate the survey for free. To ensure the survey had face validity the International Committee of ATTUD reviewed preliminary drafts. Once the survey was entered into the online survey program links were distributed and committee members completed versions and provided feedback to the authors, who repeated this survey/revision process until the questions and data collection form functioned smoothly. In order to protect respondents’ privacy the option to collect computer IP addresses was switched to ‘No’.
Quantitative data were summarized using means and frequencies. To examine access to tobacco treatment training by economy level, we conducted a Chi-Square analysis of self-reported access to training by respondents’ World Bank country economy classifications (low/lower middle; upper middle; high) (World Bank, 2016). Qualitative data analysis was performed by three authors (Gomide, Cruvinel, and Richter). We each individually grouped all participant responses to questions using content analysis (Miles & Huberman, Reference Miles and Huberman1984). This involved two investigators independently ‘open coding’ the text data by identifying keywords, themes, and categories that tended to group participant responses. As a team, we compared our draft codes, combined them into a master list, and created a definition for each code. We then categorized all responses to each open-ended question using the master list of codes.
Results
Participants
One hundred fifty-eight professionals responded to the survey; their average age was 47.5 (22–75) and most were female (60.4%). Thirty-eight percent were physicians, 15.2% nurses, 12.7% psychologists, 5.1% pharmacists, and 29.1% other professions. Respondents were from 45 countries. The countries with most respondents were: Australia (19), Taiwan (19), United States (19), Spain (11), and Canada (8). Almost a quarter of respondents were members of ATTUD. According to the 2015 World Bank income classification 75.9% were from high, 9.5% upper-middle, 12.7% lower-middle, and 1.9% were from low-income countries (World Bank, 2016).
Activities and Training
Participants were engaged in a variety of tobacco control activities: 78.6% treated tobacco users, 65.4% trained health professionals how to treat, 47.2% administered programs, 45.3% conducted research, 36.5% developed policy, and 8.2% performed other activities. They learned how to provide treatment through written materials (69.8%), in-person training (68.6%), information from web pages on the internet (49.1%), professional education (34.6%), structured online training (28.3%), other sources (2.5%), and some reported no training (1.3%). Almost half of participants (48.1%) reported receiving less than 6 hours of training. This differed by income: 78.3% of respondents from low/lower-middle income countries (LMICs) had less than 6 hours, followed by 60% from upper middle and 40.8% from high-income countries (p < 0.014).
Treating Tobacco Training Certification and Guidelines
Fifty-four percent of all participants reported their country had some form of certification for treating tobacco dependence. In LMICs, most (91.3%) did not have professional certification, compared to 53.3% in upper middle and 25% in high income countries (p < 0.001). Eighteen percent reported their country did not have any form of training for treating tobacco outside of their original health care provider education. This was true for 47.8% of LMICs, 20% of upper middle income countries and 12.5% of high income countries (p < 0.001). Most (66%) respondents believed their country had national guidelines for treating tobacco dependence. This also differed by country income; 66% of respondents from LMICs, 87.7% from upper middle and 89.2% from high income countries reported their country had national guidelines (p < 0.002).
Tobacco Treatment Training Access
Forty-three percent (43%) had poor or very poor access to training, and this differed by country income (Figure 1). Among LMICs all respondents (100%) reported poor or very poor access, compared to 73.4% from upper middle and 25% from high income countries (p < 0.001). When asked what language training should be provided in, 62.9% noted other languages than English, including Spanish, Arabic, Chinese and French, and others. “Insert Figure 1 here”
Countries access to tobacco treatment training stratified by economy level.
Provider Perspectives on Barriers and Solutions
The open-ended questions and analyses are displayed in (Table 1). As these were open-ended questions, providers were free to list as many barriers, resources, and solutions as they were inclined to record. The most frequent barriers were lack of funds for provision of smoking cessation services, including limited access to medication, and treatment. Lack of opportunities and incentives for training were common concerns. Low interest/priority for treatment among providers or services was another predominant barrier.
Resources respondents suggested would improve their services included government funding for pharmacotherapy and reimbursement of services. Other requested resources included better training (especially during university), training in specific forms of tobacco treatment (e.g., for treating smokeless tobacco use), and trainee certification. Respondents noted that consistent sources of online information (such as websites, tools, books, trainings) would also be helpful. “Insert Table 1 here”
When asked what they ‘liked’ and ‘disliked’ about their country guidelines, most reported they did not have a tobacco treatment guideline or they did not know whether they had one (I do not know if they exist. I will find out). Among those who reported having guidelines, some reported they were easy to use (Very quick and easy for health professionals to grasp), as well as evidence-based and comprehensive. Others, however, felt their guidelines were not accessible (e.g., the format is not completely user friendly and hard to get copies). It was noted that the guidelines are often poorly implemented and are not accompanied by incentives or resources for training, medication, and treatment.
The changes suggested to improve their country guidelines echoed the main themes from the previous question. Many participants stated that providers should be encouraged to implement the guidelines. They called for systematic, regular updates, more comprehensive guidelines, and funding/reimbursement for treatment.
Most participants did not respond to the question regarding how ATTUD could better serve the needs of tobacco treatment providers. Those who did (N = 29) requested online training, certification opportunities, translated material in different languages, advocacy, and providing local activities and networks.
Discussion
We found that tobacco treatment providers in lower income countries have poor access to training but many ideas for strengthening supports for evidence-based care. Resources for tobacco treatment, and access to training, are very much functions of country income. All respondents from LMICs rated their access to tobacco treatment training as poor to very poor, and a majority of these respondents received less than 6 hours of training on how to treat tobacco dependence. Respondents named numerous barriers to providing evidence-based care. They also offered a number of suggestions for overcoming barriers including funding treatment and medication, updating guidelines regularly, and increasing guideline comprehensiveness, and creating a central website with information, resources and training. Notably, many reported they either did not have country guidelines or did not know whether they existed.
These findings are generally consistent with findings from previous research (Rigotti et al., Reference Rigotti, Bitton, Richards, Reyen, Wassum and Raw2009; Kruse et al., Reference Kruse, Rigotti, Raw, McNeill, Murray and Piné-Abata2016). LMICs face more barriers for finding funding for treatment and for training programs. Kruse found that the proportion of countries with at least one training program ranged from 94% among high-income countries to 50% among low-income countries (Kruse et al., Reference Kruse, Rigotti, Raw, McNeill, Murray and Piné-Abata2016). Respondents from LMICs in the present study gave the front-line provider perspective, which may have differed from the perspectives of participants in prior surveys on national treatment guidelines or training programs. By expanding the reach of the survey beyond international organization and listserv members, we found that many respondents did not know whether their country had national treatment guidelines. Similarly, our survey identified many requests for online training in native languages, which might not have been perceived as necessary by respondents of earlier surveys. In addition, our survey respondents felt they had poor/very poor access to training.
This study has limitations. First, our data came from a convenience sample of providers contacted via listservs and organizations focusing on tobacco treatment. The findings represent the perspectives of health providers already engaged in tobacco treatment and do not represent all health providers. By providing the survey in only three languages, we limited the survey reach. Many respondents were from Australia, Taiwan, and Spain which biased the findings toward the health provider perspectives of those countries. In addition, data were self-reported so we were not able to check accuracy of the information provided. Moreover, the procedures used for translating the English version of the survey into Portuguese and Spanish were weak and may have resulted in inaccuracies with these versions of the surveys.
Encouraging countries to fully fund tobacco treatment, and treatment training, remains a major global barrier to full implementation of Article 14. Respondents did, however, offer a number of ‘small wins’ that tobacco control advocates could pursue. Online trainings exist, and they could be made available in open-access formats to permit countries to tailor them to their local needs and languages. Country collaborations exist across income levels, often through geographical proximity or historical linguistic/political alliances (for example, Commonwealth Countries or colonial alliances). These linkages could form the basis of cross-country mentoring relationships and mutual support for training.
ATTUD, in partnership with NAADAC and the Council for Tobacco Treatment Programs has announced a new U.S. National Certificate in Tobacco Treatment Practice (NCTTP; see https://www.naadac.org/NCTTP). This certification may provide a model for other countries regarding how best to adapt evidence-based care to local resources and patterns of tobacco use.
Acknowledgements
ATTUD International Relations Committee Members: WaelSafat Al Elmeguid (Egypt), Chair; Mira B. Aghi (India); Yael Bar Ze'ev (Israel); Joan M. Davis (United States); Claire Gignac (Canada); David D. McFadden (United States); Sidney Pratt (Costa Rica).
Financial Support
This work was supported by ‘Science without Borders’ program of the National Council of Science and Technology Development (CAPES/CNPq) (grant number 103897/2012), Brazil.
Conflict of Interest
None.
Ethical Standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. The authors assert also that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional guides on the care and use of laboratory animals.
