Advancing Tobacco Cessation in LMICs: Comparison
Please note this is a comparison between Version 2 by Jason Zhu and Version 1 by Abhishek Shankar.

Tobacco kills more than 8 million people worldwide every year. Over 80% of the world’s 1.3 billion tobacco users live in low- and middle-income countries (LMICs), where the future burden is projected to grow. At the same time, progress in tobacco control has not advanced as far as in many LMICs. In particular, the implementation of tobacco-cessation programs and interventions remains limited. The bulk of the evidence for tobacco-cessation interventions comes from high-income countries and may not reflect the context in LMICs, particularly as resources and training for tobacco cessation are limited.

  • tobacco
  • tobacco cessation
  • smoking
  • LMIC

1. Background

Tobacco use is the leading cause of preventable death globally [1]. Over 80% of the world’s 1.3 billion tobacco users live in low- and middle-income countries (LMICs), and it is projected that, if current trends continue, by the year 2030, 70% of the estimated 10 million smoking-related deaths will occur in LMICs [2]. While in many high-income countries, smoking prevalence has been decreasing in response to decades of tobacco-control efforts, this is not the case in many LMICs [3]. Moreover, as in most high-income countries, there are substantial disparities in tobacco use and its health consequences among LMICs, as tobacco use tends to be greater among men, those with lower education, less household wealth, living in rural areas, and higher age [4,5][4][5].

2. Policy Measures

Evidence-based tobacco-control policies and programs implemented by the government help promote cessation, even when they are not specifically targeted at treating tobacco dependence by creating a conducive environment for cessation. Tobacco-control policies, including raising taxes and smokefree laws, reduce smoking and increase quit attempts at the population level [19][6]. Mass media campaigns have been used since the 1970s to reduce tobacco use at population level, educate about the harms of smoking, change smoking attitudes and beliefs, increase quitting intentions and quit attempts, and reduce adult smoking prevalence. A Cochrane review by Bala et al. found that mass media campaigns, when included in comprehensive tobacco-control programs, can be effective in changing smoking behavior in adults [20][7]. Additionally, evidence from a variety of countries demonstrates that tax policies to increase the price of tobacco products and comprehensive smoke-free policies prohibiting smoking in workplaces, and public places, including bars and restaurants, can encourage more tobacco users to quit [13][8].
A recent literature review by Byron et al. found that where smoke-free policies exist in LMICs, they reduce smoke exposure, increase quit intentions, and potentially decrease youth smoking initiation. However, the actual implementation of smoke-free policies in LMICs has been mixed in various regions of the world [21][9]. Support for tobacco cessation needs to be comprehensive and available at population level.

3. Pharmacological Measures

While a substantial body of evidence exists to support a range of pharmacological interventions for tobacco cessation, most of this evidence comes from HICs and is only partly applicable to many LMICs [21,22,23,24,25][9][10][11][12][13]. As more studies have been conducted in LMICs, more recent reviews have added further support, though the evidence base remains limited. Akanbi et al. conducted a meta-analysis of 24 tobacco-cessation RCTs in LMICs limited to those with at least 6 months of follow-up; 4 trials that compared nicotine replacement therapy to placebo found NRT improved cessation rates (n: NRT 546, control 684, OR = 1.76, 95% CI = 1.30–2.77, p < 0.001) [25][13]. A recent scoping review by Kumar et al. identified 92 tobacco-cessation RCTs conducted across 16 LMICs, with the majority from India and China. However, they described the evidence as weak in quality and severely limited. Most RCTs were limited to evaluating the effects of different forms of counseling rather than targeted behavioral and pharmacological interventions [26][14].
Studies across a number of LMICs have shown benefits from nicotine replacement therapy and other pharmacologic treatments in isolation or in conjunction with behavioral therapy for cessation compared to placebo. A randomized control trial (RCT) conducted in India by Singh et al., using bupropion, had a significant difference in the 7-day point prevalence abstinence rate at the end of week 2 (p = 0.04) [27][15]. Sharma et al. used varenicline for RCT among smokeless tobacco users receiving behavioral counseling in India. Self-reported abstinence was significantly greater for varenicline (43%) versus placebo (31%; adjusted odds ratio = 2.6, 95% CI = 1.2–4.2, p = 0.009) [28][16]. Heydari et al. in Iran compared three interventions among smokers: Brief counseling vs. Nicotine patch vs. Varenicline. They employed brief counseling sessions and nicotine patches 15 mg/daily for 8 weeks, or one 0.5 mg varenicline pill daily dosed up over 8 weeks. Follow-up at a year showed 6.6% of the first group, 25% of the second group, and 32.6% of the third group remained smoke-free [29][17]. Koegelenberg et al. in South Africa, in their RCT of 435 patients, concluded Varenicline in combination with NRT was more effective than varenicline alone at achieving tobacco abstinence at 12 weeks (end of treatment) and at 6 months [30][18].
However, despite significant efforts, several factors have limited the reach of tobacco-cessation treatment in LMICs. Potential barriers include a perceived lack of interest from patients, continued tobacco use among medical practitioners, lack of familiarity or training related to pharmacological and behavioral treatments, and lack of government support [31][19]. Additionally, the cost may be seen as a barrier to government support for cessation clinics and the provision of medication, particularly when faced with competing health priorities. However, tobacco-cessation support remains highly cost-effective, even in low-resource settings.

4. Non-Pharmacological Measures

In addition to pharmacological treatments, behavioral therapies and other non-pharmacological interventions can also be effective in helping smokers to quit. There is substantial evidence for individual, group, and telephone counseling, telephone quitlines, and mass media campaign strategies [32][20]. Evidence for the effectiveness of these interventions from LMICs remains relatively limited. As more studies have been conducted in LMICs, more recent reviews have added further support, though the evidence base remains limited. A 2012 systematic review of 45 pharmacologic and behavioral trials conducted in LMICs found limited evidence that nicotine replacement therapy (NRT) and bupropion may help smokers to stop smoking and probably reduce smoking rates [24][12].
Several studies conducted in LMICs provide noteworthy findings. The ESCAPE study conducted in Thailand employed a multi-component intervention consisting of regular patient motivation by the same nurse over a 3-month period, a monthly Smokerlyzer test for 3 months, continual assistance from a trained family member, use of a smoking-cessation diary, and access to optional nicotine replacement chewing gum. At the end of one year, the intervention arm participants achieved a significantly higher smoking cessation rate than the control arm (25.62% vs. 11.32%), which received only brief counseling and casual follow-up, suggesting that intensive tobacco-cessation interventions can be effective within primary health care settings in an LMIC [33][21]. Otero et al. in Brazil compared cognitive behavioral therapy (CBT) sessions with and without nicotine replacement therapy for smoking cessation. They found that the use of NRT along with CBT increased abstinence, but also that a greater number of CBT sessions increased abstinence, independent of NRT, suggesting a dose–response relationship [34][22]. An RCT by Sorensen et al. in India used a cluster-randomized design to test the intervention, which comprised educational efforts, tobacco-control policies, and cessation support targeting the t school teachers reported a 30-day abstinence rate of 50% and a 6-month abstinence rate of 20% among the teachers, who may go on to serve as role models for tobacco control in their communities [35][23].
In an RCT in Vietnam, Shelley and colleagues established the effectiveness of a multi-component strategy model (4As—Ask about tobacco use, Advise to quit, Assess readiness, and Assist with brief counseling plus more intensive counseling by health workers) in enhancing tobacco dependence treatment rates. However, access to cessation treatment was limited to major health centers. After studying barriers and facilitators to delivering cessation treatment, they tested a strategy to train community health workers to provide counseling and conduct follow up with patients in their local communities [36][24]. Strategies involving “task shifting” provide an important avenue to scaling up cessation services.
Integrating tobacco cessation into existing health systems represents another important strategy for increasing access and reach of cessation services. Brief advice is provided to TB patients using tobacco under integrated TB-tobacco programs. A study in India showed that more than 67% of TB patients who used tobacco were able to quit tobacco use at the completion of TB treatment when provided brief advice by trained DOTS providers [37][25].
Digital technologies (such as mobile phone-based tools) also offer novel opportunities for increasing the reach of cessation services, especially for challenging or low-resource settings in LMICs.In recent years, cell phone penetration has increased to over 90% in LMICs, a figure that is higher than the global average [38][26]. There is now moderate evidence that automated-text-message-based smoking cessation interventions result in higher quit rates than minimal smoking-cessation support [39][27]. An RCT by Ybarra et al. in turkey employed a text-messaging-based smoking cessation program for adult smokers and found that employing mobile technologies may be able to affect quitting rates in environments with high smoking prevalence [40][28]. Another RCT by Liao et al. compared 12 weeks of the “Happy Quit” text messaging intervention, using either high-frequency messaging (HFM) or low-frequency messaging (LFM) intervention in a control group in China; they found that both the high- and low-frequency message conditions increased cessation [41][29]. The mCessation program implemented by the Government of India to help tobacco users quit by using mobile-phone-based messages motivated a large number of subscribers to attempt to quit tobacco use and for many to achieve 30-day quit status [42][30]. National toll-free quitlines have been established by many countries to support tobacco cessation. In resource-limited settings, quitlines can play a greater role in helping people quit smoking as part of a comprehensive approach [43][31].
While anti-tobacco mass media campaigns have been employed in LMICs as well, there are limited data on their impact on cessation. In India, a national television and radio campaign targeting smokeless tobacco users was associated with increased awareness and cessation-oriented intentions and behaviors [44][32]. However, there is still a need for more studies to be conducted in LMICs.


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