The World Health Organisation Global Status Report on NCDs has estimated that 80% of mortality from NCDs occurs in Low and Middle Income Countries (LMICs).1 Tobacco is a major risk factor for many NCDs including CVD. While prevalence of tobacco use remains higher in higher income countries, its use is rapidly increasing in LMICs.
Accelerating and strengthening tobacco cessation support in LMICs, through effective cessation programmes is the need of the hour. It is critical not only to prevent CVDs and cancers, but also for decreasing premature mortality due to these, and several other chronic health conditions (including COPD, chronic kidney disease, chronic liver disease etc.) for which tobacco is a common risk factor.
Treating nicotine dependence is identified by World Health Organisation (WHO) as a low cost and cost effective, population wide intervention to reduce risk factors. There is an urgent need to provide support at an individual level for quitting tobacco, especially in LMICs. This is reflected in Article 14 of the Global Framework Convention on Tobacco Control (FCTC), Demand reduction measures concerning tobacco dependence and cessation and ‘O’ of the WHO MPOWER initiative, ‘offering help to quit’.2,3
Several reputed global health organizations like World Health Organization (WHO), World Heart Federation (WHF), The Union, and others have been highly active in supporting national governments in LMICs for design and implementation of key FCTC recommendations, including cessation.4, 5, 6 For example, WHF envisages to do this through providing guidance to countries in development and adaptation of WHF tobacco roadmaps.
There are several types of smoking cessation interventions with varying levels of effectiveness.
The following table gives a summary of effectiveness of selected smoking cessation interventions (abstinence for at least six months).7
|Intervention source vs comparator group
||Odds ratio (95% CI)
||Increased chances of quitting successfully
|Physician brief advice vs no advice
|Nursing intervention vs usual care
|Nicotine replacement therapy (NRT) vs placebo or non-NRT
||1.58 (1.50 -1.66)
|Bupropion vs placebo
||1.94 (1.72 – 2.19)
|Varenicline vs placebo
|Clonidine vs placebo
||1.63 (1.22- 2.18)
|Nortriptyline vs placebo
||2.34 (1.61 – 3.41)
One of the most common evidence based physician brief advice techniques accepted worldwide are the 5As model. The 5As model i.e. ‘Ask’, ‘Advise’, ‘Assess’, ‘Assist’ and ‘Arrange’ for tobacco cessation counselling is an evidence-based approach whose feasibility in primary care has already been proved.8 It includes five components: ‘asking’ about tobacco use, ‘advising’ to quit, ‘assessing’ willingness to quit, ‘assisting’ the patient in making a quit attempt, and ‘arranging’ follow-up to prevent relapse [see appendix].9
The Ministry of Health and Family Welfare in India issued tobacco treatment guidelines in 2011 which recommends physicians in primary care and other settings identifying and treating every tobacco user seen in healthcare settings. It specifies that all health care providers must provide 5As counselling as a part of routine health care consultations and dedicated tobacco cessation specialists services should also be set up in health care settings.10
There is currently a gap between the evidence base available and the implementation of the evidence. For example, it was shown that the patients visiting primary health care facilities in India neither receive tobacco cessation counselling, nor referral to tobacco cessation centres.11,12An earlier quantitative cross-sectional study conducted in India showed that patients who reported that they were ‘advised’ to quit, ‘assessed’ for readiness to quit and offered cessation ‘assistance’ were more satisfied with the counselling services than those who were not (OR 9.6, 2.1 and 2.2 respectively).10 Also, patients who were satisfied with the counselling services, were five times more likely to have an intention to quit tobacco and four times as likely to recommend counselling to other fellow tobacco users.13 It has also been reported that concordance rates between physicians and patients for various components of 5A’s varied from 41.4% for ‘Arrange’ and 76.4% for ‘Ask’. This point towards the wide disparities that exist in terms of what happens in usual clinical practice and what is perceived by patients and healthcare professionals as the actions taken towards tobacco cessation.
One study in India found that there were significantly high (more than double that of counselling group) continuous abstinence rates observed in the medication group as compared to the counselling group alone.14
In the case of Kenya, the International Tobacco Control Policy Evaluation (ITC) Project, Kenya Survey found that about three-quarters (76%) of tobacco users are in favour of a ban on tobacco products within 10 years if the government provided assistance such as cessation clinics.15 It was reported from the same survey that tobacco users in Kenya are not well connected to sources of cessation assistance. Only one-fifth (20%) of tobacco users reported that they had consulted a health care professional in the last 6 months. Among smokers who had visited a doctor, only 35% were advised to quit tobacco, which apparently was lower than most of the other ITC LMICs. Of those who were given advice to quit, 82% reported that the advice made them think about quitting tobacco.15.Naturally one of the key recommendations of the ITC Kenya team was to establish cessation services to support tobacco users who wish to quit.
Kenya signed and ratified the FCTC in June 2004, and the treaty became effective as of February 27, 2005. Kenya’s 2007 Tobacco Control Act came into force in July 2008, providing the legal framework for the implementation of FCTC policies in Kenya.16 The National Tobacco Control Action Plan (NTCAP) 2010-2015 has listed a range of effective interventions available to motivate and support those attempting to quit including brief advice delivered by health and social care professionals including doctors, dentists, nurses and pharmacists, as well as by allied health professionals, behavioural and support services, pharmacotherapy, as well as counselling and referral by health professionals.17 Smoking cessation support is available in some hospitals, offices of health professionals, health clinics or primary care facilities, and community centres.18 Nicotine replacement therapy and bupropion are legally sold in Kenya, but not vareniclin.18
In one study from Kenya, it was found that 73% of the respondents (health care professionals) correctly identified the 5A’s model as a recommended behavioural intervention and 66.3% of respondents correctly identified advice from a health care provider as a recommended behavioural intervention for smoking cessation.19 The same study also found that more than half of the respondents did not correctly identify various smoking cessation medications. Nicotine gum was correctly identified by only 41% of the respondents while nicotine patch was correctly identified by a mere 35% of the respondents. Only 18% and 11.5% of the respondents correctly identified nicotine lozenges and bupropion respectively as smoking cessation medications.
Most LMICs lack good quality qualitative data which provide an in-depth understanding of how the health system in LMICs work, particularly with respect to tobacco cessation in terms of care pathways, referral, and coordination of services between health and social care professionals at different levels of care. There is also a dire need of understanding the implementation barriers and facilitators in these countries to providing effective tobacco cessation interventions in healthcare facilities. This issue has to be addressed urgently, given the lack of implementation of cessation support services in LMICs, which is only possible through understanding of the perspectives of various stakeholders like patients, health care professionals, and policy makers. Thus, the present qualitative study has been planned in two LMICs, i.e. India and Kenya with the expectation that the findings would set a platform for advocacy to various stakeholders in these countries and ultimately help drive evidence based policy formulation and implementation of tobacco cessation support services.