Evaluation of smoking cessation training in Armenia

Background Healthcare providers play a central role in promoting smoking cessation. Patients getting advice from physicians are 1.6 times more likely to quit, and trained physicians are twice as likely to offer assistance to patients. This study aimed to design, implement, and evaluate the first smoking cessation training for primary healthcare physicians (PHP) in Armenia. Methods We recruited 58 PHPs for a two-day training (intervention group) and 51 PHPs in the control group from the two biggest cities. We utilized a quasi-experimental design to evaluate the training effectiveness using a self-administered questionnaire at baseline and 4-months follow-up. Practice score was calculated by awarding 1 point when the recommended practice was reported as being “Always” performed in physicians'' everyday work. We performed paired analysis to compare baseline and follow-up data using paired t-test and Wilcoxon test. Results Overall, 105 PHPs (57-intervention, 48-control) participated in both baseline and follow-up surveys. The self-reported mean practice score significantly increased in the intervention group (10.34 vs. 14.96; p< 0.001) but not in the control group (10.03 vs. 10.25; p=0.739). The improvements from baseline to follow-up in the intervention group were observed regarding most of the selected evidence-based recommendations. However, the most vivid improvements were observed pertaining to practices in assisting patients to quit. At follow-up, more intervention group PHPs were always proposing their help to patients in quitting (45.61% vs. 85.96%, p< 0.001) and prescribing pharmacological aids such as Nicotine replacement therapy (5.36% vs. 24.56%, p< 0.001), Cytisine (1.75% vs. 24.56%, p< 0.001) and Varenicline (3.51% vs. 8.77%, p< 0.001). Conclusions Training of healthcare providers can greatly improve compliance with the evidence-based smoking cessation recommendations. Similar tobacco dependence treatment trainings should be applied for all primary healthcare physicians in Armenia as well as adapted and implemented for other healthcare professional groups

Tobacco dependence treatment provision by tuberculosis physicians in Armenia

Introduction The integration of tobacco dependence treatment interventions into routine tuberculosis (TB) services is broadly acknowledged as an important measure to tackle the dual burden of TB and tobacco. The study aimed to explore TB physicians’ practice of tobacco dependence treatment based on the recommended 5 “A’s” model. Methods A cross-sectional study was conducted among TB physicians from inpatient and out-patient TB facilities throughout Armenia. Self-administered questionnaire included questions on demographics, knowledge, attitude, practice and confidence in providing tobacco dependence treatment. The predictors of the high practice score (number of activities always performed during physicians’ daily practice) were assessed using multiple linear regression analysis. Results Overall, 91 TB physicians completed the survey. The mean self-reported practice score was 5.71 (max=15). Majority of TB physicians always asked about smoking status of their patients (72.53%) and always advised smoking patients to quit (93.41%). About half of them always assessed patients’ willingness to quit (54.95%). Conversely, less than half of physicians always assisted their patients in smoking cessation (43.96%) and only few respondents (3.30%) mentioned about always arranging follow-up to review patients’ progress in quitting. Regression analysis revealed that TB physicians’ knowledge on smoking cessation (β=0.22) and monthly number of their patients (β=-0.05) were significantly associated with practice score. Conclusions Recommended interventions were not fully implemented into routine TB services. TB physicians with higher knowledge score on smoking cessation and lower patient load were more likely to have higher practice score. These predictors should be targeted for future interventions improving tobacco dependence treatment practices

Self-efficacy predicts the outcome of smoking cessation attempts

Background Despite well-established advantages of smoking cessation in the prevention and treatment of myocardial infarction (MI) many patients continue smoking after a diagnosis of MI. Recent evidence suggests that higher self-efficacy (SE), or confidence in one's ability to abstain from smoking, is positively associated with successful smoking cessation attempts. This study aimed to investigate the association between SE and smoking cessation outcome at 6 to 12 months after MI in Armenia. Methods Cross-sectional survey was conducted among smoker adult MI patients who were hospitalized at the largest cardiac hospital in Armenia (Nork-Marash Medical Center). Data collection was done at 6 to 12 months after MI through medical chart review and interviewer administered telephone survey. SE at the time of MI was measured through widely used and validated Self-Efficacy Questionnaire (SEQ-12). SEQ-12 consists of two six-item subscales which measure confidence in aptitude to abstain from smoking when facing internal stimuli (e.g. feeling nervous) and external stimuli (e.g. being with a smoker). Logistic regression analysis was performed to reveal the association between SE and quitting outcome. Results About half (54.37%) of 103 surveyed participants quitted smoking after MI. The mean SE score was 33.55 (SD: 16.49) (out of possible 60) which was significantly higher among quitters compared to non-quitters (45.55 vs. 19.26, p< 0.001). Likewise, the difference between was significant in terms of both internal and external subscale scores. Adjusted logistic regression elucidated that each unit increase in SE score was associated with 1.3 times higher odds of quitting (95% CI: 1.17-1.44; p< 0.001). Conclusions The results illustrated that SE is an independent predictor of smoking cessation after MI suggesting that increase in patients' confidence in ability to abstain from smoking will contribute to successful cessation outcomes. This emphasized the importance of behavioral interventions in encouraging and assisting smoking cessation attempts among MI patients

Smoking cessation counseling: a survey among tuberculosis patients in Armenia

Introduction Smoking negatively affects tuberculosis (TB) treatment outcomes and increases the risk of recurrence. TB healthcare providers (HCP) are in regular contact with their patients and have a unique opportunity to deliver smoking cessation interventions at every encounter. This study aimed to explore the provision of smoking cessation services among TB patients in Armenia. Methods Interviewer-administered phone survey was conducted among adult TB patients (excluding prisoners and patients with psychiatric diseases) within 2 months after completion of the treatment. The smoking cessation services were assessed according to "5 A's" strategy. Results Out of 163 TB patients who completed the survey, 58.3% (n=95) were smokers during their last treatment (77.6% of males). Majority of smokers (92.6%) were asked about their smoking status (Ask) and 89.5% received cessation advice from HCP (Advice). Around 33.0% of the smokers were asked about their interest in quitting (Assess). Only 5.3% of patients received a cessation assistance from HCP (Assist) and 6.3% reported about follow up appointments to discuss smoking (Arrange). Around 60.0% of smokers made a quit attempt during the treatment and 25.3% were abstinent during the last two weeks of the treatment (quitters). However, 45.8% of quitters relapsed and were current smokers at the time of the interview. Conclusion The TB patients did not receive recommended smoking cessation counselling according to 5 “A’s” model. There is a need for further integration of smoking cessation assistance into TB care in Armenia to increase the quitting rate, decrease the relapse rate among quitters and consequently improve TB treatment outcomes

Tuberculosis and Tobacco in Armenia: Physicians’ perspective on two global epidemics

Introduction Aim: Tuberculosis and smoking are two colliding epidemics which independently pose a significant threat to global health. There is consistent epidemiological evidence of the association between smoking and TB. This study aims to investigate Armenian TB physicians’ perceptive on the association between smoking and TB treatment. Methods The study team implemented the qualitative study through in-depth interviews (IDIs) and focus group discussions (FGDs) with TB physicians. Study participants were from in-patient and outpatient healthcare settings from Yerevan (the capital city), Syunik and Gegharkunik marzes. Semi-structured guides were used for moderating the IDIs and FGDs. The snowball sampling technique was utilized to identify 21 TB physicians. Results The overwhelming majority of TB physicians knew about the influence of smoking on TB treatment and agreed that TB patients need to quit smoking. Improved TB treatment outcomes, accelerated recovery, and decreased risk of TB relapse were identified as the most common positive effects of smoking cessation among TB patients. Some physicians mentioned other benefits of quitting smoking which were not directly linked to TB treatment, such as improved health outcomes related to non-communicable diseases, improved metabolism, and stronger immune system. However, a few TB physicians were skeptical about smoking adversely affecting the TB treatment process and outcomes. They commented on the shortage of statistical data supporting the direct effect of smoking and the perception that smoking harms the body but does not specifically impede the process of TB treatment demonstrating their doubts regarding the adverse effects of smoking. Conclusions The acknowledgment of negative association of smoking on TB treatment process and outcomes could facilitate provision of smoking cessation interventions by TB physicians and ultimately address the dual burden of TB and tobacco in Armenia. Funding The study was supported by the Global Bridges Healthcare Alliance for Tobacco Dependence Treatment, hosted by Mayo Clinic and Pfizer Independent Grants for Learning and Change

Price and Affordability of Cigarettes among 14 European Countries

Introduction The aim of this study was to explore price and affordability of cigarettes and make comparisons across 15 European partner countries (Albania, Armenia, Belgium, Bulgaria, Georgia, Greece, Italy, Kosovo, Poland, Romania, Russia, Serbia, Slovenia, Spain, Ukraine) of EPACTT-2 (EuroPean Accreditation Curriculum on Tobacco Treatment) project that aims to develop and expand an accredited curriculum for tobacco treatment delivery . Methods The structured 8-item self-administered questionnaire in English was distributed among partner country representatives. The questionnaire covered Marlboro and local cigarettes prices, as well as country profiles. To make comparisons across countries we converted local currencies into international dollars using the country specific purchasing power parity (PPP) conversion factor. Affordability was assessed by the relative income price (RIP) of cigarettes, which is the proportion of per capita GDP required to purchase 100 cigarette packs. Lower RIP corresponds to higher affordability. Results Overall, fourteen countries (4 lower-middle income, 5 upper-middle income, and 5 high-income) participated in the online survey in 2017. The mean price of Marlboro was higher in high income countries compared to upper-middle and lower-middle income countries (6.65$, 6.02$, and 5.15$, respectively). Similar tendency was observed regarding to the mean price of local cigarette (5.83$, 3.96$and 3.75$ in high, upper-middle and lower-middle income countries, respectively). However, in high income countries average RIP was lower than in upper-middle and lower-middle income countries: for Marlboro 1.88%, 3.45% and 5.52%, and for local cigarettes 1.66%, 2.49% and 4.07%, respectively. Conclusions Although, cigarettes were more expensive in high income countries they were about two times more affordable than in upper-middle and about three times more affordable than in lower-middle income countries. Thus, financial burden of smoking on households is more pronounced in the countries with more limited resources. Funding This study was supported by Global Bridges Healthcare Alliance for Tobacco Dependence Treatment hosted by Mayo Clinic and Pfizer Independent Grants for Learning and Change

Tobacco-related risk perceptions, social influences and public smoke-free policies in relation to smoke-free home restrictions: findings from a baseline cross-sectional survey of Armenian and Georgian adults in a community randomised trial

OBJECTIVES: Given high prevalence of smoking and secondhand smoke exposure in Armenia and Georgia and quicker implementation of tobacco legislation in Georgia versus Armenia, we examined correlates of having no/partial versus complete smoke-free home (SFH) restrictions across countries, particularly smoking characteristics, risk perceptions, social influences and public smoking restrictions. DESIGN: Cross-sectional survey study design. SETTING: 28 communities in Armenia and Georgia surveyed in 2018. PARTICIPANTS: 1456 adults ages 18-64 in Armenia (n=705) and Georgia (n=751). MEASUREMENTS: We used binary logistic regression to examine aforementioned correlates of no/partial versus complete SFH among non-smokers and smokers in Armenia and Georgia, respectively. RESULTS: Participants were an average age of 43.35, 60.5% women and 27.3% smokers. In Armenia, among non-smokers, having no/partial SFHs correlated with being men (OR=2.63, p=0.001) and having more friend smokers (OR=1.23, p=0.002); among smokers, having no/partial SFHs correlated with being unmarried (OR=10.00, p=0.001), lower quitting importance (OR=0.82, p=0.010) and less favourable smoking attitudes among friends/family/public (OR=0.48, p=0.034). In Georgia, among non-smokers, having no/partial SFHs correlated with older age (OR=1.04, p=0.002), being men (OR=5.56, p\u3c0.001), lower SHS risk perception (OR=0.43, p\u3c0.001), more friend smokers (OR=1.49, p=0.002) and fewer workplace (indoor) restrictions (OR=0.51, p=0.026); among smokers, having no/partial SFHs correlated with being men (OR=50.00, p\u3c0.001), without children (OR=5.88, p\u3c0.001), daily smoking (OR=4.30, p=0.050), lower quitting confidence (OR=0.81, p=0.004), more friend smokers (OR=1.62, p=0.038) and fewer community restrictions (OR=0.68, p=0.026). CONCLUSIONS: Private settings continue to lack smoking restrictions in Armenia and Georgia. Findings highlight the importance of social influences and comprehensive tobacco legislation, particularly smoke-free policies, in changing household smoking restrictions and behaviours. TRIAL REGISTRATION NUMBER: NCT03447912

Community coalitions for smoke-free environments in Armenia and Georgia: A mixed methods analysis of coalition formation, implementation and perceived effectiveness

Effective models for aligning public health and civil society at the local level have the potential to impact various global health issues, including tobacco. Georgia and Armenia Teams for Healthy Environments and Research (GATHER) is a collaboration between Armenia, Georgia and U.S. researchers involving a community randomized trial testing the impact of community coalitions to promote smoke-free policy adoption and compliance in various settings. Community Coalition Action Theory (CCAT) was used to guide and describe coalition formation, implementation and effectiveness. Mixed methods were used to evaluate 14 municipality-based coalitions in Georgia and Armenia, including semi-structured interviews (n = 42) with coalition leaders and active members, coalition member surveys at two timepoints (n = 85 and n = 83), and review of action plans and progress reports. Results indicated successful creation of 14 multi-sectoral coalitions, most commonly representing education, public health, health care, and municipal administration. Half of the coalitions created at least one smoke-free policy in specific settings (e.g., factories, parks), and all 14 promoted compliance with existing policies through no-smoking signage and stickers. The majority also conducted awareness events in school, health care, and community settings, in addition to educating the public about COVID and the dangers of tobacco use. Consistent with CCAT, coalition processes (e.g., communication) were associated with member engagement and collaborative synergy which, in turn, correlated with perceived community impact, skills gained by coalition members, and interest in sustainability. Findings suggest that community coalitions can be formed in varied sociopolitical contexts and facilitate locally-driven, multi-sectoral collaborations to promote health. Despite major contextual challenges (e.g., national legislation, global pandemic, war), coalitions were resilient, nimble and remained active. Additionally, CCAT propositions appear to be generalizable, suggesting that coalition-building guidance may be relevant for local public health in at least some global contexts