A narrative review of facilitators and barriers to smoking cessation and tobacco-dependence treatment in patients with tuberculosis in low- and middle-income countries

INTRODUCTION: Smoking is a substantial cause of premature death in patients with tuberculosis (TB), particularly in low- and middle-income countries (LMICs) with high TB prevalence. The importance of incorporating smoking cessation and tobacco-dependence treatment (TDT) into TB care is highlighted in the most recent TB care guidelines. Our objective is to identify the likely key facilitators of and barriers to smoking cessation for patients with TB in LMICs. METHODS: A systematic search of studies with English-language abstracts published between January 2000 and May 2019 was undertaken in the EMBASE, MEDLINE, EBSCO, ProQuest, Cochrane and Web of Science databases. Data extraction was followed by study-quality assessment and a descriptive and narrative synthesis of findings. RESULTS: Out of 267 potentially eligible articles, 36 satisfied the inclusion criteria. Methodological quality of non-randomized studies was variable; low risk of bias was assessed in most randomized controlled studies. Identified facilitators included brief, repeated interventions, personalized behavioural counselling, offer of pharmacotherapy, smoke-free homes and a reasonable awareness of smoking-associated risks. Barriers included craving for a cigarette, low level of education, unemployment, easy access to tobacco in the hospital setting, lack of knowledge about quit strategies, and limited space and privacy at the clinics. Findings show that the risk of smoking relapse could be reduced through consistent follow-up upon completion of TB therapy and receiving a disease-specific smoking cessation message. CONCLUSIONS: Raising awareness of smoking-related health risks in patients with TB and implementing guideline-recommended standardized TDT within national TB programmes could increase smoking cessation rates in this high-risk population

Protocol for the mixed-methods process and context evaluation of the TB & Tobacco randomised controlled trial in Bangladesh and Pakistan: a hybrid effectiveness–implementation study

Introduction: Tuberculosis (TB) remains a significant public health problem in South Asia. Tobacco use increases the risks of TB infection and TB progression. The TB& Tobacco placebo-controlled randomised trial aims to (1) assess the effectiveness of the tobacco cessation medication cytisine versus placebo when combined with behavioural support and (2) implement tobacco cessation medication and behavioural support as part of general TB care in Bangladesh and Pakistan. This paper summarises the process and context evaluation protocol embedded in the effectiveness–implementation hybrid design. Methods: and analysis We are conducting a mixed-methods process and context evaluation informed by an intervention logic model that draws on the UK Medical Research Council’s Process Evaluation Guidance. Our approach includes quantitative and qualitative data collection on context, recruitment, reach, dose delivered, dose received and fidelity. Quantitative data include patient characteristics, reach of recruitment among eligible patients, routine trial data on dose delivered and dose received, and a COM-B (‘capability’, ‘opportunity’, ‘motivation’ and ‘behaviour’) questionnaire filled in by participating health workers. Qualitative data include semistructured interviews with TB health workers and patients, and with policy-makers at district and central levels in each country. Interviews will be analysed using the framework approach. The behavioural intervention delivery is audio recorded and assessed using a predefined fidelity coding index based on behavioural change technique taxonomy. Ethics and dissemination: The study complies with the guidelines of the Declaration of Helsinki. Ethics approval for the study and process evaluation was granted by the University of Leeds (qualitative components), University of York (trial data and fidelity assessment), Bangladesh Medical Research Council and Bangladesh Drug Administration (trial data and qualitative components) and Pakistan Medical Research Council (trial data and qualitative components). Results of this research will be disseminated through reports to stakeholders and peer-reviewed publications and conference presentations. Trial registration number: ISRCTN43811467; Pre-results

The effectiveness of nurse-led interventions for cancer symptom management 2000-2018: a systematic review and meta-analysis

Background Evidence for effectiveness of nurse-led interventions for cancer-related symptoms is of variable quality. This study aimed to identify, appraise and evaluate the nature and effectiveness of nurse-led interventions on symptoms for people with cancer. Methods A systematic review and meta-analysis. Ten major databases were searched (2000 to 2018, no language restrictions). Two reviewers applied a priori selection criteria; data extraction included design, population, cancer type, and cancer-related symptoms. Interventions and providers were profiled using TIDieR reporting guidelines, and content analysis of components. Methodological quality was assessed using Cochrane risk of bias. A meta-analysis was performed using mean and standardised mean differences with 95% confidence intervals. Overall certainty was assessed using GRADE. Results From 29193 records, 149 studies (n = 107286 participants) from 22 countries were eligible. Interventions included multiple components; education and psychological approaches dominated. Pooled meta-analyses found evidence of benefit for nurse-led interventions on measures of constipation (MD −4.54, 95% CI −8.08 to −0.99; 645 participants; 6 trials; I2 = 0%; P = 0.01); nausea and vomiting (MD −1.97, 95% CI −3.61 to −0.33; 957 participants; 8 trials; I 2 = 12%; P = 0.02) and fatigue (MD −4.63, 95% CI −7.97 to −1.30; 1208 participants; 11 trials; I2 = 34%; P = 0.007). Psychological morbidity (anxiety, depression, mood) also improved. However, few trials used consistent outcome measures, interventions were poorly defined, and certainty of evidence was low or very low. Conclusion Nurse-led interventions improve specific cancer-related symptoms, including psychological morbidity. Enhanced reporting and collaboration to develop a minimum core dataset would strengthen the quality of evidence

Health worker and patient views on implementation of smoking cessation in routine tuberculosis care

Böckmann M, Warsi S, Noor M, et al. Health worker and patient views on implementation of smoking cessation in routine tuberculosis care. NPJ primary care respiratory medicine. 2019;29(1): 34.Smoking worsens tuberculosis (TB) outcomes. Persons with TB who smoke can benefit from smoking cessation. We report findings of a multi-country qualitative process evaluation assessing barriers and facilitators to implementation of smoking cessation behaviour support in TB clinics in Bangladesh and Pakistan. We conducted semi-structured qualitative interviews at five case study clinics with 35 patients and 8 health workers over a period of 11 months (2017-2018) at different time points during the intervention implementation phase. Interviews were conducted by trained researchers in the native languages, audio-recorded, transcribed into English and analysed using a combined deductive-inductive approach guided by the Consolidated Framework for Implementation Research and Theoretical Domains Framework. All patients report willingness to quit smoking and recent quit attempts. Individuals' main motivations to quit are their health and the need to financially provide for a family. Behavioural regulation such as avoiding exposure to cigarettes and social influences from friends, family and colleagues are main themes of the interviews. Most male patients do not feel shy admitting to smoking, for the sole female patient interviewee stigma was an issue. Health workers report structural characteristics such as high workload and limited time per patient as primary barriers to offering behavioural support. Self-efficacy to discuss tobacco use with women varies by health worker. Systemic barriers to implementation such as staff workload and socio-cultural barriers to cessation like gender relations, stigma or social influences should be dealt with creatively to optimize the behaviour support for sustainability and scale-up

Real life impact of educating nurses in tobacco cessation intervention

Introduction Nurses, when educated in tobacco cessation interventions, are well positioned to address smoking with their patients achieving a long-time quit rate of approximately 10%, according to the literature. Methods Together in partnership with the International Society of Nurses in Cancer Care and University of California in Los Angeles, USA, and the Society for Treatment of Tobacco Dependence, Czech Republic, an international project funded by Bristol-Myers Squibb Foundation “The Eastern Europe Nurses‘ Centre of Excellence in Tobacco Control – Developing Nurse Champions for Tobacco Dependence Treatment” (EE-COE) involves six Eastern European countries (CZ, HU, MD, RO, SI, SK). The EE-COE offers to nurses various educational activities in tobacco control, i.e. train of trainer workshops, short seminars, or online e-learning. Through these methods positively evaluated in previous projects, thousands of nurses have already been educated. Results Results from EE-COE 2016 five country 3-month post-training online surveys, a total of 507 trained nurses estimated that they offered cessation intervention to 850 to 1239 patients a week (minimum / maximum weekly estimates, respectively), a mean of 1,044 patients per week. Assuming a 10% long-term quit rate from nurses’ intervention, we estimated that 104 patients quit tobacco use per week, or 5,408 ex-smokers per year in five countries alone. Simplified calculation of investment into nurses’ education translated to $63 USD spent per ex-smoker. Conclusion Investment into nurses‘ education in tobacco control knowledge and skills is an effective approach with substantial impact on patients quitting smoking, improved patient health, in addition to health care cost savings

Looking back where it all started

Introduction There is a need to increase awareness among nursing professionals about tobacco dependence and treatment, including brief interventions, in Central and Eastern Europe. The Czech Republic, a central European country, has 10 million inhabitants, 2,200,000 smokers (30 % of the population 15 years and older), 40,000 doctors and approximately 90,000 nurses. It is the nurses who are uniquely positioned to deliver evidence-based interventions for tobacco dependence including to patients already diagnosed with cancer. Methods Report about activities of the Czech Society for Treatment of Tobacco Dependence, and what nurses achieved in tobacco control over 10 years from the initiation. Results Since 2007, regular one-day “train the trainer” (TTT) workshops (taught by nurses trained in tobacco intervention) are organized for nurses about basics in tobacco control and smoking cessation methods, mainly the brief intervention and the possible role of nurses in its application in selected groups. In addition since 2012, more such activities are conducted through the collaborative project with the ISNCC as reported in another abstract. During this decade, a total of 735 nurses have participated in the TTT program, while additional 700 nurses have been trained via e-learning program in the Czech Republic. Conclusion Continuing increasing interest in the tobacco control education as well as promoting positive attitudes toward smoking cessation intervention among Czech nurses can impact future trends in nursing practice. Adequate education and training is essential for nurses to be able to successfully include the short intervention into daily practice. It must be supported and widely offered in both academic and clinical settings

Building capacity in tobacco control by establishing the Eastern Europe Nurses' Center of Excellence for Tobacco Control.

IntroductionProperly educated nurses delivering evidence-based tobacco dependence treatment could contribute to improving health and reducing regional disparities in tobacco-related disease and death in Central and Eastern Europe. The aims of this study are to describe development of the Eastern European Nurses' Centre of Excellence for Tobacco Control (COE) and evaluate its online educational program on tobacco dependence treatment using the 5As framework.MethodsThe online education evaluation followed a prospective, single group, pre- and post-assessment of changes in nurses' self-reported tobacco cessation interventions. Leaders from five Eastern European countries (Hungary, Czech Republic, Romania, Slovakia, Slovenia) developed protocols for in-country tobacco control education. Nurses responded to a baseline survey, accessed an online nursing educational program, and completed a follow-up survey at 3 months, in the period December 2015 to June 2016. A total of 695 nurses from five countries answered questions on cessation interventions at baseline and of these 507 (73%) completed a follow-up survey at 3 months.ResultsAt the follow-up at 3 months, the 507 nurses self-reported a significant increase in providing all 5A components, i.e. nurses were significantly (p<0.0001) more likely to always /usually advise a patient to quit, assess interest in quitting (p=0.002), assist with a quit plan, review barriers to quitting and recommend a smoke-free home post-discharge (all p<0.0001). They were also significantly more likely (p=0.01) to agree or strongly agree that nurses have an obligation to advise patients on the risks of smoking. There was a significant increase (p<0.0001) in nurses' estimate of the number of patients they provided a cessation intervention the previous week. Nurses who smoked were 60% more likely to assist and arrange compared to nurses who never smoked.ConclusionsCoordinating multi-country activities through a COE was successful in engaging a network of nurses to use an online educational program and participate in other tobacco control activities

A scoping review of trials of interventions led or delivered by cancer nurses

Background: Advances in research and technology coupled with an increased cancer incidence and prevalence have resulted in significant expansion of cancer nurse role, in order to meet the growing demands and expectations of people affected by cancer (PABC). Cancer nurses are also tasked with delivering an increasing number of complex interventions as a result of ongoing clinical trials in cancer research. However much of this innovation is undocumented, and we have little insight about the nature of novel interventions currently being designed or delivered by cancer nurses. Objectives: To identify and synthesise the available evidence from clinical trials on interventions delivered or facilitated by cancer nurses. Data sources and review methods: A systematic review of randomised controlled trials (RCT), quasi-RCTs and controlled before and after studies (CBA) of cancer nursing interventions aimed at improving the experience and outcomes of PABC. Ten electronic databases (CENTRAL, MEDLINE, AMED, CINAHL, EMBASE, Epistemonikos, CDSR, DARE, HTA, WHO ICTRP) were searched between 01 January 2000 and 31 May 2016. No language restrictions were applied. Bibliographies of selected studies and relevant Cochrane reviews were also hand-searched. Interventions delivered by cancer nurses were classified according to the OMAHA System. Heat maps were used to highlight the volume of evidence available for different cancer groups, intervention types and stage of cancer care continuum. Results: The search identified 22,450 records; we screened 16,169 abstracts and considered 925 full papers, of which 214 studies (247,550 participants) were included in the evidence synthesis. The majority of studies were conducted in Europe (n = 79) and USA (n = 74). Interventions were delivered across the cancer continuum from prevention and risk reduction to survivorship, with the majority of interventions delivered during the treatment phase (n = 137). Most studies (131/214) had a teaching, guidance or counselling component. Cancer nurse interventions were targeted at primarily breast, prostate or multiple cancers. No studies were conducted in brain, sarcoma or other rare cancer types. The majority of the studies (n = 153) were nurse-led and delivered by specialist cancer nurses (n = 74) or advanced cancer nurses (n = 29), although the quality of reporting was poor. Conclusions: To the best of our knowledge, this is the first review to synthesise evidence from intervention studies across the entire cancer spectrum. As such, this work provides new insights into the nature of the contribution that cancer nurses have made to evidence-based innovations, as well as highlighting areas in which cancer nursing trials can be developed in the future