Scaling Up Tobacco Cessation within TB Programmes: Findings from a Multi-Country, Mixed-Methods, Implementation Study.

Abstract Background: Brief behavioural support can effectively help TB patients to quit smoking and improve their outcomes. In collaboration with TB programmes in Bangladesh, Nepal and Pakistan, we evaluated implementation and scale-up of cessation support using four strategies: i) brief tobacco cessation intervention ii) integration of tobacco cessation within routine training iii) inclusion of tobacco indicators in routine records and iv) embedding research within TB programmes.Methods: We used mixed methods of observation, interviews and routine data within WHO’s ExpandNet framework for scale-up. We aimed to understand the extent of, and strategies which facilitated vertical scale-up (institutionalisation) within 59 health facility learning sites in Pakistan, 18 in Nepal and 15 in Bangladesh and horizontal scale-up (increased coverage beyond learning sites). We observed training and surveyed 169 TB health workers to measure changes in their confidence to deliver cessation. Routine TB data from the learning sites was analysed to assess delivery of the intervention and use of TB forms revised to report smoking status and cessation support provided. A purposive sample of TB health workers, managers and policymakers were interviewed (Bangladesh: n=12; Nepal n=13; Pakistan n=19;). Costs of scale-up were estimated using activity-based cost-analysis. Results: Routine data indicated health workers in learning sites asked all TB patients about tobacco use and offered them cessation support. Qualitative data showed use of intervention materials, often with adaptation and partial implementation in busy clinics. Short (1-2 hours) training integrated within existing programmes increased mean confidence to deliver cessation by 17% (95% CI: 14% to 20%). A focus on health system changes (reporting, training, supervision) facilitated vertical scale-up. Dissemination of materials beyond learning sites and changes to national reporting forms and training indicated horizontal scale-up. Embedding research within TB health systems was crucial for horizontal scale-up and required dynamic use of tactics e.g. alliance-building, engagement in wider policy process, use of insider-researchers, and deep understanding of health system actors and processes. Conclusions: System-level changes within TB programmes may enable routine delivery of cessation support to TB patients. These strategies are inexpensive and, with concerted efforts from TB programmes and donors, tobacco cessation can be institutionalised at-scale.