Challenges to implementing the WHO Framework Convention on Tobacco Control guidelines on tobacco cessation treatment: a qualitative analysis.

AIM: To identify barriers to implementing the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) Article 14 guidelines on tobacco dependence treatment (TDT). DESIGN: Cross-sectional survey conducted from December 2014 to July 2015 to assess implementation of Article 14 recommendations. SETTING AND PARTICIPANTS: Survey respondents (n = 127 countries) who completed an open-ended question on the 26-item survey. MEASUREMENTS: The open-ended question asked the following: 'In your opinion, what are the main barriers or challenges to developing further tobacco dependence treatment in your country?'. We conducted thematic analysis of the responses. FINDINGS: The most frequently reported barriers included a lack of health-care system infrastructure (n = 86) (e.g. treatment not integrated into primary care, lack of health-care worker training), low political priority (n = 66) and lack of funding (n = 51). The absence of strategic plans and national guidelines for Article 14 implementation emerged as subthemes of political priority. Also described as barriers were negative provider attitudes towards offering offer TDT (n = 11), policymakers' lack of awareness about the effectiveness and affordability of TDT (n = 5), public norms supporting tobacco use (n = 11), a lack of health-care leadership and expertise in the area of TDT (n = 6) and a lack of grassroots and multi-sector networks supporting policy implementation (n = 8). The analysis captured patterns of co-occurring themes that linked, for example, low levels of political support with a lack of funding necessary to develop health-care infrastructure and capacity to implement Article 14. CONCLUSION: Important barriers to implementing the Framework Convention on Tobacco Control Article 14 guidelines include lack of a health-care system infrastructure, low political priority and lack of funding.

Prevalence of tobacco use in healthcare workers: A systematic review and meta-analysis.

OBJECTIVES: To estimate tobacco use prevalence in healthcare workers (HCW) by country income level, occupation and sex, and compare the estimates with the prevalence in the general population. METHODS: We systematically searched five databases; Medline, EMBASE, CINHAL Plus, CAB Abstracts, and LILACS for original studies published between 2000 and March 2016 without language restriction. All primary studies that reported tobacco use in any category of HCW were included. Study extraction and quality assessment were conducted independently by three reviewers, using a standardised data extraction and quality appraisal form. We performed random effect meta-analyses to obtain prevalence estimates by World Bank (WB) country income level, sex, and occupation. Data on prevalence of tobacco use in the general population were obtained from the World Health Organisation (WHO) Global Health Observatory website. The review protocol registration number on PROSPERO is CRD42016041231. RESULTS: 229 studies met our inclusion criteria, representing 457,415 HCW and 63 countries: 29 high-income countries (HIC), 21 upper-middle-income countries (UMIC), and 13 lower-middle-and-low-income countries (LMLIC). The overall pooled prevalence of tobacco use in HCW was 21%, 31% in males and 17% in females. Highest estimates were in male doctors in UMIC and LMLIC, 35% and 45%, and female nurses in HIC and UMIC, 21% and 25%. Heterogeneity was high (I2 > 90%). Country level comparison suggest that in HIC male HCW tend to have lower prevalence compared with males in the general population while in females the estimates were similar. Male and female HCW in UMIC and LMLIC tend to have similar or higher prevalence rates relative to their counterparts in the general population. CONCLUSIONS: HCW continue to use tobacco at high rates. Tackling HCW tobacco use requires urgent action as they are at the front line for tackling tobacco use in their patients.

A survey of tobacco dependence treatment guidelines content in 61 countries.

AIMS: To assess tobacco dependence treatment guidelines content in accordance with Article 14 of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) and its guidelines, and association between content and country income level. DESIGN: Cross-sectional study. SETTING: On-line survey from March to July 2016. PARTICIPANTS: Contacts in 77 countries, including 68 FCTC Parties, six Signatories and three non-Parties which had indicated having guidelines in previous surveys, or had not been surveyed before. MEASUREMENTS: A nine-item questionnaire on guidelines content, key recommendations, writing and dissemination. FINDINGS: We received responses from contacts in 63 countries (82%); 61 had guidelines. The majority are for doctors (93%), primary care (92%) and nurses (75%). All recommend brief advice, 82% recording tobacco use in medical notes, 98% nicotine replacement therapy (NRT), 61% quitlines, 31% text messaging and 87% intensive specialist support, and 54% stress the importance of health-care workers not using tobacco. Only 57% have a dissemination strategy, and 62% have not been updated for 5 or more years. Compared with high-income countries, quitlines are less likely to be recommended in upper middle-income countries guidelines [odds ratio (OR) = 0.15, 95% confidence interval (CI) = 0.04-0.61] and intensive specialist support in lower middle-income countries guidelines (OR = 0.01, 95% CI = 0.00-0.20). Guidelines updating is associated positively with country income level (P = 0.027). CONCLUSIONS: Although most tobacco dependence treatment guidelines in the 61 countries assessed in 2016 follow the World Health Organization's Framework Convention on Tobacco Control Article 14 recommendations and do not differ significantly by income level, improvements are needed in keeping guidelines up-to-date, applying good writing practices and developing a dissemination strategy.

Progress in implementation of WHO FCTC Article 14 and its guidelines: a survey of tobacco dependence treatment provision in 142 countries.

AIMS: To (1) estimate the number of Parties to the Framework Convention on Tobacco Control (FCTC) providing tobacco dependence treatment in accordance with the recommendations of Article 14 and its guidelines; (2) assess association between provision and countries' income level; and (3) assess progress over time. DESIGN: Cross-sectional study. SETTING: Online survey from December 2014 to July 2015. PARTICIPANTS: Contacts in 172 countries were surveyed, representing 169 of the 180 FCTC Parties at the time of the survey. MEASUREMENTS: A 26-item questionnaire based on the Article 14 recommendations including tobacco treatment infrastructure and cessation support systems. Progress over time was assessed for those countries that also participated in our 2012 survey and did not change country income level classification. FINDINGS: We received responses from contacts in 142 countries, an 83% response rate. Overall, 54% of respondents reported that their country had an officially identified person responsible for tobacco dependence treatment, 32% an official national treatment strategy, 40% official national treatment guidelines, 25% a clearly identified budget for treatment, 17% text messaging, 23% free national quitlines and 26% specialized treatment services. Most measures were associated positively and significantly with countries' income level (P < 0.001). Measures not associated significantly with income level included mandatory recording of tobacco use (30% of countries), offering help to health-care workers (HCW) to stop using tobacco (44%), brief advice integrated into existing services (44%), and training HCW to give brief advice (81%). Reporting having an officially identified person responsible for tobacco cessation was the only measure with a statistically significant improvement over time (P = 0.0351). CONCLUSION: Fewer than half of countries that are Parties to the Framework Convention on Tobacco Control have implemented the recommendations of Article 14 and its guidelines, and for most measures, provision was greater the higher the country's income. There was little improvement in treatment provision between 2012 and 2015 in all countries.