Interventions for tobacco use cessation in people living with HIV.

BACKGROUND: The prevalence of tobacco use among people living with HIV (PLWH) is up to four times higher than in the general population. Unfortunately, tobacco use increases the risk of progression to AIDS and death. Individual- and group-level interventions, and system-change interventions that are effective in helping PLWH stop using tobacco can markedly improve the health and quality of life of this population. However, clear evidence to guide policy and practice is lacking, which hinders the integration of tobacco use cessation interventions into routine HIV care. This is an update of a review that was published in 2016. We include 11 new studies. OBJECTIVES: To assess the benefits, harms and tolerability of interventions for tobacco use cessation among people living with HIV. To compare the benefits, harms and tolerability of interventions for tobacco use cessation that are tailored to the needs of people living with HIV with that of non-tailored cessation interventions. SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group's Specialised Register, CENTRAL, MEDLINE, Embase, and PsycINFO in December 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of individual-/group-level behavioural or pharmacological interventions, or both, for tobacco use cessation, delivered directly to PLWH aged 18 years and over, who use tobacco. We also included RCTs, quasi-RCTs, other non-randomised controlled studies (e.g. controlled before and after studies), and interrupted time series studies of system-change interventions for tobacco use cessation among PLWH. For system-change interventions, participants could be PLWH receiving care, or staff working in healthcare settings and providing care to PLWH; but studies where intervention delivery was by research personnel were excluded. For both individual-/group-level interventions, and system-change interventions, any comparator was eligible. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods, and used GRADE to assess certainty of the evidence. The primary measure of benefit was tobacco use cessation at a minimum of six months. Primary measures for harm were adverse events (AEs) and serious adverse events (SAEs). We also measured quit attempts or quit episodes, the receipt of a tobacco use cessation intervention, quality of life, HIV viral load, CD4 count, and the incidence of opportunistic infections. MAIN RESULTS: We identified 17 studies (16 RCTs and one non-randomised study) with a total of 9959 participants; 11 studies are new to this update. Nine studies contributed to meta-analyses (2741 participants). Fifteen studies evaluated individual-/group-level interventions, and two evaluated system-change interventions. Twelve studies were from the USA, two from Switzerland, and there were single studies for France, Russia and South Africa. All studies focused on cigarette smoking cessation. All studies received funding from independent national- or institutional-level funding. Three studies received study medication free of charge from a pharmaceutical company. Of the 16 RCTs, three were at low risk of bias overall, five were at high risk, and eight were at unclear risk. Behavioural support or system-change interventions versus no or less intensive behavioural support Low-certainty evidence (7 studies, 2314 participants) did not demonstrate a clear benefit for tobacco use cessation rates in PLWH randomised to receive behavioural support compared with brief advice or no intervention: risk ratio (RR) 1.11, 95% confidence interval (CI) 0.87 to 1.42, with no evidence of heterogeneity. Abstinence at six months or more was 10% (n = 108/1121) in the control group and 11% (n = 127/1193) in the intervention group. There was no evidence of an effect on tobacco use cessation on system-change interventions: calling the quitline and transferring the call to the patient whilst they are still in hospital ('warm handoff') versus fax referral (RR 3.18, 95% CI 0.76 to 13.99; 1 study, 25 participants; very low-certainty evidence). None of the studies in this comparison assessed SAE. Pharmacological interventions versus placebo, no intervention, or another pharmacotherapy Moderate-certainty evidence (2 studies, 427 participants) suggested that varenicline may help more PLWH to quit smoking than placebo (RR 1.95, 95% CI 1.05 to 3.62) with no evidence of heterogeneity. Abstinence at six months or more was 7% (n = 14/215) in the placebo control group and 13% (n = 27/212) in the varenicline group. There was no evidence of intervention effects from individual studies on behavioural support plus nicotine replacement therapy (NRT) versus brief advice (RR 8.00, 95% CI 0.51 to 126.67; 15 participants; very low-certainty evidence), behavioural support plus NRT versus behavioural support alone (RR 1.47, 95% CI 0.92 to 2.36; 560 participants; low-certainty evidence), varenicline versus NRT (RR 0.93, 95% CI 0.48 to 1.83; 200 participants; very low-certainty evidence), and cytisine versus NRT (RR 1.18, 95% CI 0.66 to 2.11; 200 participants; very low-certainty evidence). Low-certainty evidence (2 studies, 427 participants) did not detect a difference between varenicline and placebo in the proportion of participants experiencing SAEs (8% (n = 17/212) versus 7% (n = 15/215), respectively; RR 1.14, 95% CI 0.58 to 2.22) with no evidence of heterogeneity. Low-certainty evidence from one study indicated similar SAE rates between behavioural support plus NRT and behavioural support only (1.8% (n = 5/279) versus 1.4% (n = 4/281), respectively; RR 1.26, 95% CI 0.34 to 4.64). No studies assessed SAEs for the following: behavioural support plus NRT versus brief advice; varenicline versus NRT and cytisine versus NRT. AUTHORS' CONCLUSIONS: There is no clear evidence to support or refute the use of behavioural support over brief advice, one type of behavioural support over another, behavioural support plus NRT over behavioural support alone or brief advice, varenicline over NRT, or cytisine over NRT for tobacco use cessation for six months or more among PLWH. Nor is there clear evidence to support or refute the use of system-change interventions such as warm handoff over fax referral, to increase tobacco use cessation or receipt of cessation interventions among PLWH who use tobacco. However, the results must be considered in the context of the small number of studies included. Varenicline likely helps PLWH to quit smoking for six months or more compared to control. We did not find evidence of difference in SAE rates between varenicline and placebo, although the certainty of the evidence is low.

Second-Hand Tobacco Smoke Exposure: Results of Particulate Matter (PM2.5) Measurements at Hospitality Venues in Addis Ababa, Ethiopia.

INTRODUCTION: In Ethiopia, a comprehensive smoke-free law that bans smoking in all public areas has been implemented since 2019. This study aimed to evaluate compliance with these laws by measuring the air quality and conducting covert observations at 154 hospitality venues (HVs) in Addis Ababa. METHODS: Indoor air quality was measured using Dylos air quality monitors during the peak hours of the venues, with concentrations of particulate matter <2.5 microns in diameter (PM2.5) used as a marker of second-hand tobacco smoke. A standardized checklist was used to assess compliance with smoke-free laws during the same peak hours. The average PM2.5 concentrations were classified as good, moderate, unhealthy for sensitive groups, unhealthy for all, or hazardous using the World Health Organization's (WHO) standard air quality index breakpoints. RESULTS: Only 23.6% of the venues complied with all smoke-free laws indicators. Additionally, cigarette and shisha smoking were observed at the HVs. Overall, 63.9% (95% confidence interval: 56-72%) of the HVs had PM2.5 concentrations greater than 15 µg/m3. The presence of more than one cigarette smoker in the venue, observing shisha equipment in the indoor space, and the sale of tobacco products in the indoor space were significantly associated with higher median PM2.5 concentration levels (p < 0.005). Hazardous level of PM2.5 concentrations-100 times greater than the WHO standard-were recorded at HVs where several people were smoking shisha and cigarettes. CONCLUSIONS: Most HVs had PM2.5 concentrations that exceeded the WHO average air quality standard. Stricter enforcement of smoke-free laws is necessary, particularly for bars and nightclubs/lounges.

Compliance with tobacco advertising and promotion laws at points-of-sale in Ethiopia: an observational study in 10 cities.

BACKGROUND: Ethiopia enacted a comprehensive tobacco control law in 2019, which bans tobacco advertising and promotion activities. However, compliance with these laws at points-of-sale (PoS) has not been studied, resulting in a lack of research evidence on how the regulations are implemented. The purpose of the study was to assess compliance with tobacco advertising and promotion laws at PoS in 10 cities in Ethiopia. METHODS: Multi-stage cluster sampling was used to select 1468 PoS (supermarkets, minimarkets, merchandise stores, regular shops, permanent kiosks, khat shops, street vendors, and food and drink wholesalers). Data were collected using standardized observational checklists. Tobacco advertising and promotion indicators were used to compute indoor and outdoor compliance. Poisson regression models with log link function and robust variance were used to assess factors associated with open display of cigarette packages and indoor non-compliance. RESULTS: The average indoor compliance rate was 92.9% (95% CI:92.3-93.5). Supermarkets had the highest compliance (99.7%), while permanent kiosks showed the lowest compliance (89.8%). The highest average indoor compliance was observed at PoS in Addis Ababa (98.0%). About 60% of PoS were fully compliant in indoors. Indoor open display of cigarette packages was prevalent (32.5%, 95% CI:30.0-35.1). The average outdoor compliance was 99.6% (95% CI:99.5-99.7). Outdoor full compliance was 96.5%. Open display of cigarettes was significantly higher in permanent kiosks (adjusted prevalence ratio (adjPR) 6.73; 95% CI: 3.96-11.42), regular shops (adjPR 5.16; 95% CI: 3.05-8.75), and khat shops (adjPR 2.06; 95% CI: 1.11-3.83), while indoor non-compliance was significantly higher in these same types of PoS. CONCLUSIONS: While outdoor compliance rates were relatively high, the lower indoor compliance rates particularly due to the high prevalence of open cigarette package displays indicates a major area for improvement in enforcing anti-tobacco advertising and promotion laws.

Reasons for shisha smoking: Findings from a mixed methods study among adult shisha smokers in Nigeria.

Shisha smoking has increased significantly worldwide over the past decade including in developing countries such as Nigeria. We aimed to understand the reasons for shisha smoking in Nigeria in order to address the lack of context-specific evidence to inform the national response to the growing threat posed by shisha smoking. We adopted the Theory of Planned Behaviour to conduct in-depth interviews among 78 purposely sampled current shisha smokers in 13 states (six in each state), and a quantitative survey including a random sample of 611 current shisha smokers in 12 states, across the six geopolitical zones in Nigeria. The in-depth interview data was analysed using thematic analysis whilst the quantitative survey data was analysed descriptively. We triangulated the key findings from the two datasets using a triangulation matrix organised by the three meta-themes: attitude, subjective norms, perceived behavioural control. Positive attitudes towards shisha smoking stem from shisha flavours, perceived pleasure from shisha smoking, curiosity about product attributes, beliefs about health benefits, limited knowledge on the health effects, and weak regulation. Having friends and family members who smoke shisha and the need to belong, particularly during social events, also promote shisha smoking. Negative societal views towards shisha smoking are potentially a protective factor. The availability of and ability to smoke shisha in many places makes shisha more accessible, whilst the high costs of shisha are potentially prohibitive. The findings also indicate that quitting shisha smoking without support is difficult. Restrictions on flavours, strengthening compliance monitoring and enforcement of the tobacco control laws in relation to shisha (e.g., smoke-free environments in indoor and outdoor public places; health warnings in English on shisha products including the pots; and tax and price measures) have the potential to minimise initiation and use, and to protect the health and wellbeing of Nigeria's general public.

Costs and cost-effectiveness of treatment setting for children with wasting, oedema and growth failure/faltering: A systematic review.

This systematic review aimed to address the existing evidence gaps, and guide policy decisions on the settings within which to treat infants <12 months of age with growth faltering/failure, and infants and children aged <60 months with moderate wasting or severe wasting and/or bilateral pitting oedema. Twelve electronic databases were searched for studies published before 10 December 2021. The searches yielded 16,709 records from which 31 studies were eligible and included in the review. Three studies were judged as low quality, whilst 14 were moderate and the remaining 14 were high quality. We identified very few cost and cost-effectiveness analyses for most of the models of care with the certainty of evidence being judged at very low or low. However, there were 17 cost and 6 cost-effectiveness analyses for the initiation of treatment in outpatient settings for severe wasting and/or bilateral pitting oedema in infants and children <60 months of age. From this evidence, the costs appear lowest for initiating treatment in community settings, followed by initiating treatment in community and transferring to outpatient settings, initiating treatment in outpatients then transferring to community settings, initiating treatment in outpatient settings, and lastly initiating treatment in inpatient settings. In addition, the evidence suggested that initiation of treatment in outpatient settings is highly cost-effective when compared to doing nothing or no programme implementation scenarios, using country-specific WHO GDP per capita thresholds. The incremental cost-effectiveness ratios ranged from $20 to $145 per DALY averted from a provider perspective, and $68 to $161 per DALY averted from a societal perspective. However, the certainty of the evidence was judged as moderate because of comparisons to do nothing/ no programme scenarios which potentially limits the applicability of the evidence in real-world settings. There is therefore a need for evidence that compare the different available alternatives.

IMPACT smoking cessation support for people with severe mental illness in South Asia (IMPACT 4S): A protocol for a randomised controlled feasibility trial of a combined behavioural and pharmacological support intervention.

INTRODUCTION: The prevalence of smoking is high among people living with severe mental illness (SMI). Evidence on feasibility, acceptability and effectiveness of smoking cessation interventions among smokers with SMI is lacking, particularly in low- and middle-income countries. We aim to test the feasibility and acceptability of delivering an evidence-based intervention,i.e., the IMPACT smoking cessation support for people with severe mental illness in South Asia (IMPACT 4S) intervention that is a combination of behavioural support and smoking cessation pharmacotherapies among adult smokers with SMI in India and Pakistan. We will also test the feasibility and acceptability of evaluating the intervention in a randomised controlled trial. METHODS: We will conduct a parallel, open label, randomised controlled feasibility trial among 172 (86 in each country) adult smokers with SMI in India and Pakistan. Participants will be allocated 1:1 to either Brief Advice (BA) or the IMPACT 4S intervention. BA comprises a single five-minute BA session on stopping smoking. The IMPACT 4S intervention comprises behavioural support delivered in upto 15 one-to-one, face-to-face or audio/video, counselling sessions, with each session lasting between 15 and 40 minutes; nicotine gum and/or bupropion; and breath carbon monoxide monitoring and feedback. Outcomes are recruitment rates, reasons for ineligibility/non-participation/non-consent of participants, length of time required to achieve required sample size, retention in study and treatments, intervention fidelity during delivery, smoking cessation pharmacotherapy adherence and data completeness. We will also conduct a process evaluation. RESULTS: Study will address- uncertainty about feasibility and acceptability of delivering smoking cessation interventions, and ability to conduct smoking cessation trials, among adult smokers with SMI in low- and middle-income countries. CONCLUSIONS: This is to inform further intervention adaptation, and the design and conduct of future randomised controlled trials on this topic. Results will be disseminated through peer-review articles, presentations at national, international conferences and policy-engagement forums. TRIAL REGISTRATION: ISRCTN34399445 (Updated 22/03/2021), ISRCTN Registry https://www.isrctn.com/.

Socio-Economic Status Differences in Changing Affordability of Tobacco Products from 2011-2012 to 2018-2019 in India.

INTRODUCTION: We studied the change in affordability of tobacco products, an important determinant of tobacco use, across the different socio-economic status (SES) in India. AIMS AND METHODS: We calculated affordability in the form of relative income price (RIP-cost of tobacco products relative to income) for the years 2011-2012 and 2018-2019 using three different denominators, that is per capita gross domestic product (GDP) and net state domestic product at national and state levels, respectively; monthly per capita consumer expenditure (MPCE); and individual wages. We investigated RIP for cigarettes, bidis, and smokeless tobacco (SLT) across different SES groups (caste groups, type of employment, and education). RESULTS: RIP increased marginally for cigarettes, bidis and remained almost constant for SLT across casual workers. However, when RIP was adjusted with SES variables, there was no significant change (p > .05) in the affordability of products for casual workers in the year 2018-2019 as compared to 2011-2012. For regular workers, cigarettes and bidis became marginally less affordable (ß < 1), whereas affordability remained constant for SLT. All products became more affordable for backward caste groups within regular workers. When RIP was calculated using MPCE all tobacco products became less affordable in the year 2018-2019. However, after adjusting for SES variables SLT reported no change in affordability. There was a marginal increase in affordability for all products when RIP was calculated with GDP. CONCLUSIONS: Although implementation of GST has increased the price of tobacco products, it is still not sufficient to reduce the affordability of tobacco products, particularly SLT and especially for the lower SES group. IMPLICATIONS: Tobacco use and economic disadvantage conditions of the population are intricately linked. Affordability of tobacco products is influenced by socio-economic indicators like age, sex, income, education, etc. The literature measuring the affordability of tobacco products across different SES groups is scant in India. Additionally, existing literature measures affordability of tobacco products based on per capita GDP as a proxy for income. This is the first study in Indian context to report the change in affordability of tobacco products across different SES groups after adjusting for SES indicators, using individual-level income data. We have calculated the change in affordability of tobacco products between the year 2011-2012 and 2018-2019 using GDP, household income, and individual wages as a proxy for income.

"Everything the hujur tells is very educative but if I cannot apply those in my own life then there is no meaning": a mixed-methods process evaluation of a smoke-free homes intervention in Bangladesh.

BACKGROUND: Second-hand smoke exposure from tobacco significantly contributes to morbidity and mortality worldwide. A cluster RCT in Bangladesh compared a community-based smoke-free home (SFH) intervention delivered in mosques, with or without indoor air quality (IAQ) feedback to households to no intervention. Neither was effective nor cost-effective compared to no intervention using an objective measure of second-hand smoke. This paper presents the process evaluation embedded within the trial and seeks to understand this. METHODS: A mixed method process evaluation comprising interviews with 30 household leads and six imams (prayer leader in mosque), brief questionnaire completed by 900 household leads (75% response), fidelity assessment of intervention delivery in six (20%) mosques and research team records. Data were triangulated using meta-themes informed by three process evaluation functions: implementation, mechanisms of impact and context. RESULTS: IMPLEMENTATION: Frequency of SFH intervention delivery was judged moderate to good. However there were mixed levels of intervention fidelity and poor reach. Linked Ayahs (verses of the Qur'an) with health messages targeting SHS attitudes were most often fully implemented and had greatest reach (along with those targeting social norms). Frequency and reach of the IAQ feedback were good. MECHANISMS OF IMPACT: Both interventions had good acceptability. However, views on usefulness of the interventions in creating a SFH were mixed. Individual drivers to behaviour change were new SFH knowledge with corresponding positive attitudes, social norms and intentions. Individual barriers were a lack of self-efficacy and plans. CONTEXT: Social context drivers to SFH intervention implementation in mosques were in place and important. No context barriers to implementation were reported. Social context drivers to SHS behaviour change were children's requests. Barriers were women's reluctance to ask men to smoke outside alongside general reluctance to request this of visitors. (Not) having somewhere to smoke outside was a physical context (barrier) and driver. CONCLUSIONS: Despite detailed development and adaption work with relevant stakeholders, the SFH intervention and IAQ feedback became educational interventions that were motivational but insufficient to overcome significant context barriers to reduce objectively measured SHS exposure in the home. Future interventions could usefully incorporate practical support for SFH behaviour change. Moreover, embedding these into community wide strategies that include practical cessation support and enforcement of SFH legislation is needed. TRIAL REGISTRATION: Current Controlled Trials ISRCTN49975452.

Second-Hand Tobacco Smoke Exposure and Smoke-Free Environments in Ethiopia: A Scoping Review and Narrative Synthesis.

Ethiopia passed a law prohibiting tobacco smoking in all public places in 2019. We conducted a scoping review to identify gaps in the existing literature on second-hand smoke (SHS) exposure and smoke-free environments in Ethiopia that need to be prioritised for future research to support policy and practice. We conducted systematic searches in January 2022 in the following databases: Medline, EMBASE, and PsycInfo. Two reviewers independently screened the identified study reports for eligibility and extracted data from the eligible studies. The extracted data was descriptively analysed, and research recommendations were drawn. A stakeholder consultation workshop was held to identify research topics on SHS exposure and smoke-free environments in Ethiopia that they perceived to be priorities for primary research. Of the 388 research reports identified, only nine were included in the scoping review. The topics explored includes prevalence of SHS exposure (six studies); knowledge on SHS exposure (three studies); compliance to smoke-free environments legislation (two studies); and exposure to anti-smoking messages (one study). The stakeholders prioritised further research addressing compliance monitoring and enforcement of the smoke free laws in Ethiopia. There is a need for studies that test new methods for compliance monitoring and enforcement, evaluate strategies to increase knowledge on the harms of SHS exposure and the smoke-free legislation, and evaluate the current smoke-free legislation in Ethiopia.

Muslim Communities Learning About Second-hand Smoke in Bangladesh (MCLASS II): a combined evidence and theory-based plus partnership intervention development approach.

INTRODUCTION: Deaths from second-hand smoke (SHS) exposure are increasing, but there is not sufficient evidence to recommend a particular SHS intervention or intervention development approach. Despite the available guidance on intervention reporting, and on the role and nature of pilot and feasibility studies, partial reporting of SHS interventions is common. The decision-making whilst developing such interventions is often under-reported. This paper describes the processes and decisions employed during transitioning from the aim of adapting an existing mosque-based intervention focused on public health messages, to the development of the content of novel community-based Smoke-Free Home (SFH) intervention. The intervention aims to promote smoke-free homes to reduce non-smokers' exposure to SHS in the home via faith-based messages. METHODS: The development of the SFH intervention had four sequential phases: in-depth interviews with adults in households in Dhaka, identification of an intervention programme theory and content with Islamic scholars from the Bangladesh Islamic Foundation (BIF), user testing of candidate intervention content with adults, and iterative intervention development workshops with Imams and khatibs who trained at the BIF. RESULTS: It was judged inappropriately to take an intervention adaptation approach. Following the identification of an intervention programme theory and collaborating with stakeholders in an iterative and collaborative process to identify barriers, six potentially modifiable constructs were identified. These were targeted with a series of behaviour change techniques operationalised as Quranic verses with associated health messages to be used as the basis for Khutbahs. Following iterative user testing, acceptable intervention content was generated. CONCLUSION: The potential of this community-based intervention to reduce SHS exposure at home and improve lung health among non-smokers in Bangladesh is the result of an iterative and collaborative process. It is the result of the integration of behaviour change evidence and theory and community stakeholder contributions to the production of the intervention content. This novel combination of intervention development frameworks demonstrates a flexible approach that could provide insights for intervention development in related contexts.

The association between the retail price of manufactured cigarettes and bidis on current smoking status in India.

INTRODUCTION: In India, the retail prices of bidis and cigarettes varied between the two Global Adult Tobacco Surveys (GATS) conducted in 2009-2010 and 2016-2017. The relationship between the retail price of smoked tobacco products and their use is unclear for India. Our study thus aimed to use available datasets to investigate the association between the retail price and current smoking status of bidis and cigarettes in India. METHODS: Current smoking status data for bidis and cigarettes were obtained from the two GATS rounds. The average state-level retail prices of bidis and cigarettes were obtained from India's Consumer Price Index- Industrial Workers database. Descriptive statistics were used to describe current smoking status patterns. Generalized Linear Mixed Models were used to investigate the association between the retail prices and current smoking status of bidis and cigarettes. RESULTS: For cigarettes, an increase in the average retail price by one Indian Rupee was associated with a reduction in the odds of being a current smoker of 7% (OR=0.925; 95% CI: 0.918-0.932, p<0.001). For bidis, the association between the retail price and current smoking status was not statistically significant (OR=1.01; 95% CI: 1.00-1.02, p=0.082). CONCLUSIONS: Current increases in the retail prices of tobacco products in India seem to have an impact on the use of cigarettes but not bidis. This highlights the need for tobacco product tax increases that result in sufficient retail prices increase to make all tobacco products less affordable and reduce their use.

Corrigendum to: Addressing tobacco smoking and drinking to improve TB treatment outcomes, in South Africa: a feasibility study of the ProLife program.

Alcohol and tobacco use may lead to negative treatment outcomes in tuberculosis (TB) patients, and even more so if they are HIV-infected. We developed and tested the feasibility of a complex behavioral intervention (ProLife) delivered by lay health workers (LHWs) to improve treatment outcomes in TB patients who smoke tobacco and/or drink alcohol, at nine clinics in South Africa. The intervention comprised three brief motivational interviewing (MI) sessions augmented with a short message service (SMS) program, targeting as appropriate: tobacco smoking, harmful or hazardous drinking and medication adherence. Patients received SMSs twice a week. We measured recruitment and retention rates and assessed fidelity to the MI technique (MI Treatment Integrity 4.1 tool). Finally, we explored LHWs' and patients' experiences through interviews and semistructured questionnaires, respectively. We screened 137 TB patients and identified 14 smokers, 13 alcohol drinkers, and 18 patients with both behaviors. Participants' mean age was 39.8 years, and 82.2% were men. The fidelity assessments pointed to the LHWs' successful application of key MI skills, but failure to reach MI competency thresholds. Nevertheless, most patients rated the MI sessions as helpful, ascribed positive attributes to their counselors, and reported behavioral changes. SMSs were perceived as reinforcing but difficult language and technical delivery problems were identified as problems. The LHWs' interview responses suggested that they (a) grasped the basic MI spirit but failed to understand specific MI techniques due to insufficient training practice; (b) perceived ProLife as having benefitted the patients (as well as themselves); (c) viewed the SMSs favorably; but (d) considered limited space and privacy at the clinics as key challenges. The ProLife program targeting multiple risk behaviors in TB patients is acceptable but LHW training protocol, and changes in wording and delivery of SMS are necessary to improve the intervention. Trial registration: ISRCTN14213432.

Effect of relative income price on smoking initiation among adolescents in Ghana: evidence from pseudo-longitudinal data.

OBJECTIVE: Many smokers initiate smoking during adolescence. Making tobacco products less affordable is one of the best ways to control tobacco use. Studies on the effect of relative income price (RIP (ie, affordability)) of cigarettes on smoking initiation are scarce in low-income and middle-income countries, especially in Sub-Saharan Africa where data are limited. The goal of this study is to examine the effect of cigarette RIP on adolescent smoking initiation in Ghana. SETTING: The study uses a pseudo-longitudinal data set constructed from the Global Youth Tobacco Surveys (GYTS (2000-2009 and 2017)) and RIP for the most sold cigarette brand in Ghana. PARTICIPANTS: The GYTS is a national survey on adolescents. PRIMARY AND SECONDARY OUTCOME: Effect of RIP on adolescent smoking initiation in Ghana. RESULTS: Using the GYTS 2000-2009 data, we find that the probability of smoking initiation falls significantly in response to a higher RIP, with an elasticity of -0.372 (95% CI -0.701 to -0.042) for the unmatched sample and -0.490 (95% CI -0.818 to -0.161) for the matched sample. The RIP elasticity for women ((-0.888) (95% CI -1.384 to -0.392) and (-0.928) (95% CI -1.434 to -0.422)) is statistically significant at 1% in both the unmatched and the matched samples, respectively, while the RIP elasticity for men is statistically insignificant in the 2000-2009 surveys. Analysis of the 2017 GYTS shows a similar outcome: a negative relationship between RIP and smoking initiation, and the results are statistically significant for both men and women, and for both matched and unmatched samples. CONCLUSION: The affordability (RIP) of cigarettes is negatively related to the probability of smoking initiation among adolescents in Ghana. Raising tobacco taxes in line with income growth would make cigarettes less affordable and dissuade adolescents from initiating smoking.

Effect of a brief motivational interview and text message intervention targeting tobacco smoking, alcohol use and medication adherence to improve tuberculosis treatment outcomes in adult patients with tuberculosis: a multicentre, randomised controlled trial of the ProLife programme in South Africa.

OBJECTIVE: To investigate the effectiveness of a complex behavioural intervention, ProLife, on tuberculosis (TB) treatment success, medication adherence, alcohol use and tobacco smoking. DESIGN: Multicentre, individual, randomised controlled trial where participants were assigned (1:1) to the ProLife intervention or usual care. SETTING: 27 primary care clinics in South Africa. PARTICIPANTS: 574 adults starting treatment for drug-sensitive pulmonary TB who smoked tobacco or reported harmful/hazardous alcohol use. INTERVENTIONS: The intervention, delivered by lay health workers (LHWs), consisted of three brief motivational interviewing (MI) sessions, augmented with short message service (SMS) messages, targeting medication adherence, alcohol use and tobacco smoking. OUTCOME MEASURES: The primary outcome was successful versus unsuccessful TB treatment at 6-9 months, from TB records. Secondary outcomes were biochemically confirmed sustained smoking cessation, reduction in the Alcohol Use Disorder Identification Test (AUDIT) score, improved TB and antiretroviral therapy (ART) adherence and ART initiation, each measured at 3 and 6 months by questionnaires; and cure rates in patients who had bacteriology-confirmed TB at baseline, from TB records. RESULTS: Between 15 November 2018 and 31 August 2019, 574 participants were randomised to receive either the intervention (n=283) or usual care (n=291). TB treatment success rates did not differ significantly between intervention (67.8%) and control (70.1%; OR 0.9, 95% CI 0.64% to 1.27%). There was no evidence of an effect at 3 and 6 months, respectively, on continuous smoking abstinence (OR 0.65, 95% CI 0.37 to 1.14; OR 0.76, 95% CI 0.35 to 1.63), TB medication adherence (OR 1.22, 95% CI 0.52 to 2.87; OR 0.89, 95% CI 0.26 to 3.07), taking ART (OR 0.79, 95% CI 0.38 to 1.65; OR 2.05, 95% CI 0.80 to 5.27) or AUDIT scores (mean score difference 0.55, 95% CI -1.01 to 2.11; -0.04, 95% CI -2.0 to 1.91) and adjusting for baseline values. Cure rates were not significantly higher (OR 1.16, 95% CI 0.83 to 1.63). CONCLUSIONS: Simultaneous targeting of multiple health risk behaviours with MI and SMS using LHWs may not be an effective approach to improve TB outcomes. TRIAL REGISTRATION NUMBER: ISRCTN62728852.

Smoking behaviours and indoor air quality: a comparative analysis of smoking-permitted versus smoke-free homes in Dhaka, Bangladesh.

INTRODUCTION: Exposure to secondhand smoke (SHS) is a health risk to non-smokers. Indoor particulate matter (PM2.5) is associated with SHS exposure and is used as a proxy measure. However, PM2.5 is non-specific and influenced by a number of environmental factors, which are subject to geographical variation. The nature of association between SHS exposure and indoor PM2.5-studied primarily in high-income countries (HICs) context-may not be globally applicable. We set out to explore this association in a low/middle-income country setting, Dhaka, Bangladesh. METHODS: A cross-sectional study was conducted among households with at least one resident smoker. We inquired whether smoking was permitted inside the home (smoking-permitted homes, SPH) or not (smoke-free homes, SFH), and measured indoor PM2.5 concentrations using a low-cost instrument (Dylos DC1700) for at least 22 hours. We describe and compare SPH and SFH and use multiple linear regression to evaluate which variables are associated with PM2.5 level among all households. RESULTS: We surveyed 1746 households between April and August 2018; 967 (55%) were SPH and 779 (45%) were SFH. The difference between PM2.5 values for SFH (median 27 µg/m3, IQR 25) and SPH (median 32 µg/m3, IQR 31) was 5 µg/m3 (p<0.001). Lead participant's education level, being a non-smoker, having outdoor space and smoke-free rule at home and not using kerosene oil for cooking were significantly associated with lower PM2.5. CONCLUSIONS: We found a small but significant difference between PM2.5 concentrations in SPH compared with SFH in Dhaka, Bangladesh-a value much lower than observed in HICs.

HIV healthcare providers' perceptions on smoking behavior among PLHIV and smoking cessation service provision in HIV clinics in Uganda.

INTRODUCTION: Integration of smoking cessation interventions into HIV care can play a crucial role in reducing the growing burden of disease due to smoking among people living with HIV (PLHIV). However, there is a dearth of information on HIV care providers' perspectives towards integrating smoking cessation interventions into HIV care programs. We explored HIV healthcare providers' perceptions on the smoking behavior among PLHIV, and the provision of smoking cessation services to PLHIV who smoke within HIV care services in Uganda. METHODS: Semi-structured face-to-face qualitative interviews were conducted with 12 HIV care providers between October and November 2019. Data were collected on perceptions on smoking among HIV-positive patients enrolled in HIV care, support provided to PLHIV who smoke to quit and integrating smoking cessation services into HIV care programs. Data were analyzed deductively following a thematic framework approach. RESULTS: Findings show that: 1) HIV care providers in HIV clinics had low knowledge on the prevalence and magnitude of smoking among PLHIV who attended the clinics; 2) HIV care providers did not routinely screen HIV-positive patients for smoking and offered sub-optimal smoking cessation services; and 3) HIV care providers had a positive attitude towards integration of tobacco smoking cessation services into HIV care programs but called for support in form of guidelines, capacity building and strengthening of data collection and use as part of the integration process. CONCLUSIONS: Our study shows that HIV care providers did not routinely screen for tobacco use among PLHIV and offered suboptimal cessation support to smoking patients, but had a positive attitude towards the integration of tobacco smoking into HIV care programs. These findings suggest a favorable ground for integrating tobacco smoking cessation interventions into HIV care programs.

Exposure to Second-Hand Smoke in Public Places and Barriers to the Implementation of Smoke-Free Regulations in The Gambia: A Population-Based Survey.

INTRODUCTION: Second-hand smoke is associated with more than 1.2 million deaths per year among non-smokers. Smoking in public places is prohibited in The Gambia but there is no information on the level of exposure to second-hand smoke among adolescents and adults 15-64 years. The aim of this study was to assess the level and predictors of exposure to second-hand smoke in public places and compliance with smoke-free regulations in The Gambia. METHODS: A population-based survey was conducted in an established Health and Demographic Surveillance System (HDSS). A total of 4547 participants (15-64 years) from households within the Farafenni HDSS were interviewed at their homes but only 3343 were included in our analysis. Factors associated with exposure to second-hand smoke in public places were assessed by three different multivariable regression models. RESULTS: Exposure to tobacco smoke in public places was high (66.1%), and higher in men (79.9%) than women (58.7%). Besides being male, less education, lower household income, urban residence and not aware of smoke-free regulations were strongly associated with exposure to second-hand smoke. CONCLUSION: Despite existing smoke-free regulations, reported exposure to second-hand smoke remains high in public places in The Gambia. The Ministry of Health should continue to strengthen their advocacy and sensitization programs to ensure smoke-free regulations are fully implemented. Some population subgroups are at a higher risk of exposure and could be targeted by interventions; and settings where these subgroups are exposed should be targeted by enforcement efforts.

Efficacy and cost-effectiveness of a community-based smoke-free-home intervention with or without indoor-air-quality feedback in Bangladesh (MCLASS II): a three-arm, cluster-randomised, controlled trial.

BACKGROUND: Exposure to second-hand smoke from tobacco is a major contributor to global morbidity and mortality. We aimed to evaluate the efficacy and cost-effectiveness of a community-based smoke-free-home intervention, with or without indoor-air-quality feedback, in reducing second-hand-smoke exposure in homes in Bangladesh. METHODS: We did a three-arm, cluster-randomised, controlled trial in Dhaka, Bangladesh, and randomly assigned (1:1:1) mosques and consenting households from their congregations to a smoke-free-home intervention plus indoor-air-quality feedback, smoke-free-home intervention only, or usual services. Households were eligible if they had at least one resident attending one of the participating mosques, at least one adult resident (age 18 years or older) who smoked cigarettes or other forms of smoked tobacco (eg, bidi, waterpipe) regularly (on at least 25 days per month), and at least one non-smoking resident of any age. The smoke-free-home intervention consisted of weekly health messages delivered within an Islamic discourse by religious leaders at mosques over 12 weeks. Indoor-air-quality feedback comprised providing households with feedback on their indoor air quality measured over 24 h. Households in the usual services group received no intervention. Masking of participants and mosque leaders was not possible. The primary outcome was the 24-h mean household airborne fine particulate matter (<2·5 microns in diameter [PM2·5]) concentration (a marker of second-hand smoke) at 12 months after randomisation. Cost-effectiveness was estimated using incremental cost-effectiveness ratios (ICERs). This trial is registered with ISRCTN, 49975452. FINDINGS: Between April 11 and Aug 2, 2018, we enrolled 1801 households from 45 mosques. 640 households (35·5%) were assigned to the smoke-free-home intervention plus indoor-air-quality feedback group, 560 (31·1%) to the smoke-free-home intervention only group, and 601 (33·4%) to the usual services group. At 12 months, the adjusted mean difference in household mean 24-h PM2·5 concentration was -1·0 µg/m3 (95% CI -12·8 to 10·9, p=0·88) for the smoke-free-home intervention plus indoor-air-quality feedback group versus the usual services group, 5·0 µg/m3 (-7·9 to 18·0, p=0·45) for the smoke-free-home intervention only group versus the usual services group, and -6·0 µg/m3 (-18·3 to 6·3, p=0·34) for the smoke-free-home intervention plus indoor-air-quality feedback group versus the smoke-free-home intervention only group. The ICER for the smoke-free-home intervention plus indoor-air-quality feedback versus usual services was US$653 per quality-adjusted life-year (QALY) gained, which was more than the upper limit of the Bangladesh willingness-to-pay threshold of $427 per QALY. INTERPRETATION: The smoke-free-home intervention, with or without indoor-air-quality feedback, was neither effective nor cost-effective in reducing household second-hand-smoke exposure compared with usual services. These interventions are therefore not recommended for Bangladesh. FUNDING: Medical Research Council UK. TRANSLATION: For the Bengali translation of the abstract see Supplementary Materials section.

Tobacco use and cessation in the context of ART adherence: Insights from a qualitative study in HIV clinics in Uganda.

Sub-Saharan Africa carries a disproportionate burden of human immunodeficiency virus (HIV). Tobacco use amongst people living with HIV is higher than in the general population even though it increases the risk of life-threatening opportunistic infections including tuberculosis (TB). Research on tobacco use and cessation amongst people living with HIV in Africa is sparse and it is not clear what interventions might achieve lasting cessation. We carried out qualitative interviews in Uganda in 2019 with 12 current and 13 former tobacco users (19 men and 6 women) receiving antiretroviral therapy (ART) in four contrasting locations. We also interviewed 13 HIV clinic staff. We found that tobacco use and cessation were tied into the wider moral framework of ART adherence, but that the therapeutic citizenship fashioned by ART regimes was experienced more as social control than empowerment. Patients were advised to stop using tobacco; those who did not concealed this from health workers, who associated both tobacco and alcohol use with ART adherence failure. Most of those who quit tobacco did so following the biographical disruption of serious TB rather than HIV diagnosis or ART treatment, but social support from family and friends was key to sustained cessation. We put forward a model of barriers and facilitators to smoking cessation and ART adherence based on engagement with either 'reputation' or 'respectability'. Reputation involved pressure to enjoy tobacco with friends whereas family-oriented respectability demanded cessation, but those excluded by isolation or precarity escaped anxiety and depression by smoking and drinking with their peers.

Impact of tobacco price and taxation on affordability and consumption of tobacco products in the South-East Asia Region: A systematic review.

INTRODUCTION: The objective of the review was to study the impact of tobacco taxes or prices on affordability and/or consumption of tobacco products in WHO South-East Asia Region (SEAR) countries, overall and by socioeconomic status; and change in consumption of one tobacco product for a given change in price/tax on another tobacco product. METHODS: The searches were made in five databases (Medline, Embase, Cinahl, EconLit, Tobacconomics) using keywords such as 'tobacco', 'tax', 'price', 'impact' with their synonyms. Additionally, the first 100 articles through google search and e-reports from targeted sources were also reviewed. Studies illustrating the impact of prices/taxes on consumption/affordability of tobacco products in SEAR, in English and with no limitation on year, were included in the review. After two steps of screening, data from 28 studies were extracted using a structured and pre-tested data extraction form. RESULTS: Of the 28 studies, 12 studies reported an inverse association between price and consumption/affordability, while 11 studies reported no or positive association between price and consumption/affordability of tobacco products. Five studies had unclear interpretations. The majority of studies estimated that the less affluent group were more price responsive compared to the more affluent group. Some studies indicated increased consumption of one product in response to price rise of another product, although, the findings were inconsistent. CONCLUSIONS: The findings of our review support the use of tobacco tax and price measures as effective tools to address the tobacco epidemic. Our findings, however, also emphasize the importance of increasing tobacco product taxes and prices sufficiently to outweigh the effects of income growth, in order for the measures to be effective in reducing the affordability and consumption of tobacco products.