Treating tobacco dependence is paramount for global tobacco control efforts, but is often overshadowed by other policy priorities. As stated by Jha (2009), “cessation by current smokers is the only practical way to avoid a substantial proportion of tobacco deaths worldwide before 2050.” Its importance is codified in Article 14 of the Framework Convention on Tobacco Control (FCTC), and in the WHO's MPOWER package of effective country-level policies. Unfortunately, only 15% of the world's population have access to appropriate cessation support (WHO, 2015). Moreover, parties to the FCTC have implemented only 51% of the indicators within Article 14, on average, which is far lower than many other articles (WHO, 2014). Further, commenting on the use of “O” measures (Offer help to quit tobacco use) in the MPOWER acronym, WHO recently concluded, “while there has been improvement in implementing comprehensive tobacco cessation services, this is nonetheless a most under-implemented MPOWER measure in terms of the number of countries that have fully implemented it” (WHO, 2015). To the detriment of global tobacco control efforts, only one in eight countries provides comprehensive cost-covered services, only one in four provide some cost coverage for nicotine replacement therapy, and fewer than one third provide a toll-free quit line (WHO, 2015).

The Associate Editor for this themed issue (Deborah Ossip) also wishes to express her appreciation on behalf of the Journal of Smoking Cessation to Dr Kenneth Ward for his outstanding job as Guest Editor to provide this compendium of lessons learned from LMICs around the globe regarding tobacco cessation research.

The tobacco epidemic is increasingly concentrated in low- and middle-income countries (LMICs) (WHO, 2008). These countries often have very limited resources and infrastructure to confront this epidemic. Public knowledge of tobacco health harms may be quite limited and, unfortunately, this is often true for health professionals as well (Nichter, 2006). Clinical practice guidelines have identified effective tobacco cessation interventions (Clinical Practice Guideline, 2008), but these have been focused primarily upon high-income countries. Approaches that have been successful in high-income countries may not be directly applicable in low-resource settings. Thus, for example, medications may not be readily accessible and infrastructure to support quit line programs may be minimal or non-existent.

For over half a century, the U.S. National Cancer Institute (NCI) has supported research on tobacco and health, which has contributed to reductions in tobacco-caused morbidity and mortality in the U.S. But while tobacco use has been slowly declining in most high-income nations, including the US, it has continued to increase in other parts of the globe. Of the 800 million adult men who currently smoke cigarettes, over 80% are in low- and middle-income countries (LMICs), and these countries will bear an increasing share of the health and economic burden of tobacco use. At the same time, there are additional challenges to implementing tobacco control programs in LMICs, including a diversity of tobacco products, limited capacity and resources for tobacco control, and competing health priorities. While a large body of evidence has been generated around tobacco dependence treatment and other measures in high-income countries, this work is only partly applicable to many LMICs. In this paper we focus on research needs and opportunities around tobacco cessation interventions for LMICs, highlighting four areas: understanding diverse tobacco products, development of low-cost cessation interventions, integrating tobacco cessation into health systems, and understanding tobacco use behaviors across different contexts. Expanding tobacco control research and research capacity in LMICs is crucial to reducing tobacco use and cancer rates worldwide. Furthermore, research conducted in countries around the world can yield important insights for understanding tobacco use behaviors and the effectiveness of tobacco control interventions in the US.

Introduction: Global Bridges, hosted at Mayo Clinic since 2010, is the only international network of healthcare professionals dedicated to tobacco dependence treatment. Globally, fewer resources have been dedicated to treatment than to other evidence-based tobacco control policies. The Global Bridges network seeks to aid in filling this gap in tobacco control.

Aims: This paper identifies ways to advance tobacco dependence treatment, as well as tobacco control, through efficient and effective use of a global health care provider network.

Methods: Observation and critical analysis of lessons learned, project outcomes to date, and network analysis.

Results/Findings: The initiative has built a strong global foundation, with training curricula developed and delivered in a number of countries, including low- and middle-income countries. While basic evaluation of content mastery and learner satisfaction has been conducted, more intensive evaluation and follow-up to confirm public health impact are essential needs. Finally, program analysis and application of management theory can be used in aiding future activities aimed at providing support for health care providers in the delivery of tobacco dependence treatment and in similar global public health endeavors.

Conclusions: The Global Bridges healthcare professional network, now in its sixth year, has developed training curricula and expanded evidence-based tobacco dependence education among healthcare professionals. Global Bridges comprises a unique and important component of the broader tobacco control community, and can play an integral role in furthering global tobacco control progress.

The Framework Convention on Tobacco Control (FCTC) set standards for global tobacco control, including the implementation of evidence-based tobacco dependence treatment. However, efforts to implement tobacco treatment programmes globally have been few. In order to expand tobacco treatment expertise and programmes, a new network called Global Bridges (GB) was established. This network provided training in tobacco treatment and opportunities to share best practices on implementation of tobacco dependence treatment and training programmes. In this analysis of the GB network, we found that 75% of the network members attended trainings, 60% disseminated knowledge gained through GB training, and network centralization was high (0.85). These results demonstrate initial success in network implementation, and create a foundation for expanded focus on tobacco treatment globally.

Engaging partners for tobacco control within low and middle income countries (LMICs) at early stages of tobacco control presents both challenges and opportunities in the global effort to avert the one billion premature tobacco caused deaths projected for this century. The Dominican Republic (DR) is one such early stage country. The current paper reports on lessons learned from 12 years of partnered United States (US)-DR tobacco cessation research conducted through two NIH trials (Proyecto Doble T, PDT1 and 2). The projects began with a grassroots approach of working with interested communities to develop and test interventions for cessation and secondhand smoke reduction that could benefit the communities, while concurrently building local capacity and providing resources, data, and models of implementation that could be used to ripple upward to expand partnerships and tobacco intervention efforts nationally. Lessons learned are discussed in four key areas: partnering for research, logistical issues in setting up the research project, disseminating and national networking, and mentoring. Effectively addressing the global tobacco epidemic will require sustained focus on supporting LMIC infrastructures for tobacco control, drawing on lessons learned across partnered trials such as those reported here, to provide feasible and innovative approaches for addressing this modifiable public health crisis.

Introduction: Offering tobacco cessation interventions to TB patients is highly desirable due to the interaction between TB and tobacco use and the potential benefits of quitting. However, implementing such interventions in TB programmes remains a challenge and an under-researched area. Using two initiatives to implement tobacco cessation within TB programmes in Nepal and Pakistan as case studies, we describe these challenges and highlight lessons learnt in the process.

Methods: We first conducted a documentary review of all published and unpublished reports of the two initiatives including relevant qualitative and quantitative data and its’ analyses. We then analysed this information using the Consolidated Framework for Implementation Research (CFIR) under the five domains of implementation: intervention characteristics, outer settings, inner settings, participant characteristics and the process of implementation.

Findings: We faced a number of challenges in implementing tobacco cessation within TB programmes both in Nepal and in Pakistan. These included: doubts about the contextual relevance of the intervention, environments conducive to smoking and political inertia for a cultural shift, service providers’ workload, priorities, and their motivation and capacity to deliver tobacco cessation, and inadequate training and support during implementation. We learned that by adapting intervention to the local context, securing mandate from higher authorities, aligning tasks to service providers’ roles and receptivity, building capacity through adequate training and providing support, monitoring and feedback during implementation can help in integrating tobacco cessation within TB programmes.

Conclusions: Lessons from existing studies can help TB programmes in implementing tobacco cessation interventions and enable greater integration and sustainability of cessation services within routine TB care.

The tobacco epidemic in Syria is characterised by high rates of cigarettes smoking in men and dramatic re-emergence of waterpipe smoking, especially among youths and women. The Syrian Center for Tobacco Studies (SCTS), an NIH-funded pioneer research and capacity building institution, has developed a research infrastructure and conducted three randomised clinical trials to develop and rigorously test culturally appropriate tobacco treatment programmes integrated into primary healthcare (PHC) centres. This review aimed to discuss challenges and lessons learned from the Syrian experience. Addressing these challenges may inform future cessation research activities in Syria and other developing countries. To develop a research infrastructure, the SCTS has established Syria's first IRB and trained physicians/medical students in both tobacco treatment and research methods. Main challenges to conduct the cessation trials were difficulties of coordination between the local and international collaborators; high Smoking Rates among PHC providers; lack of pharmacological agents used in tobacco treatment; and difficulties of conducting research in a politically volatile region. Strategies to overcome these challenges were ensuring an active and regular involvement of all investigators; and advocating for a national smoking cessation plan that involves training healthcare providers in smoking cessation treatment and make pharmacological agents used in smoking cessation available.

Malaysia introduced graphic health warning labels (GHWLs) on all tobacco packages in 2009. We aimed to examine if implementing GHWLs led to stronger warning reactions (e.g., thinking about the health risks of smoking) and an increase in subsequent quitting activities; and to examine how reactions changed over time since the implementation of the GHWLs in Malaysia and Thailand where GHWL size increased from 50–55% in 2010. Data came from six waves (2005–2014) of the International Tobacco Control Southeast Asia Survey. Between 3,706 and 4,422 smokers were interviewed across these two countries at each survey wave. Measures included salience of warnings, cognitive responses (i.e., thinking about the health risks and being more likely to quit smoking), forgoing cigarettes, and avoiding warnings. The main outcome was subsequent quit attempts. Following the implementation of GHWLs in Malaysia, reactions increased, in some cases to levels similar to the larger Thai warnings, but declined over time. In Thailand, reactions increased following implementation, with no decline for several years, and no clear effect of the small increase in warning size. Reactions, mainly cognitive responses, were consistently predictive of quit attempts in Thailand, but this was only consistently so in Malaysia after the change to GHWLs. In conclusion, GHWLs are responded to more frequently, and generate more quit attempts, but warning wear-out is not consistent in these two countries, perhaps due to differences in other tobacco control efforts.