Introduction: Establishing the Need for Global Bridges
Globally, more than 1 billion people smoke cigarettes on a daily, or near daily, basis. The majority of these smokers would like to quit, but lack access to science-based, medically proven treatments for tobacco dependence, which has been shown to be both efficacious and cost effective (WHO, 2015). Even brief advice from a healthcare professional (HCP) can increase a smoker's chances of stopping smoking. In terms of efficacy, cost effectiveness, and impact, tobacco dependence treatment has been ranked in the top three preventive services (e.g. cholesterol reduction, hypertension management), and has been found to be cost saving (Maciosek et al., 2006). The figure below (World Bank, 1999) illustrates that, if 50% of all adult smokers could stop by the year 2020, nearly 180 million lives could be saved by 2050, resulting in enormous public health and economic benefit.
Source: World Bank, 1999.
However, especially in low- and middle-income countries (LMICs), healthcare professionals (HCPs) often lack experience and knowledge about the devastating health toll of tobacco and how to effectively treat tobacco dependence. Further, the infrastructure to support treatment services is highly variable and often non-existent in LMICs. Thus, in order to maximise their effectiveness, many HCPs in LMICs have found that, in addition to treating tobacco dependence, they must also become advocates for systems changes to support delivery of this treatment. Simply stated, building capacity for tobacco dependence treatment among HCPs remains an unaddressed need in most LMICs, and in many high-income countries.
In addition to treatment capacity, credible health advocacy is urgently needed in the many countries where tobacco use represents one of the most important threats to public health. Because HCPs are among the most educated members of any community and are viewed as the most credible source of health information, they represent a highly motivated, yet largely untapped, force for addressing the tobacco pandemic.
Addressing the Need – Accomplishments of Global Bridges
Global Bridges: Healthcare Alliance for Tobacco Dependence Treatment was created in 2010 with an unrestricted education grant to Mayo Clinic from Pfizer Medical Education Group. The initiative's primary objective was to expand the reach of evidence-based tobacco dependence treatment through the development of a global network of HCPs and organisations. A secondary, but related, objective was to aid in facilitating the global implementation of the WHO's Framework Convention on Tobacco Control (FCTC) Article 14, which requires all 180+ countries which have ratified this treaty to develop national guidelines for the delivery of tobacco dependence treatment to all who express interest in stopping tobacco use.
During the first phase of the initiative (2010–2014), four initial partner organisations (King Hussein Cancer Center in the Eastern Mediterranean Region, InterAmerican Heart Foundation in the Americas, and the University of Pretoria in Africa, later joined by the National Centre for Smoking Cessation and Training (NSCST) in Europe) were carefully selected based on their expertise and dedication to the treatment field. Partners pledged to devote a significant portion of time (estimated at 30% FTE for each Regional Director, plus administrative support) to development of a Global Bridges network and training curriculum, and promoting tobacco dependence treatment in their region.
In the first months of the project, each Regional Director reviewed their region's landscape with respect to tobacco dependence treatment and, using the ATTUD (Association for the Treatment of Tobacco Use and Dependence) ‘Core Competencies’ as a guide (ATTUD, 2005), developed evidence-based, culturally appropriate training curricula in local language(s). Regional Directors were also responsible for working with colleagues in their region to schedule and populate training sessions. The first Global Bridges training was held in April 2011, in Puebla, Mexico and included 70 trainees. In total, Global Bridges partners in the first phase conducted 80 training sessions, ranging in duration from 1–3 days, with participants from 62 countries, for a total of more than 30,000 person-hours of training (see Table 1). Mastery of core content increased significantly post-training (Personal communication; Hawari and Zabert, 2015). During the first phase, Global Bridges-trained HCPs treated an estimated 3.8 million tobacco users (Network survey of Global Bridges grantees, 2013; unpublished).
Table 1 Global bridges training sessions all regions through dec 2014
In addition to onsite training, the initiative's strategy has included the creation and maintenance of a multilingual website (www.globalbridges.org) used by grantees, trainees, and other network members to share information on tobacco dependence treatment and training worldwide. Global Bridges also partnered with the University of Toronto Centre for Addiction and Mental Health to review existing English-language distance learning programmes (Selby et al., 2015) and develop distance learning curricula in Arabic and Spanish to further expand the reach of this initiative.
The impact of Pfizer's investment in, and Mayo Clinic's stewardship of, the Global Bridges network is ongoing. Regional partners from the first phase of the initiative have continued to play leadership roles in promoting and advocating for tobacco dependence treatment in their regions, and continue to be active in treatment and tobacco policy. They are also serving as mentors for second-phase grantees, as described below.
The second phase of the initiative – a competitive, peer-reviewed grant programme – began in 2014, and currently supports 19 educational projects working in LMICs across all six WHO regions (see Table 2). While these new projects will not conclude until 2016, as of July 2015 (the last report submitted as of this writing) an additional 1,943 HCPs had been trained. In total, second-phase grantees expect to train more than 12,500 HCPs during their projects, representing a significant increase in scale over the first phase.
Table 2 Global bridges 2014 tobacco dependence treatment award recipients
In addition to building worldwide treatment capacity through training, the Global Bridges network has sought to fulfil another important need: urging national healthcare systems to make treatment support available and affordable for all tobacco users. Among evidence-based tobacco control policies, countries’ implementation of treatment measures has been disappointingly slow. A recent report by the World Health Organization (WHO) released on the 10th anniversary of the WHO's FCTC, found that implementation of FCTC Article 14, which deals with treatment, lags behind other important tobacco control policy areas, such as smoke-free environments and raising taxes on tobacco products, which have been implemented by more than half of the countries which have ratified the FCTC. By comparison, only 24 countries, or 12% of the parties to the FCTC, have reported complete implementation of cessation programmes, lower than for any other MPOWER (WHO, 2015) measure. In Global Bridges’ second phase, two grants were awarded in a special project category for ‘A14 implementation’; these projects (in Bolivia and Mexico) are now in process. A third-phase Request for Proposals, released on 17 November 2015 and focused in the WHO European Region, also included this project category with an increased award level. Through its multilingual website, active presence at professional conferences, publications, and partnerships with other leadership organisations, Global Bridges continues to build a more prominent profile for treatment within the specific effort to implement the FCTC's Article 14 and in the wider context of global tobacco control.
More broadly, there is reason for optimism concerning implementation of Article 14 and greater focus on tobacco dependence treatment globally. Three events in which Global Bridges played an active role at the 2015 World Conference on Tobacco OR Health, in Abu Dhabi, UAE, have helped give rise to this optimism: (1) the Bloomberg initiative gave its first international tobacco dependence treatment award (to Uruguay, for its national efforts to provide cessation support to any tobacco user who wishes to stop) after declining to do so for nearly a decade, citing the lack of worthy recipients; (2) the American Cancer Society awarded its prestigious Luther Terry Award, for the first time, to an individual – Dr. Eduardo Bianco – whose career has focused on establishing tobacco dependence treatment as a global imperative; and (3) the Conference itself adopted a resolution calling for at least 50% of Parties to have developed and published a national treatment strategy, in accordance with Article 14 guidelines, by the time of the next World Conference in 2018. Continued progress in this direction by the tobacco control community will ensure that treatment capacity is better able to meet the increased global demand generated by complementary MPOWER policies.
Some of the network participants have endeavoured to share their experience and learning with the broader scientific and medical community, on the Global Bridges website, in peer-reviewed publications, and/or other venues. In some cases, the network connections enabled by Global Bridges have led to broader collaborative efforts. The team at King Hussein Cancer Center worked with the WHO and international colleagues to develop and publish tobacco dependence treatment guidelines for Jordan (Hawari et al., 2014). A grantee in Brazil convened a ‘virtual webinar’ on treatment, featuring presentations from grantees in India, Argentina, and Armenia. Another grantee, at the American University of Armenia, is conducting cross-country analyses of treatment barriers in cooperation with other Global Bridges grantees. Beyond the grant projects which it supports, the initiative has been supportive of the preparation of publications such as a recent Comment in The Lancet which calls for broader implementation of Article 14 of the FCTC.
Lessons Learned in Multinational Project Management
The Global Bridges network remains in the early stages of development. Long-term impact of the first phase – providing training in the treatment of, and advocacy for, tobacco dependence treatment – remains to be fully evaluated, and the activities being conducted through the grants funded in the second phase are ongoing.
Yet, even in this early stage, there are important lessons which can be derived from the experience thus far in establishing and maintaining a global HCP network. These lessons may, perhaps, be generalised to other global efforts to address vital public health needs. Some of the lessons derived thus far include:
• Get the right core management and regional teams on board. The Global Bridges Executive Team includes expert leaders from respected organisations (including Mayo Clinic and the American Cancer Society) with deep experience in tobacco use and dependence and, equally important, extensive global networks. Regional partners and grantees, working largely independently, have had broad responsibility to develop curricula, implement trainings, document accomplishments, and nurture relationships on an ongoing basis. These activities have led them to be called on to support treatment and tobacco control in other ways within their regions and globally. Finally, in order to facilitate ongoing dialogue within the network via the website and social media, digital communications expertise has been essential.
• Develop and follow a clear strategy. The Executive Team's first task was to develop a mission statement, measurable objectives, and a vivid description of what ‘success’ would look like to the team. Adherence to a strategy which is developed and agreed to by the full team has aided in the group's efforts to stay focused and efficient. Periodic review of the strategy, and updating where required, is essential, and ensures that the group can adapt to significant changes in the environment or other factors. Having a trusted, capable team and a clear strategy enables the members to work independently to reach shared goals.
• A ‘ready-to-use’ global training template does not exist. Although the evidence supporting tobacco dependence treatment's effectiveness applies universally, there are many other local lessons which can be productively shared and there are important contextual variations between countries’ treatment scenarios. For example, pharmacotherapy is often less available and affordable in LMICs. And in countries where HCPs have historically used a directive, therapeutic approach to treatment, behavioural techniques such as motivational interviewing need careful contextual presentation in order to be fully embraced. Therefore, each Global Bridges regional partner conducted a thorough local needs analysis before developing their curriculum. Subsequently, the WHO developed a comprehensive training package for tobacco dependence treatment (World Health Organization, 2013) which was piloted in and adapted for multiple countries and served as an important resource for later grantees’ curricula.
• Recognise and leverage the team's diversity to enhance its effectiveness. In a global team, a variety of cultures, perspectives, and languages will, and should, be represented. While this can pose some logistical challenges (such as needing to communicate across different time zones and languages), management studies have shown that, if cultivated properly, cultural diversity can improve effectiveness and problem-solving. If team meetings are held in English, remember your partners may be communicating in their second or third language and it may take longer for all members to make themselves understood. Do not mistake this for a lack of expertise or reluctance to fully participate.
• Communicate early and often. Touch base with partners early and often during the development phase of the initiative, so there is time to understand barriers and correct them before they adversely affect the project. Leverage opportunities to be together, such as conferences. At the 2015 World Conference on Tobacco or Health in Abu Dhabi, daily breakfast briefings on topics of interest provided a forum for Global Bridges grantees to connect and network. Grantees later remarked on how much easier it is to reach out for advice after actually meeting colleagues face-to-face. Monthly web calls involving all grantees, supplemented by informal communication methods (social media, email) and regular website updates, provide an ongoing forum for continuing communication as projects move forward.
• Understand that all of us are smarter than any one of us. A diverse collaborative network can be a powerful problem-solver, and an active listserv is a great resource. When one grantee organisation had difficulty reaching a specialty target audience, they used the network to find other expert leaders from around the world who could offer advice. Country-based teams working on advocacy programmes supported by other funders have reached out to Global Bridges network members to add medical expertise and credibility to their initiatives.
• Seek opportunities to cultivate motivated individuals with modest incremental support. It can be tempting to spend disproportionate time on ‘problem’ areas, but do not neglect opportunities to cultivate high achievers. For example, partial travel support provided by Global Bridges through King Hussein Cancer Center has allowed 12 HCPs from the WHO Eastern Mediterranean Region to complete Tobacco Treatment Specialist certification training at Mayo Clinic; this programme is now expanding to additional regions and is believed by grantees to be a significant contributor to network development. In a separate example, incremental funding helped a grantee participate in a global expert meeting in Ankara, Turkey immediately after the 2015 World Conference in Abu Dhabi and bring the expertise gained at that meeting back to her own country/region, as well as expanding her personal network of global tobacco experts.
• Build a robust evaluation plan into the programme. While regional partners used pre- and post-learning surveys to measure learner mastery of content, longer-term follow up and patient impact were not included in the initial phase due to resource constraints. As the second phase is a decentralised set of independent grant projects, measurement along a common set of standards is not feasible. Therefore, the patient impact of HCP training can only be estimated. Longer-term, it will be vital, for the generalisability of the initiative, to confirm this through a well-designed evaluation programme.
Going Forward: Leveraging the Potential of the Global Bridges Treatment Network
In order to adapt its strategy and methods for the future, the team looks to external sources for inspiration. A recent paper by Uwe Gneiting provides some important guidance which could be applied to planning the next steps for the Global Bridges initiative and others in a similar phase of their development. Gneiting compared the global implementation of two policies promulgated by the FCTC – smoke-free environments (FCTC Article 8) and tobacco taxation (FCTC Article 6). Citing the relatively low success of taxation policy implementation as identified in the 2015 WHO report previously cited, Gneiting hypothesised that specific network, political, and issue characteristics play a vital role in how, and if, these policies are implemented. While treatment was not addressed in this paper, global implementation of treatment to date has been even less successful than taxation – as noted earlier, only 12% of the FCTC's signatory countries are compliant with the recommended tobacco dependence treatment actions – and reviewing Gneiting's analysis with respect to treatment may help guide future Global Bridges (and other) network activities towards greater success.
Gneiting identifies three categories of factors which have affected implementation of these polices:
1. Network and actor features: Gneiting's analysis emphasises the creation, evolution, and management of the Framework Convention Alliance (FCA) as a defining factor in tobacco control progress over the past 20 years. Overall, the FCA, consisting of more than 300 organisations both within and outside the global health field, has proven consistently adept at publicising the enormous public health toll of tobacco, motivating research to support policy, providing guidance and support for domestic implementation, and monitoring progress of FCTC measures. While treatment can be viewed as a subset of broader tobacco control (and indeed many treatment leaders are members of FCA's global network), to date, there has been little specific focus on treatment, beyond adoption of Article 14 Guidelines in 2010. Conventional wisdom and ‘framing’ has dictated that countries should implement other demand-side policies, such as smoke-free, before they are ‘ready’ for treatment. National treatment strategies may differ due to the low availability and relatively high cost of pharmacotherapy in many LMICs. Finally, many healthcare providers who could be effective policy champions prefer to dedicate their time to patient care rather than advocacy.
2. Policy environment: Treatment may have fewer allies and fewer opponents within the broader tobacco control context. While there are fewer groups whose interests align with treatment implementation, the tobacco industry has kept a close watch on any treatment advances that could impact its profits, while offering less aggressive opposition than in other policy areas such as taxation and smoke-free workplaces. Treatment has had modest funding compared to other tobacco control policies. The majority of Global Bridges’ funding comes from the pharmaceutical industry, which is a perceptual problem for some. However, treatment could be carried along with the tide, as other policies are implemented and build demand for cessation support.
3. Issue characteristics: Ample evidence supports the cost-effectiveness of treatment and the relatively immediate impact of treatment on tobacco-caused death and disease. However, proponents of the ‘population impact’ approach to policy implementation argue that helping tobacco users affects a smaller subset of the population than taxation or smoke-free legislation, and therefore should be lower priority. Nonetheless, there is general agreement that a comprehensive approach, i.e. one that encompasses all evidence-based policies, is preferred.
Based on the analysis above, an overall prescription for solidifying and extending Global Bridges’ progress in promoting global tobacco dependence treatment/Article 14 could include the following:
• Global Bridges can work to become a more effective champion for treatment within FCTC/FCA, i.e. allying itself with a broader array of global tobacco control policy advocates, as well as domestic allies, and the general public.
• Simplify and communicate the importance of treatment and the impact of making treatment available.
• Change the mindset of tobacco dependence treatment advocates that adoption of Article 14 in 2010 was an end in itself, but rather the signal for a new effort in tobacco dependence treatment, i.e. the global implementation of Article 14.
• Broaden the initiative's funding base.
The Gneiting analysis provides Global Bridges with an excellent, data-based, basis for future planning of the initiative, as well as incentive to continue seeking out other methods and analyses which can inform the future implementation of global tobacco dependence treatment.
The Global Bridges HCP network, now in its sixth year, has expanded, on a global scale, evidence-based tobacco dependence education among HCPs and facilitated efforts to increase implementation of FCTC Article 14. With an experienced management team, strong global collaborators, and an enduring mission, the Global Bridges network comprises a unique and important component of the broader tobacco control community, and is poised to play an integral role in future global tobacco control progress.