Building primary care capacity to treat tobacco dependence: Lessons from evaluating a Teach the Teacher programme in low- and middle-income countries

Smoking and other forms of tobacco use are prevalent in many middle and low-income countries and are a leading preventable cause of non-communicable diseases (NCDs). Primary care is uniquely positioned to deliver support and services for tobacco cessation. However, despite being a cost-effective intervention and globally recognised and mandated by the World Health Organization, tobacco cessation services, such as Very Brief Advice (VBA) are currently underprovided. Scalable capacity building programmes are needed to strengthen the knowledge, confidence and competence of practising clinicians. The International Primary Care Respiratory Group designed and implemented a three-tiered "Teach the Teacher" (TtT) programme to build teaching capacity in treating tobacco dependence in Romania, Bulgaria. North Macedonia, and the Kyrgyz Republic. The TtT model engaged national educators in adapting a core VBA+ curriculum-designed to reflect limited access to pharmacotherapy and specialist services-and cascaded teaching through local networks of primary care professionals. Evaluation of the TtT model showed that while co-developing context-specific curricula for treating tobacco dependence is feasible and effective, sustained success requires structural reforms-such as improving access to cessation support, incentivising providers, and embedding tobacco dependence treatment into national education and policy frameworks. The TtT approach offers a replicable model for rapid capacity-building, but its full potential depends on alignment with broader health system priorities.