Improving implementation of tobacco dependence treatment practice in low and middle-income countries settings: a perspective from Jordan

In Jordan, a Low- Middle-Income Country (LMIC) in the Eastern Mediterranean Region (EMR), tobacco use rates are among the highest globally. These alarming rates impose a huge economic and health burden and are exacerbated by cultural norms, societal misperceptions, and insufficient policy implementation. The tobacco epidemic is a multidimensional and complex one requiring multiple complementary solutions. One such solution is the availing of tobacco dependence treatment (TDT) services. However, establishing and maintaining TDT services can be challenging in resource-challenged countries. In this Policy and Practice Paper, we conducted a comprehensive critical analysis of Jordan's experience in initiating, expanding and maintaining TDT services, with the intention of providing insight which other LMICs seeking to establish TDT services can find useful. Our analysis is guided by the Consolidated Framework for Implementation Research (CFIR). Specifically, information was collected through both a desk review of the available evidence, and through expert insight from six healthcare practitioners directly involved in the establishment and/or implementation of TDT in Jordan. A CFIR assessment template was used to document the evidence and gather expert insights across the five CFIR domains (Innovation Domain, Outer Setting, Inner Setting, Individuals Domain, and Implementation Process Domain). Lessons learned and recommendations also were generated within each CFIR domain. Our findings, while presented in the context of Jordan as an LMIC, can be of use to other countries and settings with similar limited resources that will need to consider the adaptability and complexity of TDT, the broader policy and environmental setting within which TDT will be established, the physical and practice settings hosting TDT services, the potential stakeholders to engage in TDT establishment, and the changing implementation challenges faced when sustaining TDT services in an LMIC. Thus, our review can assist resource-limited countries planning or preparing to implement TDT services.