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- Supporting Information
In this global tobacco treatment survey, just under half of the countries surveyed had national treatment guidelines, and our results suggest that most were broadly in line with the evidence base, recommending brief advice, intensive specialist support, medications and quitlines, and most were peer reviewed. Most were developed in a collaborative way, involving national professional associations in drafting and being formally supported by government. Most clearly described the writing and review process; however, fewer than half included conflict of interest statements for all authors, and some received financial support from the pharmaceutical industry and even included the names and logos of pharmaceutical companies.
The main limitation of our study is that there was no way of verifying the accuracy of survey responses. However, we selected our survey contacts as carefully as we could by using tobacco treatment specialists known to us, and other tobacco control specialists recommended by professional colleagues and highly respected organisations. The process of identifying guidelines was limited in that it was not always possible to identify a contact in all Parties to the FCTC and, in cases where we did identify contacts, to get responses from them despite sending reminder emails. Nevertheless, we did get in touch with contacts in all but 10 Parties to the FCTC, and, based on the knowledge we have of guidelines from our previous survey  and the guidelines available on http://www.treatobacco.net, we believe that our sample is highly likely to have captured virtually all, if not all, existing guidelines.
To our knowledge this is the largest ever detailed global survey of tobacco dependence treatment, with a response rate of 73% (121 countries). Results reported here are for 68% of FCTC Parties, and show good global representation, including well over half of all World Bank income categories and WHO regions. The lowest response rate by region was in the Western Pacific region (65%), and the highest in Europe and Southeast Asia (83%).
Fifty-three countries (44%) reported having guidelines and 38 (31%) reported that these guidelines were comprehensive, meaning for the whole health-care system and all health-care professionals. There was a linear relationship between income level and having guidelines, with results ranging from 75% of high-income countries to 11% of low-income countries (Fig. 2). Guideline development can be time consuming and expensive, and this may suggest that development of treatment guidelines is not a priority for middle- and low-income countries. None of the Parties surveyed from the African region had guidelines; more than half the countries in the region are low-income and almost a quarter are lower-middle-income . Interestingly, Africa has the lowest annual per capita cigarette consumption of all the WHO regions  and perhaps this, inter alia, makes treatment guidelines a low priority for Parties in the region. Lack of money and lack of expertise were cited as reasons for not having treatment guidelines in a previous survey .
The apparently low priority given to development of treatment guidelines may also reflect a rational response not just to their potential cost but also to the broad content of the FCTC itself  and the MPOWER measures [8-10]. These emphasise the implementation of policies, such as smoke-free legislation, higher taxation, advertising bans, large graphic health warnings and education on the dangers of tobacco, in order to promote cessation at population level. Logically, until those measures are in place and generating demand for cessation support, it would not make sense to devote substantial resources to developing such support. Furthermore, at the start of our survey it had only been 1 year since the FCTC Article 14 guidelines were adopted, which is very little time in which to develop guidelines in accordance with FCTC recommendations. It is therefore likely that some Parties are currently developing guidelines. Given that 57% of guidelines in our survey were published before 2010, arguably even Parties with guidelines may consider updating them at some point in the near future.
We already commented that most guidelines recommended brief advice, intensive specialist support, medications and quitlines. The Cochrane library was referenced or referred to by the majority of guidelines, suggesting that the FCTC recommendation that guidelines should be ‘based on scientific evidence’ is being taken seriously. Over half of the guidelines were based on those of other countries, mostly the US and UK guidelines, possibly a very practical cost-saving approach.
A key finding, however, was that only 57% of countries said they had a strategy to disseminate their guidelines. Given that, logically, national guidelines will form the basis for treatment services, the lack of a dissemination plan is of concern, and the FCTC Article 14 guidelines clearly state that national guidelines should include a dissemination plan. However, in some countries the existence of official national guidelines is a powerful statement of the importance of the issue, so even without a dissemination strategy, guidelines can be very important.
Rates of tobacco use by health professionals are very high in some countries , which is why the FCTC Article 14 guidelines recommend that guidelines stress the importance of health-care providers not using tobacco and of helping them stop. In spite of this, only 57% of guidelines stress this.
The high proportions of guidelines that involved national professional associations in their drafting (70%), which were formally supported by government (70%) and by public health organisations (68%), and which received financial support from government or other public health organisations (77%), suggests that the majority of the guidelines were produced as a result of genuine collaboration between relevant stakeholders, a recommendation of the FCTC Article 14 guidelines. We believe such collaboration is important for at least two reasons: no country has unlimited resources so all resources available should be used; and the failure of genuine collaboration can result in real confusion, as in one country we surveyed that has fractured national consensus on treatment and three ‘competing’ guidelines. Furthermore, it is likely that this collaboration resulted in the high levels of endorsement from national health professional organisations and governments.
Fifteen percent of guidelines in our survey received financial support from the pharmaceutical industry, 11% carried pharmaceutical company names and/or logos (in one case a logo on the title page), and fewer than half included conflict-of-interest statements for all authors. The FCTC Article 14 guidelines do not actually prohibit pharmaceutical company support, but do state that the development process must be protected from vested interests. Arguably it is at least unwise to develop guidelines with such industry support, but, in our opinion, it is entirely unacceptable to promote company names and logos in guidelines. If pharmaceutical company funding is considered necessary, then there must be very clear rules to guarantee the independence and integrity of the guidelines. However guideline development need not be expensive, as tools are being developed to assist countries, which would greatly reduce costs and which will be available in 2013. We believe this route to be far preferable to pharmaceutical company funding, which will, inevitably, in many peoples' views undermine guidelines. Finally, we believe that full declaration of all interests is essential.
Overall, our findings suggest that the development of guidelines is not yet a priority for many Parties to the FCTC, but that most existing guidelines followed Article 14 guideline recommendations quite closely. The aim of treatment guidelines is to assist health care practitioners and patients in making decisions regarding tobacco dependence and cessation , and yet the majority of FCTC Parties do not have guidelines. The cost of producing guidelines appears to be a significant barrier; therefore, initiatives to provide technical and/or financial support to resource limited countries are likely to expedite guidelines development in these Parties.
The finding that the majority of existing guidelines are based on the guidelines of other countries shows that guideline production need not necessarily start from scratch and may provide a way to help resource limited countries. The development and dissemination of a guidelines ‘template’, so to speak, which FCTC Parties could subsequently tailor to suit their respective national situations may translate into significant time and cost savings for Parties and spur progress with guidelines development. Although the focus of this report is the FCTC Article 14 significant gains can only be made if other complementary FCTC Articles are implemented concurrently by Parties.
Declarations of interest
Dr Rigotti has been an unpaid consultant for Pfizer and Alere Wellbeing, and has received royalties from UpToDate, Inc. No other author declares any conflict of interest.