Table 2.

Summary and quality assessment of included non-randomized studies concerning smoking cessation/TDT in patients with TB of LMICs (N=28)

Author, year	Country	Study design	Sample size/age/sex/type of sample	Study purpose	Findings	Limitations	Selection*	Comparability*	Outcome*
Amara et al.21 (2008)	Morocco	Comprehensive cross-sectional telephone survey	75 respiratory physicians working in TB diagnosis and monitoring centres; 10.7% smokers (8/75), 58.7% men.	To evaluate attitudes and knowledge of Moroccan respiratory physicians towards smoking in the management of patients with TB and the feasibility of integrating smoking interventions into the national TB program. Of these, 84% still reported smoking status in patients’ medical records.	66.7% of those interviewed by phone were certain that smoking increases the incidence of TB, 96% believed that smoking would worsen the disease. More than 84% of the physicians inquired their patients about their smoking habits. Only 5.3% believed they were well trained to help smokers to stop.	Not reported	***		*
Aryanpur et al.22 (2016)	Iran	Crosssectional study	Newly-diagnosed PTB patients aged ≥18 years; self-reported smoking status; 248 (22%) patients were current smokers including 228 (20.2%) daily smokers and 20 (1.8%) occasional smokers. Setting: health centre	To determine the intention to quit and its associated factors among smokers newly diagnosed with PTB.	When diagnosed with TB, 59 smoker patients (23.8%) quit smoking. After PTB diagnosis, 99 patients (52.4%) had the intention to quit in the next month. Living in urban areas, office jobs, being single and a one unit increase in the motivation scale significantly increased the intention to quit smoking.	Cross-sectional nature of this study does not allow evaluation of the causal relationship between factors and smoking cessation, and its prognostic factors. Thus, further prospective studies are required. Meanwhile, as this study was conducted on patients with newly diagnosed PTB, its results cannot be generalized to all TB patients.	**		**
Awaisu et al.23 (2010)	Malaysia	Crosss-ectional study	n=817 newly diagnosed TB patients, 40.3% were smokers, 13.9% ex-smokers; 120 enrolled in the SCIDOTS project, 98.7% were males. Setting: TB clinics	To determine the prevalence of smoking among newly diagnosed TB patients and to evaluate the tobacco use knowledge and attitudes of those who are smokers in this population using a 58-item questionnaire.	Patients who were in the stage of contemplation/pre-contemplation had significantly less knowledge than those in the preparation stage of change (3.73 vs 5.38; p=0.004). 65.1% of patients believed that smoking is fun and 61.3% that it calms nerves. 70.1% of respondents also agreed or strongly agreed that smoking makes them relieve all life stresses. However, 87.5% of patients agreed or strongly agreed that: smoking is a waste of money, 91.3% that tobacco use is very dangerous to health; and 81.3% that smokers are more likely to die from heart disease compared with non-smokers.	The rates in study might have been grossly underestimated due to the unknown smoking status of a reasonable proportion of the newly diagnosed TB patients who might as well be tobacco smokers. A trend of underestimation when smoking prevalence is based on self-reports.	**		**
Awaisu et al.24 (2011)	Malaysia	Prospective non-randomized controlled intervention (the SCIDOT project)	n=80 current smokers at the time of TB diagnosis; 40 patients motivated to quit smoking (in preparation stage) received SCI in addition to DOTS (the intervention group and 46 unmotivated patients (in pre-contemplation and contemplation stages) received conventional DOTS regimen (the usual care group). SCI = eleven sessions of individualized cognitive behavioural therapy with (60%) or without (40%) nicotine replacement therapy (nicotine gum 2 mg and 4 mg, nicotine transdermal patch, and nicotine inhaler). Setting: respiratory clinics	To evaluate the impact of adding smoking cessation intervention (SCI) to conventional DOTS for TB on tobacco abstinence rates and TB treatment outcomes.	Subjects in the DOTS group were more dependent on nicotine than those in the SCIDOTS group (FTND, 5.43 ± 1.96 vs 4.32 ± 2.26; t = -2.439; p=0.017). At the end of 6-month follow-up, the one-month self-reported continuous abstinence rate, confirmed biochemically by both CO and saliva cotinine tests, was nearly 78% (31/40) in the intervention group versus 9% (4/46) in the usual care group (Pearson χ2=41.97; df=1; N=86; p<0.001).	The study compared persons motivated to quit smoking in an intervention group with those contemplating quitting smoking in a control group; therefore, the observed difference in smoking cessation between the groups would likely not have been so great.	***	*	**
Bam et al.25 (2015)	Indonesia	Cohort study	n=750 new smear-positive TB patients, 82.3% male, 77.6% current smokers. Of the 80 healthcare facilities, 52 (65 %) were tobacco-free in March 2011, the number of which increased to 80 (100%) by December 2012. Smoking was not permitted in any buildings, grounds or carparks. Cigarettes were not sold, and tobacco advertising, promotion and sponsorship were not permitted on the premises. Setting: health centres that provided DOTS services	To assess the implementation and effectiveness of the ABC smoking cessation approach for TB patients and the establishment of smoke-free environments in healthcare facilities and TB patients’ homes in Indonesia.	The point prevalence of the quit rate was 66.8% (389/582) at month 6. Predictors independently associated with quitting were the time from waking to the first cigarette >30 min, having a smoke-free home and the display of ‘no smoking’ signage at home at month 6. The ABC smoking cessation intervention was effective for: i) creating 100% tobacco-free health services, ii) promoting quitting smoking (66.8%), and iii) establishing smoke-free environments at home (86.1%).	Self-reporting of smoking status although the status of the patients’ smoking and of their smoke-free home were validated with a family member at month 6. Issues of time constraints and high workload were raised at the initial training by the healthcare staff before the intervention; however, healthcare workers reported neither high workloads nor time constraints during the review meeting at months 2, 5, and 6.	***	*	***
Boeckmann et al.26 (2019)	Bangladesh and Pakistan	Qualitative study	n=6 healthcare workers in Pakistan and 2 in Bangladesh (5 men), ranging in age from 23 to 60 years; n=35 patients (34 males), age ranging from 18 to 60 years Setting: clinics	Findings of a multi-country qualitative process evaluation assessing barriers to and facilitators of implementation of smoking cessation behavior support in TB clinics in Bangladesh and Pakistan.	All patients report willingness to quit smoking and recent quit attempts. Individuals’ main motivations to quit include their health and the need to provide financially for their family. Behavioural regulation such as avoiding exposure to cigarettes and social influences from friends, family and colleagues are the main themes of the interviews. Most male patients do not feel shy admitting to smoking, for the sole female patient interviewee, stigma was an issue. Health workers report structural characteristics such as high workload and limited time per patient as primary barriers to offering behavioural support.	Sample size, gender bias	***		***
Brunet et al.27 (2011)	South Africa	Cross-sectional study	n=424 patients with suspected TB; mean age 39.5 (18–82) years, 67% male, 71% black African, 28% HIV infected, 36% reported having previously suffered from TB, 65% current smokers and 17% had previously quit smoking. Setting: clinics	1) To estimate the prevalence of tobacco smoking in patients with suspected TB; and 2) to measure the sensitivity and specificity of their self-reported smoking status using plasma cotinine as the reference standard.	The prevalence of current smoking was estimated at 54% (95% CI: 49–58%) by plasma cotinine and 57% (95% CI: 52–61%) by self-report. The sensitivity and specificity of self-reported smoking was 89% (95% CI: 84–93%) and 81% (95% CI: 75–86%), respectively, using plasma cotinine as a reference standard.	Potential mis-classification of exposure due to self-report. The use of cotinine concentration has its own limitations, including the detection of tobacco chewers and patients using NRT, and failure to detect those who had not smoked for >48 h.	***		***
Campbell et al.28 (2014)	Nepal	Prospective controlled intervention study	n=246 cigarette smokers with smear-positive pulmonary TB, aged >16 years. Setting: TB centre	Continuous abstinence for more than 6 months.	Brief simple (= advice given over approximately 10 min at the beginning of TB treatment by a staff member, repeated at 2 and 5 months into TB treatment) resulted in a significant number (39%) quitting the habit for 6 months (CO-validated abstinence) vs 0% in a control group without gender difference.	Allocation to intervention or controls was not randomized. A further weakness was the delay of just over 2 years between the original training and start of enrollment, which arose mainly as a result of administrative problems.	**	*	***
Deepak et al.29 (2012)	India	Community-based, cross-sectional study	n=202 former patients with TB who had completed TB treatment at least 6 months before the interview; mean age 48 years; 52% (106/202) of users of any form of tobacco, 33 smokers, 60 smokeless tobacco (SLT) users, 13 both forms. Setting: TB units	Semi-structured pre-tested interview schedule; abstinence, persistence and relapse rates at eight time-points in relation to diagnosis of TB and treatment completion were analyzed separately for SLT use and smoking.	The relapse rate of SLT use was much higher than that of smoking because most tobacco messages provided by doctors to patients were general in nature and focused on smoking. More tobacco and TB-specific cessation messages need to be given to these patients.	Self-reported tobacco use. The findings of the study are not generalizable to all patients with TB since only patients who accessed TB units and completed treatment were studied.	***		**
El Sony et al.30 (2007)	Sudan	Feasibility study	48 medical assistants (MA), all presented during the study; n=513 previously untreated male patients (new cases) who were enrolled in treatment for pulmonary TB were recruited (81% of current smokers in the intervention group vs 36% in the control group). Setting: primary and respiratory care centres	To examine the feasibility of adding a simple cessation intervention to standard health care services for TB patients. A secondary question assessed the outcomes of tobacco cessation intervention by measuring reported tobacco use rates among patients in the intervention centres at the beginning and end of 12 months of follow-up.	According to baseline questionnaire given to 48 MA prior to the trial, 10 (21%) of the 48 MA reported using some form of tobacco, with no significant difference between those in the control and intervention centres. Only 8% of participating MA reported that they did not allow smoking or snuff dipping (10%) at the health centre and 22 (46%) reported almost always advising their patients about tobacco. Of all tobacco users who were followed up, reported cessation rates increased at each intervention. A 53.6% (165/308) abstinence rate at the end of TB treatment among those who were enrolled in a tobacco cessation program vs 14.3% (6/42) in a control group.	No biochemical validation of the reported high cessation rates.	****	*	***
Gupte et al.31 (2018)	India	Mixed-methods study	n=377 patients (84% men) with TB who were current tobacco users (12% smokers only, 78% SLT users only, 10% dual tobacco users); 25 DOTS providers (80% women, mean age 38 years) from 27 NGOrun centres trained to provide brief advice and cessation support in line with Union guidelines49. Setting: NGO-run DOTS centres	To determine: 1) the number of centres that started implementing brief tobacco cessation programs; 2) the characteristics of TB patients who were current tobacco users, stratified by type of tobacco; and 3) tobacco use status, stratified by TB category, following tobacco cessation advice.	A progressive trend in quit rates was observed during the treatment period (32% among new patients and 15% among those on retreatment, although the quality of documentation related to the brief advice and cessation support provided by DOTS providers declined. DOTS providers also felt that they had acquired the necessary skills needed to implement the intervention and suggested important recommendations including refresher training courses, the possibility of referring difficult patients and/or people with multiple addictions to experts and the need to simplify documentation.	Self-reported tobacco use status, study design.	***		***
Kanakia et al.32 (2016)	India	Crosssectional study	n=424 presumptive patients with TB aged >18 years, mean age 44 years (SD=16), smokers or smokeless tobacco users. Setting: tertiary care hospital	To assess the burden of tobacco use among presumptive TB patients and their willingness to avail of tobacco cessation services at a tertiary care hospital.	41.5% (176/424) use tobacco in previous 1 month (95% CI: 36.9–46.3%), 75% were smokers, 25% SLT form; 53% were willing to avail themselves of tobacco cessation services, if provided; the willingness was higher among those who had attempted to quit and failed in the past 1 year.	Not reported	***		**
Kaur et al.33 (2013)	India	Intervention study	n=2879 TB patients (81.7% with pulmonary TB), 1986 males (69%), registered for DOTS treatment; 46.3% (1333/2879) of TB patients were current users of tobacco – smokers and/or smokeless tobacco users, 89.6% males, 40.8% tobacco users resided in urban areas, and 52.2% were from rural areas. Setting: primary healthcare services	The possibility and outcome of integrating incorporating ‘brief advice’ in tobacco cessation intervention in TB patients who are registered for treatment under a TB control programme and are tobacco users.	While 35.9% of the TB patients were smokers, 39.1% used smokeless tobacco. 61.9% of males and 54.3% of females expressed their willingness to quit. At the end of 6 months, 67.3% of patients who were offered brief advice by the DOTS provider and the same advice was repeated during each interaction with the TB patient during the treatment period, quit tobacco, while 18.2% re-lapsed and 14.5% were lost to follow-up.	The confirmation regarding quitting of tobacco use was subjective assessment based on the self-statement by the patients. It was not validated by performing tests such as urine cotinine or carbon monoxide analysis of breath.	***		**
Lam et al.34 (2013)	South Africa	Cross-sectional study	n=707 recently diagnosed TB patients, aged ≥18 years and diagnosed with TB within the 2 months prior to interview date; 46% men, 73% HIV-infected; 6% (46) current smokers, 38% (267) former smokers. Setting: hospital	Assessed the current and recent smoking prevalence in those with TB and TB-HIV co-infection among hospitalized adults with recently diagnosed TB.	138 former smokers were reclassified as current smokers upon reporting smoking within 2 months before TB diagnosis, resulting in 26% of current smokers (184). By categorizing smoking status solely based on participants’ self-reported status at the time of interview, the group of participants who were current smokers but quit at symptom onset were misclassified as former smokers, when in reality they were smoking at the onset of TB symptoms.	Not reported	****		***
Lin et al.35 (2015)	China	Prospective study	n=244 patients with TB, current smokers from rural China. Setting: public health TB clinics	To assess incorporation of smoking cessation intervention (providing information on the harmful effects of tobacco smoke and smoking and TB+ every follow-up visit with reinforcement health messages and advice to quit) into routine TB services.	A majority (81.6%) had made no attempt to quit before the diagnosis of TB, 95.9% of smokers were willing to quit. 66.7% (156/244) reported abstinence at month 6 = remain abstinent at the end of TB treatment.	Findings may not be applicable to female smokers, as there were none in the study. Smoking status was based on self-report. 20.1% of the TB patients assigned to the SCI were not seen at month 6. Lack of a control group.	***		**
Louwagie & Ayo-Yusuf36 (2013)	South Africa	Cross-sectional study	n=1926 [22% (420/1924) self-reported smokers (37.6%) males] over 18 years of age seeking TB treatment. Setting: TB clinics	Semi-structured questionnaires	About half (51.8%) of current smokers had previously attempted to quit in the past 12 months (median quit duration 21 days), but very few patients had made use of cessation aids or services. The majority of respondents believed tobacco smoking was harmful for their health (90.5% were aware of the risk of lung cancer), but the level of awareness regarding the risk of stroke and heart attack was lower (48.5% and 38.2%, respectively), 40% noted that smokers were more likely to get TB and a third observed that smoking worsens TB, and were highly motivated to quit (median score 9).	The population of TB patients is not representative of all TB patients in the province or South Africa.	***		**
Louwagie et al.37 (2019)	South Africa	Mixed-method study	n=45 patients with TB (82% men, mean age 39.8 years), who smoked, drank alcohol or did both, and had not been treated for TB for more than one month. Setting: clinics	Semi-structured questionnaire to test the feasibility of the ProLife programme (a brief motivational intervention and SMS-programme) by monitoring fidelity to MI sessions and assessing the proficiency of LHW in facilitating the MI sessions.	Multiple risk behavior interventions similar to the ProLife programme can be effective and sequentially addressing smoking alongside other interventions as used in ProLife is preferable to simultaneous interventions. Most patients rated the MI sessions as helpful, ascribed positive attributes to their counselors, and reported behavioral changes. LHW: a) grasped the basic MI spirit but failed to understand specific MI techniques due to insufficient specific practice, b) viewed SMSs favourable, and c) considered limited space and privacy at the clinics as key challenges.	Small sample size. Social desirability bias may have led to overly positive feedback from both LHW and TB patients: Self-reported reductions in drinking and smoking were not validated.	**
Mariappan et al.38 (2016)	India	A community-based cross-sectional study	n=235 patients with pulmonary TB; 83 (35.3%) smokers at the time of diagnosis, 23 (9.8%) used SLT. Setting: primary health care centres	To assess the prevalence and pattern of tobacco use among pulmonary TB patients residing in urban Puducherry and to study the association of various sociodemographic factors with current tobacco smoking and current smokeless tobacco use.	30 patients quit smoking and Self-reported on tobacco use. 22 patients reduced their smoking status after being diagnosed with TB and the rest 37.3% (31/83) maintained their smoking status. Male patients and having lower education were significantly associated with current smoking during TB treatment.	Self-reported on tobacco use.	**		**
Navya et al.39 (2019)	India	Mixed-methods study including a quantitative (cohort study)	n=413 patients; 278 (67.3%) males, mean age 42.6 years; 335 (81.1%) with pulmonary TB, 320 (77.5%) new TB cases, smokers and/ or smokeless tobacco users. Setting: TB units treated under Revised National Tuberculosis Control Programme	To: 1) report the extent of documentation of tobacco and alcohol usage data in the TB treatment card, and 2) explore the process, facilitators and challenges in the linkage of services for tobacco cessation and alcohol abuse from the perspective of health care providers and adult patients with TB.	The documentation of the tobacco use status was good but not universally done. Tobacco use was documented in 322 78%) of the TB treatment cards reviewed. Among the 86 (21%) patients documented as current tobacco users, 16 (19%) were linked to tobacco cessation services while no linkage was documented in the treatment cards of 46 (53.3%) patients.	All of the new TB treatment cards were not available for data collection in the few Tuberculosis Units of Dakshina Kannada district. This would have led to an over- or under-estimation of the results. Data could be validated for only a small subset of the total study population due to challenges in the two steps for obtaining informed consent.	**		**
Ng et al.40 (2008)	Indonesia	Cross-sectional study	n=239 male TB patients who completed the DOTS-based treatment regimen; 218 (91.2%) were ever smokers who had ever smoked even a puff of a cigarette. Setting: lung clinics	Study: 1) documents smoking patterns among TB patients before diagnosis, during treatment and post treatment; 2) identifies messages that health professionals and DOTS providers give their patients about smoking; and 3) identifies factors associated with smoking relapse among TB patients.	Only 11% (n=8) remained daily smokers while on TB treatment. Relapsed smokers were significantly younger and started to smoke their first cigarette earlier than quitters, more often than quitters perceived that smoking causes TB (p=0.01). Only one-third of ex-TB patients reported that they had been advised to quit smoking by a nurse, 69.2% received such advice from a doctor. Receiving a cessation message from one’s doctor was non-significantly associated with a lower likelihood of smoking relapse (OR=0.60).	Potential of recall bias when asking ex-TB patients about smoking levels. Our intention was to assess general levels of smoking at different points of time. Some of these former patients resumed smoking at the same levels as they did prior to illness, while others smoked at lower levels, mistakenly thinking that smoking at such levels is relatively safe.	**		***
Nichter et al.41 (2016)	Indonesia	Prospective two-arm intervention study	n=87 newly diagnosed male TB patients who smoked undergoing DOTS for TB at home. Setting: home	To assess the impact of TB-specific quit smoking messages in the TB clinic and at home.	Although most patients with TB quit smoking when undertaking treatment, nearly a third resume smoking when treatment is completed and this percentage increases to 40% six months later. Many former patients and their family members do not consider low-to-moderate level smokers to be real smokers, particularly those who have reduced their smoking from one to two packs a day to just a few sticks.	Self-report; small sample size.	***	*	***
Pradeepkumar et al.42 (2008)	India	Cross-sectional study	n=215 patients with TB (males); mean age 49.0 years; 94.4% (203/215) were ever tobacco users (smokers and/ or smokeless tobacco users). Setting: TB units	1) To document tobacco use patterns among TB patients at different time points before diagnosis, during treatment and following treatment; 2) to examine how often cessation messages are given to TB patients by health staff and DOTS providers; 3) to investigate how the messages received are understood; and 4) to identify critical points of time when cessation messages need to be given based on when relapse is most likely to occur.	79% quit within 1 week of diagnosis. During treatment period there were only 12.4% of persistent smokers and 87.6% of initial quitters of whom 64.2% stayed permanent quitters at the end of 6 months. Of the 48 relapsed TB patients, one third relapsed within the first 2–3 months of treatment, another third within the next 3 months of treatment and 21% within the 3 months of treatment. More than half of all relapses occurred during the early months of treatment among patients whose DOTS providers were non-health staff. Among patients who had DOTS providers who were health staff, most relapses occurred after completion of treatment.	The data are robust enough to support the conclusions about the need for: 1) repeated exposure of TB patients to smoking cessation intervention, and 2) interventions for former and quitting smokers to encourage sustained cessation.	**		***
Sereno et al.43 (2012)	Brazil	Mixed-methods study	n=16 DOTS providers and supervising physicians; 15/16 women, mean age 45.8 years; 20 patients, current smokers, completed the follow-up questionnaire and urine testing for cotinine. Setting: primary health care centres	A pilot study to determine whether DOTS workers could be trained to deliver smoking cessation counselling and referral interventions, to identify potential barriers to a full-scale randomized controlled trial on the effectiveness of integrated smoking cessation in DOTS, and to determine whether TB patients who smoke would agree to participate in such a program.	Their self-rated ability to communicate the 5 As improved significantly between pre-training and post-training, and to provide smoking cessation support improved without statistical significance. There is a dose-response relation between the session length of person-to-person contact and successful treatment outcomes. However, even minimal interventions lasting less than 3 min increase overall tobacco abstinence rates. Person-to-person treatment delivered for four or more sessions appears to be especially effective in increasing abstinence rates.	The confirmation regarding quitting of tobacco use was subjective assessment based on the self-statement by the patients. It was not validated by performing tests such as urine cotinine or carbon monoxide analysis of breath.	**		*
Shangase et al.44 (2017)	South Africa	Qualitative research design	20 inpatients (15 men) at a TB hospital who self-identified as smokers and had drug-resistant (DR) TB. Age ranged from 18 to 70 years. Setting: hospital	What are the barriers to smoking cessation among DR-TB inpatients in South Africa?	Using smoking as a coping mechanism was identified as an addiction-related barrier (for more details, see Table 3). Lack of access to smoking cessation interventions is a key structurallevel barrier highlighted in this study.	This study recruited participants who were inpatients and were being treated for drug-resistant tuberculosis; therefore, the generalizability of the results to outpatients is limited.	***		***
Shin et al.45 (2012)	China	Qualitative study	Randomly selected hospitalized patients from an inpatient registration list and conveniently selected patients attending an outpatient clinic for screening, aged ≥18 years, had begun treatment for TB in the past 6 months, and had smoked any time during the 30 days prior to diagnosis with TB. Two focus group discussions of 17 TB physicians and five focus groups of 39 patients were conducted. Setting: hospital	To compare perceptions about smoking cessation among TB patients and their physicians.	Patients who were advised to quit smoking by their physicians after diagnosis with TB were likely to progress in their stage membership and attempt to quit smoking. Patients and physicians were concerned about the likelihood of smoking relapse after patients recovered from TB. Physicians had low levels of knowledge regarding the effect of smoking on TB. Many doctors, particularly those who smoked, did not view smoking cessation as an integral part of TB treatment.	The focus groups were conducted * in one TB hospital in Beijing, China. The findings may not be generalizable to TB patients and providers in other TB facilities. Many physicians, particularly those who were smokers, did not view smoking cessation as an integral part of TB treatment and did not believe that their patients would accept smoking cessation counselling.	*		**
Siddiquea et al.46 (2013)	Bangladesh	Cohort study	n=615 current smokers; 99% of men, mean age 38 years (range 16–77); final evaluation possible in 562 patients. Setting: peri-urban TB centres	To determine whether a modified version of The Union’s ABC guideline (5–10 min of brief advice to quit smoking) in Bangladesh was effective in promoting smoking cessation among TB patients and determinants associated with smoking cessation	Overall, 82% (464/562) of smokers had quit and the quit rate increased progressively from the first follow-up to the end of TB treatment (usually at month 6 or 8). Patients were considered to have quit smoking if they reported that they had not smoked tobacco in the past 15 days.	This was a pilot study and may have generated an exceptionally high level of enthusiasm for counselling that led to higher quit rates. Such enthusiasm may not be sustained over the long term if introduced more widely. Self-reporting of quitting.	***		***
Tsai et al.47 (2016)	Taiwan	Cross-sectional retrospective study	n=123 patients with TB at a rural district hospital (78% of men, mean age 61.4 years, 45 [46.9%] smokers before TB diagnosis). Setting: TB outpatient clinic in a local hospital	To evaluate and compare changes in cigarette smoking and health-promoting behaviours reported before and after TB diagnosis among adults in a disadvantaged region.	The percentage of participants who smoked decreased to 30.2% (29/123) after receiving or completing TB treatment, determinants for current health-promoting behaviours were chronic disease (b= –0-.25; p=0.005) and completion of TB treatment (b=0.23; p=0.007). A high prevalence of cigarette smoking and low levels of health-promoting behaviours were observed before the diagnosis and during or after completing TB treatment.	Limited generalisability (relatively uneducated patients from rural hospital were recruited), design of the study and self-reporting of certain health-related behaviours.	**		**
Warsi et al.48 (2019)	Banglades, Nepal, and Pakistan	Mixed-methods study	25 semi-structured interviews and 12 Focus Group Discussion across Bangladesh, Nepal, and Pakistan, and administered the adapted a UK National Centre for Smoking Cessation and Training questionnaire to 36 TB health workers (HWs) (100% in Pakistan and 95% in Bangladesh did not smoke).	A brief behaviour support intervention (a flip book, a leaflet and a poster) was tested with patients and health workers. Health workers received training in delivering a 15–20 min intervention.	Patients were not opposed to being approached about their smoking habit, although HW expressed concerns that women might not admit to tobacco use and that asking about tobacco use was a sensitive issue. HW ability to deliver tobacco cessation behavioural support to patients was hindered by a lack of knowledge about tobacco and TB interaction, low understanding of tobacco cessation, and poor patient communication skills. Additional barriers shown in Table 3.	Use of multiple data sources (health workers, policymakers and patients), multiple methods (focus groups, interviews and questionnaire) and drawing on the theoretical framework of COM-B to guide data collection and analysis.	***		***

^*The Newcastle–Ottawa Scale (NOS) for Assessing the Quality of Nonrandomized Studies¹¹.