Introduction

Smoking and other forms of tobacco use are significant and modifiable risk factors for most non-communicable diseases (NCDs)1, characterised by considerable morbidity and premature mortality. The global prevalence of tobacco dependence prevalence is high, underscoring the urgency of cessation interventions. Recognising this, the World Health Organization recommends ‘help to quit’ as one of its six MPOWER measures (cost-effective steps to reduce tobacco demand) together with the Framework Convention on Tobacco Control as essential to achieve the health-related Sustainable Development Goals2. In 2024, WHO published its first clinical guideline for treating tobacco dependence, reinforcing the need for evidence-based interventions3.

Primary care is uniquely positioned to deliver tobacco cessation support, given their frequent encounters with tobacco users over a year, including young people, and their ability to provide context-specific advice and continuity of care to manage relapses4. Tobacco dependence is a treatable long term condition if diagnosed, and a first line treatment for chronic obstructive pulmonary disease (COPD); and primary care is well-placed to diagnose and offer treatment1. Despite this, primary care is not always confident or competent in delivering behavioural change and evidence-based approaches such as ‘Very Brief Advice’ or ‘Brief Advice’5. A well-documented ‘practice gap’ persists: international studies indicate that only between 40 and 70% of smokers receive cessation advice from their physician; and fewer than 20% of practitioners provide specific assistance with quitting, such as behavioural support and medications6. Systemic challenges worsen this gap, including limited availability, high costs, and inadequate reimbursement for pharmacotherapy7 and, in some countries, a culture of tobacco use even amongst clinical professionals8,9. Globally, many primary healthcare systems are under-financed10. There is also a substantial variation globally and regionally in the development of the specialty of family medicine, which has the potential to spread the teaching and practice of behaviour change11.

Therefore, there is a need to find sustainable ways to build the competence and confidence of the primary care workforce2. To date, national curricula for medical trainees and in-training for specialist treatment providers do not routinely include smoking cessation education and training therefore most health professionals will not have expertise to deliver these interventions12,13,14. To address such gaps, the International Primary Care Respiratory Group (IPCRG) has developed the ‘Teach the Teacher’ programme-a flagship initiative aimed at building primary care teaching capacity. This approach equips national educators with the teaching skills and knowledge to adapt clinical content to local contexts, ensuring sustainability. IPCRG has successfully implemented this model in multiple countries for teaching asthma diagnosis and management and smoking cessation15.

Teach the teacher programme

The IPCRG Teach the Teacher (TtT) programme is a three-tiered educational capacity building intervention to develop teaching capacity in primary care (Fig. 1). It grew out of the European Academy of Teachers in General Practice (EURACT) primary care teaching and learning model9,15,16, which encompasses adult learning principles, needs assessment, objective setting, learning design and assessment, and is taught in parallel with evidence-based clinical content. The approach aims to empower clinicians working in multiple health systems and in different languages, to think creatively about the development of context specific programmes that strive to maintain fidelity to the evidence and to select appropriate teaching methods to encourage behaviour change.

Fig. 1
figure 1

Provides an overview of the Teach the Teacher model for treating tobacco dependence.

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The first step of this programme is the recruitment of an IPCRG Master Faculty, with the skills, knowledge and experience in teaching teachers and in teaching the clinical content, such as smoking cessation skills. Next, the Master Faculty analyses the current context, recruits and mentors a cohort of national teachers and leaders who can both motivate the learners to prioritise the clinical content (e.g., smoking cessation) and adapt the evidence to the local context and learning needs of the learners, whilst ensuring fidelity to the evidence.

Tobacco dependence teach the teacher

The Tobacco Dependence Teach the Teacher (TD TtT) programme was co-created with four of IPCRG’s country members: three eastern European countries; Romania, Bulgaria, North Macedonia, and one Euro-Asian country, the Kyrgyz Republic. The four countries each had a very high prevalence of smoking, particularly in those aged over 15 years (range 37.1–50.5%), and a limited availability of cessation referral services and pharmacotherapy, reflecting the reality of many regions, even where there is commitment to help smokers quit.

Tier 1: Country master faculty teaching

Prior to Tier 1, each IPCRG country partner nominated five individuals to become the Country Master Faculty. Preliminary situational analyses were undertaken to understand local healthcare contexts, smoking cessation infrastructure, and teaching traditions. In March 2017, a face-to-face international meeting was held between the IPCRG Master Faculty and 19 national teachers nominated to serve as the Country Master Faculty and lead teaching efforts in their respective countries. Tier 1 consisted of 10 modules and approximately 16 h of learning and networking.

During this meeting, participants adapted the Very Brief Advice (VBA) protocol for each country balancing fidelity17 with differences in country contexts, particularly the “Act” element reflecting limited access to treatments or specialist service. VBA is an evidence-based intervention suitable for primary care consultations and follows three steps. Healthcare providers ‘Ask’ all patients about tobacco use (smoking or smokeless) at every clinical contact and document patients’ tobacco/ smoking status, ‘Advise’ about effective ways to quit (and if necessary, about the harms of tobacco), and ‘Act’ by offering/ signposting help, where requested by the tobacco dependent patient. VBA+ adapts the “Act” step to better fit contexts where access to cessation treatments (e.g. medications, specialist services) is limited or inconsistent, health system resources are scarce, and there is a need for locally tailored strategies, including the practitioner also offering the help to quit1,18,19. The IPCRG Master Faculty role-modelled both the delivery of VBA and teaching skills such as role play, short lectures and small group work, which was not the typical teaching style in all collaborating countries. By the end of the meeting, a core curriculum (how and what to teach national teachers) was agreed, representing a draft national education programme for treating tobacco dependence using VBA.

Tier 2: National faculty development

For Tier 2, each Country Master Faculty, supported and mentored by an assigned member of the IPCRG Master Faculty (participants from each site in Tier 1) recruited a cohort of national primary care educators, based on a jointly agreed person specification. All five country sites overrecruited teachers, selecting experienced primary care educators and family physicians. In national workshops held in 2017, these educators supported by their mentors, translated the core curriculum and VBA + protocol to the national context. The Country Master Faculty applied their teaching skills to build the educators’ confidence and competence to deliver the adapted curriculum to frontline primary care professionals. All the sites used the co-developed Tier 1 materials with contextual adaptations and reported strong participation and engagement during the Tier 2 workshops. Upon completion, the “graduates” from Tier 2 then became the teachers in Tier 3—responsible for delivering Tier 3 workshops aimed at equipping primary care professionals with the skills to implement the VBA+ model in everyday practice. By the end of Tier 2, 117 teachers were equipped with the teaching skills to develop national programmes (32 in Romania, 39 in Kyrgyz republic, 21 in Bulgaria, 25 in North Macedonia), and were enthused by the value of treating tobacco dependence in primary care.

Tier 3: Local implementation and system impact

In Tier 3, the new primary care educators delivered a series of VBA+ education programmes for primary care professionals (PCPs) across regions in four participating countries between 2018 to March 2019. All the four sites achieved strong reach of 985 primary healthcare workers (456 in Romania, 225 in North Macedonia, 200 in Kyrgyz republic, and 104 in Bulgaria). Project reports from all countries indicated a positive response to the programme and adoption of VBA in clinical practice. However, in one site (Romania) clinicians were reluctant to provide counselling and prescribe pharmacological treatment without financial incentives. In North Macedonia, there was no established pathway for accessing pharmacological treatment. Despite these barriers, the programme created value that was larger than skills transfer: participants were motivated to take on leadership roles in tobacco dependence.

In Romania, the project spurred an awareness programme that gained coverage on national television and resulted in a peer-reviewed publication10. Recognising the normalisation of tobacco use in the country, the Romanian team conducted qualitative research on tobacco use in young people, leading to their inclusion in the Horizon Europe implementation science programme, FRESHAIR4Life, which focuses on protecting adolescents from exposure to tobacco20. In Bulgaria, sustained advocacy of the use of VBA in tobacco dependence led to its inclusion in the National Programme for the Prevention of Control of Respiratory Diseases and Allergy (2016–2020). Similarly, in the Kyrgyz Republic, VBA for smoking cessation has been incorporated in the State Programme for the Protection of the Health of Citizens of the Kyrgyz Republic from the harmful effects of Tobacco for 2017–2025, and the national team is now actively collaborating on the FRESHAIR4Life programme20. In North Macedonia, the team has begun working with the World Health Organization’s local office to institutionalise changes into the health system including mandatory clinical undergraduate education in tobacco dependence.

This was a complex, multi-country capacity-building project that demonstrated the value of a three-tier cascade approach to continuing medical education (CME) in the treatment of tobacco dependence in primary care. It set out to address the shortage of expert primary care teachers and built confidence and knowledge of the importance of treating tobacco dependence in primary care. The TtT approach has previously been shown to increase capacity to teach in primary care settings18.

Lessons learned

The TD TtT programme demonstrated clear value in increasing primary care use of VBA; although systematic data collection to evidence the impact on quit attempts and successful quits proved challenging. Several contextual factors contributed to this limitation. Clinicians are often burdened by competing data requests from multiple stakeholders. Documentation of patient smoking status and the delivery of VBA may not be officially mandated by national ministries of health, making it a lower priority in routine practice. Consequently, there are no country-wide data collection systems or incentives to support consistent reporting. Additionally, primary care doctors may lack motivation to complete apparently non-essential paperwork and statistical surveys, especially in the absence of electronic health records and appropriate coding frameworks.

During programme development, the North Macedonia team raised the issue of the compatibility of VBA with motivational interviewing (MI)21, which is another behaviour change model commonly used in primary care and taught in the medical education curriculum in the country. VBA avoids persuading individuals who are not ready to quit, whereas MI would typically seek to explore and enhance motivation even among ambivalent smokers, which can make these two approaches seem philosophically incompatible. These tensions required careful facilitation and clarification during curriculum adaptation and teacher training. Studies have reported the integration of VBA and motivational interviewing for tobacco cessation21,22; raising the need to explore this combined approach further.

Demonstrating impact across diverse health care systems with variable motivation, priorities, rewards and lack of appropriate systems and software is inherently complex. Given these challenges, implementation science methods would be a more appropriate evaluation approach to determine whether the intervention, VBA+, was taught and delivered accurately and consistently at all tiers of the programme and to identify the barriers and enablers. In-depth qualitative interviews with educators and clinicians could generate insights into how the programme was understood, adapted and applied but, as with most education programmes, there is insufficient funding for evaluation. IPCRG plans to rectify this gap in the FRESHAIR4Life implementation science programme, where VBA is being taught using a Teach the Teacher method, adapted for new countries and for adolescents, with funding for evaluation using the RE-AIM framework20,23.

In terms of enablers of success, it is difficult to isolate specific factors or conditions, as economic, political and social contexts all play a substantial role in shaping outcomes24. There were commonalities in broad aims and challenges across the country cases and in the motivation of the Tier 1 Masters, but also substantive differences in organisational, functional, professional, and service integration as well as population focus. These differences are useful in understanding the varied forms that implementation can take. Contrasting the country cases provides important lessons for service providers and policymakers seeking to build capacity to address tobacco dependence and similar initiatives. Several factors may be significant for the success of this model as outlined below.

Relatively new specialism of family medicine

In the World Bank classification, Romania and Bulgaria were upper-middle income countries until 2020 and 2022 respectively and are now classified as high income, North Macedonia remains categorised as upper-middle income and the Kyrgyz Republic as a lower-middle income country25. In North Macedonia, specialisation in family medicine started in 2010 and in 2011 a retraining programme for existing general practitioners was developed. In Bulgaria, primary healthcare is provided in individual or group medical practices, with around 40% of GPs being specialists in family medicine. In Romania, general practice became known as family medicine in 1999 with a major reform of the primary health care system26. In the Kyrgyz Republic family medicine is also a new specialty. Here, 80% of patients attend primary healthcare which is delivered by family physicians in urban centres and nurse-led teams in rural regions. Despite these developments, evidence indicates in all four countries, the motivation, opportunity and capability for primary care professionals to provide advice and support on smoking cessation remain low10.

Smoking status of healthcare professionals

Doctors are seen as public health role models and their smoking status can influence their motivation and credibility in delivering smoking cessation interventions. In North Macedonia, a 2014 survey found declining prevalence of smoking amongst doctors over the past decade from 42–29%27. However, based on international comparisons this rate still remains high. Anecdotal information from Romania, the Kyrgyz Republic, and Bulgaria suggests similarly high rates of prevalence of smoking amongst clinicians. This challenge is compounded by the relative novelty of the speciality of family medicine, and the lack of practical skills in cessation support in both under-graduate education and specialist training.

Capacity of primary care professionals to treat tobacco dependence

To date, there has been little investment in increasing the capacity of primary care professionals to treat tobacco dependence in these four countries. However, resources for medical education for primary care professionals and the infrastructure for delivering these are now being developed. There is also a growing awareness of and willingness among health professionals to participate in medical education initiatives. This offers an opportunity to integrate treatment for tobacco dependence in Continuing Medical Education (CME) for primary care professionals in these four countries. The IPCRG’s TtT programme was introduced to address the ‘practice gap’ by building a sustainable network of teachers equipped to train primary care professionals-including vocationally trained family physicians and GPs (and nurses in Kyrgyz republic) to treat tobacco dependence. One successful impact of this model is that the VBA+ training has now been incorporated into the vocational training of family medicine in North Macedonia, which could be extended to a wider range of primary care professionals.

Lack of pharmacotherapy or specialist services for referral

The VBA+ model was intentionally taught to be adaptable to contexts lacking dedicated specialist services1,19. However, the lack of access to specialist quit smoking services and limited availability and universal coverage for tobacco dependence pharmacotherapy remain significant barriers to successful treatment and follow-up support.

Competing primary care priorities

To overcome existing barriers such as a limited consultation time and competition with other reimbursable services, structural changes to primary care incentive systems favouring help to quit tobacco is needed. Aligning financial and operational incentives to support tobacco cessation would help ensure that smoking cessation becomes a routine and prioritised component of primary care28.

Conclusion

IPCRG’s TtT programme for tobacco dependence has demonstrated that it is both feasible and effective to co-create a single core curriculum that integrates evidence-based educational strategies with practical approaches to treating tobacco dependence. However, fidelity alone is an insufficient metric of success13, especially in countries where access to evidence-based treatments is limited. New protocols need to be developed and adapted to reflect local realities and resource constraints. Our experience underscores the insufficient investment in treatment of tobacco dependence in eastern Europe and Euro Asia, despite its high prevalence and substantial burden it places on health outcomes and healthcare system utilisation. While MPOWER has promoted prevention strategies, this should be balanced with its treatment strategies.

The ‘Teach the Teacher’ model has been demonstrated as a scalable and sustainable approach for building the capacity of primary care professional to adapt and deliver the VBA model fast and effectively, but this needs system change and organisational support. Without structural change—including better incentives, access to pharmacotherapy, and behavioural counselling—the ability of primary care professionals to deliver effective, evidence-based cessation support for patients who are most tobacco dependent, will remain constrained28.

This programme is also a good example of behavioural and structural challenges involved in promoting lasting change. It can build good habits for example, using VBA every time, but if there is poor access to nicotine replacement therapy and other support, or no real targeting of role models e.g. doctors who are tobacco dependent, and no material incentives, it is unlikely to be sustained or succeed. As highlighted by WHO, scaling up of smoking cessation services to encourage smokers to quit is “imperative”3; it is a life-saving intervention28. Treating tobacco dependence should be included in every primary care curriculum and supported by national policy and funding frameworks; without this, even the best educational interventions will fall short of their full potential.