Advancing Tobacco Dependence Treatment Services in the Eastern Mediterranean Region International collaboration for training and capacity-building e442 | SQU Medical Journal, November 2014, Volume 14, Issue 4 Sultan Qaboos University Med J, November 2014, Vol. 14, Iss. 4, pp. e442−447, Epub. 14TH Oct 14 Submitted 13TH Feb 14 Revisions Req. 11TH Mar & 22ND Apr 14; Revisions Recd. 6TH & 27TH Apr 14 Accepted 1ST May 14 Smoking tobacco-based products harms nearly every organ in the body and has been linked causally to a diminished health status in general. Specifically, smoking is linked to several non-communicable diseases (NCDs) which have recently advanced their ranking among the most frequently reported causes of death in the Arab world.1 Tobacco-related cancers include lung cancer, head and neck cancers, bladder cancers and leukaemia.2 New evidence has emerged suggesting that colorectal and liver cancers are also caused by smoking.2 In addition, smoking is a common risk factor for other NCDs, namely cardiovascular diseases and respiratory illnesses and is an independent risk factor for diabetes mellitus; in fact, smoking raises an individual’s risk of developing diabetes by 30–40% compared to non- smokers.2 The annual death toll caused by tobacco use, which stood in 2008 at five million, is expected to rise to eight million by 2030, with individuals from low- and middle-income countries making up approximately 80% of these deaths.3 Tobacco smoking, including second-hand smoke inhalation, ranked third in terms of the global burden of disease in 1990; today, it is now ranked second within an array of risk factors.4 In North Africa and the Middle East, tobacco smoking, including second-hand smoke inhalation, ranked third in 2010 only after high blood pressure and a high body mass index (BMI), based on the attributable burden of disease.4 Results from the World Health Cancer Control Office, King Hussein Cancer Center, Amman, Jordan *Corresponding Author e-mail: fhawari@khcc.jo النهوض باخلدمات العالجية إلدمان التبغ يف منطقة شرق املتوسط تعاون دويل للتدريب وبناء القدرات فرا�س الهواري و ر�شا بدر abstract: Tobacco use negatively affects health and is a major risk factor for non-communicable diseases (NCDs). Today, tobacco use ranks third among risk factors in North Africa and the Middle East in terms of disease burden. Despite the established need for these services, tobacco dependence treatment (TDT) services are still inadequate in the Eastern Mediterranean region (EMR). Among the main challenges hindering their expansion is the current lack of training opportunities. The provision of training and capacity-building—a key enabler of TDT—offers an excellent catalyst to launch TDT services in the region. This review discusses the need for TDT training in the EMR and describes a model for providing regional evidence-based training in line with international standards. The King Hussein Cancer Center in Amman, Jordan, is the regional host for Global Bridges, a worldwide TDT initiative. Using this model, they have trained 1,500 professionals and advocates from the EMR over the past three years. Keywords: Chronic Diseases; Tobacco Dependence; Smoking Cessation; Education; Capacity Building; Eastern Mediterranean Region. لعوامل الثالثة املرتبة التبغ يحتل ال�شارية. غري للأمرا�س كبري خطر عامل و ال�شحة على �شلبية تاأثريات ذا التبغ يعترب امللخ�ص: الخطرمن ناحية عبء املر�س يف �شمال اأفريقا و ال�رشق الأو�شط. بالرغم من احلاجة املعتمدة لهذه اخلدمات، تعترب خدمات علج اإدمان التبغ يف الوقت احلايل غري كافية يف منطقة �رشق املتو�شط. ويعترب النق�س احلايل يف فر�س التدريب من اأهم التحديات التي تعيق تو�شع هذه اخلدمات. اال�شتعداد امل�شبق للتدريب وبناء القدرات هام املفتاح لتمكني علج اإدمان التبغ حيث تعطي حافزا ممتازا النطلق اخلدمات املتو�شط �رشق منطقة يف التبغ اإدمان علج يف للتدريب احلاجة االستعرايض املقال هذا يناق�س املنطقة. يف التبغ لإدمان العلجية م�شيف هو الأردن، بعمان، لل�رشطان مركزاحل�شني الدولية. للمعايري موازي و الأدلة على قائم اإقليمي تدريب اعطاء منوذج وت�شف اإقليمي ملبادرة اجل�شور العاملية، كاملبادرة العاملية لعلج اإدمان التبغ. باإ�شتخدام هذا النموذج، مت تدريب 1500 من املهنيني وموؤيدي املبادئ من منطقة �رشق املتو�شط خلل الثلث �شنوات املا�شية. مفتاح الكلمات: الأمرا�س غري ال�شارية؛ التدريب؛ اإدمان التبغ؛ الإقلع عن التدخني؛ بناء القدرات؛ �رشق املتو�شط. REVIEW Advancing Tobacco Dependence Treatment Services in the Eastern Mediterranean Region International collaboration for training and capacity-building *Feras I. Hawari and Rasha K. Bader Feras I. Hawari and Rasha K. Bader Review | e443 World Bank estimated that 200 million deaths could be prevented by 2050 if adult tobacco consumption were to be halved by 2020.9 In comparison, halving the number of young people who take up smoking would have a negligible effect on short-term mortality rates.9 The inclusion of smoking cessation advice in primary healthcare settings has proven to be a low-cost strategy since the only major investment required is in training providers and availing informational materials to tobacco users.3 However, pharmacotherapy, while more expensive than offering cessation advice, has been shown to double or triple quit rates.3 In general, TDT interventions are extremely cost-effective when compared to the treatment of other chronic diseases. For example, compared to treatments for hypertension, TDT saves three times as many lives and takes on average only around two hours of a specialist’s time, which is much quicker than the time required to treat a case of hypertension.10 In general, the cost- effectiveness of TDT exceeds that of other commonly provided clinical preventative services, including Pap tests, mammographies and screening for colon cancer, as well as treatment for high serum cholesterol levels and mild to moderate hypertension.11 Different countries have adopted different systems for offering TDT, building on variables such as income level, as was observed in a case series on TDT implementation in Brazil, England, India, South Africa and Uruguay.12 Not all of the studied countries had national policies mandating that this treatment be offered, and furthermore, while some of the countries’ TDT policies relied on offering broadly available brief advice, others were dependent on specialist support which was often limited in availability. In addition, the extent of medication coverage and reimbursement of provider time varied from one country to another.12 However, training and skill-building are integral to various models of TDT provision. For example, England, a high-income country, offers TDT as part of their National Health Service (NHS) plan. Both widely available brief advice and more intensive specialist support are offered to smokers, with the majority of the costs covered by the NHS. In this model, significant emphasis is placed on the training and skills of service providers and England has accordingly established a national centre to address training, certification and performance evaluation for TDT providers.12 In Uruguay, an upper-middle-income country of 3.5 million, 100 TDT programmes were established by 2010. These programmes offer training to HCPs and provide free TDT medication to smokers. Moreover, Uruguayan law mandates that public and private service providers record the smoking status of all patients in their medical notes, incorporate a diagnosis Organization (WHO) Report on the Global Tobacco Epidemic in 2008 indicate that the age-standardised prevalence of tobacco smoking among men in the Eastern Mediterranean region (EMR) ranged from 63% in Jordan and 51% in Tunisia to 25% in Oman.3 In 2012, the estimated age-standardised prevalence of daily smoking among men in the EMR ranged from 43% in Jordan and 45% in Tunisia to 13% in Oman.5 For an individual, quitting smoking brings about immediate health benefits, including the normalisation of heart rate and blood pressure and a decrease in coughing and the production of phlegm.6 In the long term, quitting tobacco generally reduces the risk of disease and premature death by 90% for those who quit before the age of 30 and by 50% for those who quit before the age of 50.6 Five years after quitting, the risk of stroke falls to that of a non-smoker and the risk of head, neck and bladder cancers is reduced by half.7 One of the six policies recommended by the WHO to counter the tobacco epidemic is a country- level initiative in offering help to smokers in quitting tobacco use; these measures are intended to assist in reducing the demand for tobacco.3 However, despite this policy and the documented short- and long-term benefits of quitting smoking, tobacco dependence treatment (TDT) services continue to be scarce and inconsistent across the EMR. Many factors contribute to this shortage of TDT services, including the lack of training opportunities for healthcare providers (HCPs) in the basic skills needed to deliver these services. This review justifies the urgent need for establishing TDT services across the EMR and describes a model of international collaboration that addresses one of the most important limitations for establishing these services—the training of HCPs in delivering effective and relevant TDT to interested smokers. Tobacco Dependence Treatment TDT is an integral component of any comprehensive tobacco control effort. In Article 14 of their Framework Convention on Tobacco Control (FCTC), the WHO mandates that parties should design and implement effective programmes to promote the cessation of tobacco use and provide adequate treatment for tobacco dependence.8 They furthermore recommend the inclusion of cessation advice in primary healthcare services, establishing accessible and free ‘quitlines’ and making low-cost pharmacotherapy available to interested smokers.3,8 Likewise, in a report issued in 1999, the World Bank urged governments seeking health and economic gains to encourage smokers to quit.9 Building on previously published data, the Advancing Tobacco Dependence Treatment Services in the Eastern Mediterranean Region International collaboration for training and capacity-building e444 | SQU Medical Journal, November 2014, Volume 14, Issue 4 of tobacco dependence and offer relevant treatment through primary care programmes.12 National guidelines are in place and efforts are underway to ensure that the national treatment programmes have complete population coverage.12 Brazil and India, two lower-middle-income countries, have focused on establishing a limited number of specialised treatment units.12 These services, while not necessarily wide-reaching, act as training hubs for HCPs. Although only Brazil currently has a national TDT policy, both countries have developed and adopted national TDT guidelines.12,13 Medication is available through treatment units in both countries but is only reimbursed in Brazil.12 The situation in the EMR is similar to that in other parts of the world; while a significant number of smokers have shown interest in quitting, the availability of TDT services continues to be limited and grows only marginally from year to year.3,14‒16 Accordingly, TDT services are not consistently available across the EMR and are not yet integrated within the healthcare system. While some countries, including Kuwait, the United Arab Emirates (UAE) and Iran, offer a ‘quitline’ and cover costs for cessation services and nicotine replacement therapies (NRTs), most EMR countries offer partial to no coverage for smokers attempting to quit.14 Correspondingly, the data on screening for tobacco use demonstrate that there is insufficient screening and advice for smokers. For example, data from 2009 indicated that only 22% of smokers in Egypt had visited an HCP in the previous 12 months.17 Among smokers, only 74% were screened for smoking and, of those screened, only 67% were advised to quit smoking.17 In Qatar, data from 2013 revealed that only 71% of smokers in the country had been advised in the previous 12 months to quit smoking.16 Training and Capacity-Building The training and capacity-building of service providers is a key measure in developing an infrastructure that supports smoking cessation and TDT, as highlighted by the guidelines for the implementation of Article 14 of the FCTC.8 At a minimum, the guidelines recommend that HCPs be trained to record tobacco use among patients, provide brief advice, encourage attempts to quit and refer smokers to specialised TDT services. Additionally, the FCTC states that cessation training be incorporated into the curricula of all health professions as well as within continuous professional development programmes.8 Muramoto et al. noted that training and education in general enhances physicians’ confidence and their readiness to offer TDT services as well as advise and counsel patients on smoking cessation.18 In spite of the clear need for such programmes, there continues to be a lack of education and training programmes concerning TDT in healthcare disciplines. This was demonstrated during a survey of 171 countries in 2009 which found that only 27% of medical schools taught a specific module on tobacco.19 Specifically in the EMR countries, results from the Global Health Professions Student Survey indicated a shortage of formal training in smoking cessation approaches in medical schools.20 The percentage of medical students who reported receiving training ranged from approximately 40% in Kuwait, Tunisia and Bahrain to approximately 9% in Morocco.20 Similar gaps in training and education were revealed in other healthcare disciplines.20 In a survey of medical students in the USA, respondents who reported receiving instruction, modelling and feedback on TDT by their preceptors in medical school had a higher self-reported skill level compared to those who recalled receiving less comprehensive training.21 However, a lack of staff, incentive and financial resources to support TDT teaching appears to present major barriers to its implementation, preventing less developed countries from incorporating a tobacco module into their medical curricula.19 To that end, developing the capacity of faculty members becomes critical in attempts to institutionalise TDT education and training for students in health professions.18 A systematic review of educational- and practice- based programmes concluded that HCPs could be better engaged in TDT if they were intercepted both during their education and once they became healthcare professionals; while the first affects quit rates among their patients, the latter is effective in increasing screening rates.22 A recent Cochrane review looked at randomised trials with interventions involving the training of HCPs in smoking cessation techniques.23 The review concluded that such training had a measurable effect on the continuous tobacco abstinence among patients and the point prevalence of smoking. Additionally, trained HCPs were more likely to make follow-up appointments, provide smoking cessation counselling and ask patients to set a quit date.23 Yet, and despite the proven value of such training progammes, an international survey of TDT training programmes could identify only four programmes in the EMR, training a total of 98 individuals in 2007.24 Model for Tobacco Dependence Treatment: King Hussein Cancer Center The King Hussein Cancer Center (KHCC) is a comprehensive cancer care facility in Amman, Jordan. Since 2008, KHCC has offered TDT services to Feras I. Hawari and Rasha K. Bader Review | e445 TDT services. The methods employed vary between teaching, interactive exercises and case studies derived from the trainers’ own treatment practices. Pre- and post-workshop tests are utilised to gauge the benefits of the training while a workshop evaluation is used to collect feedback in order to inform any updates and upgrades to the curriculum. Workshops are conducted in close coordination with in-country partners who understand the situation within the local context and can influence the programme’s design and execution, in addition to providing continuing medical education accreditation for the workshops. The international collaboration demonstrated within the Global Bridges initiative is testimony to how a regional problem can be successfully addressed through global partnerships. To date, KHCC has trained over 1,500 HCPs and advocates from the EMR on tobacco control and TDT [Figure 1]. A total of 20 workshops and conferences have been held in six cancer patients and the general public, endeavouring to address the gaps in capacity and competence that limit the reach of TDT services and patients’ access to help. Realising the importance of training HCPs in evidence-based treatment, KHCC started offering TDT training to HCPs in EMR countries in 2011. This was done via a collaboration with Global Bridges, an international healthcare TDT alliance that was co- founded by the Mayo Clinic, the American Cancer Society and the University of Arizona. The Global Bridges initiative seeks to create opportunities to share treatment and advocacy expertise and to provide state-of-the-art training to countries around the world in order to help them fulfill Article 14 of the FCTC. While other organisations represent Global Bridges throughout Latin America, Africa and Europe, KHCC is the regional host and partner for this initiative in the EMR. In this capacity, KHCC developed a standard TDT curriculum designed to respond to the identified needs and gaps in the region. The training curriculum content was built on internationally recognised standards and is implemented during a three-day workshop which aims to enhance the participants’ understanding of TDT as an integral component of tobacco control and to equip trainees to practice TDT and handle various cases. The topics covered include a general introduction to tobacco and its products; tobacco and NCDs; the process of addiction, withdrawal and relapse; conducting counselling and motivational interviews; pharmacotherapies, and building individualised treatment plans. Additional training sessions seek to present TDT in the context of tobacco control in general; highlight ethical issues in TDT; present the water-pipe as a regional and global health hazard, and guide participants through establishing and sustaining Figure 1: Graph indicating the recent cumulative growth in the number of trained healthcare providers and advocates attending tobacco dependence treatment training conducted by the King Hussein Cancer Centre in the Eastern Mediterranean region. Figure 2: Distribution map representing the geographic reach of the tobacco dependence treatment training conducted by the King Hussein Cancer Centre in the Eastern Mediterranean region (EMR). Jordan, Tunisia and the United Arab Emirates have hosted three or more workshops to date. Most countries in the EMR region have been represented at these workshops. Advancing Tobacco Dependence Treatment Services in the Eastern Mediterranean Region International collaboration for training and capacity-building e446 | SQU Medical Journal, November 2014, Volume 14, Issue 4 countries in the EMR; participants attended from a total of 19 countries, spanning Morocco to the UAE, as well as Iran and Afghanistan [Figure 2]. Additionally, the participants had varying professional backgrounds, including cardiology, oncology, pulmonology, general medical practice, nursing and pharmacology, among others. This diversity highlights the level of interest in such training and the enthusiasm for establishing these programmes across the region. Other Challenges Facing Tobacco Dependence Treatment in the Eastern Mediterranean Region While training programmes such as the one described above seek to bring about significant progress, the EMR continues to face other challenges that hinder service expansion. Political commitment across the region to tobacco control is not uniform and the tobacco industry has been gaining traction in some EMR countries.25–27 As developed nations around the world tighten their regulations on the tobacco industry, the developing nations of the EMR, with their relaxed tobacco control regulations, may present a safe haven for this industry.25–27 Tobacco companies are state-owned in eight EMR countries, while multinational corporations have recently established operations in other Middle Eastern countries, such as in Jordan and Egypt.26‒28 Another challenge that may hinder the expansion of TDT services in the region is the prevalence of tobacco use among physicians and other healthcare workers. In 2010, 24–42% of medical students in the EMR were either current smokers or had previously been smokers.20 This undermines the role that HCPs should play in diminishing the social acceptability of tobacco use; it also reduces their credibility in promoting TDT services.8 It is therefore imperative that teaching and training programmes for HCPs address tobacco control and TDT early on and that special attention is given to first helping these professionals quit tobacco use themselves. In general, the infrastructure necessary to enable TDT services is not yet available in many EMR countries, particularly as there are no national policies to promote tobacco cessation. Screening for and recording tobacco use is not yet common practice among HCPs and the availability of TDT medication may be interrupted. Inadequate accessibility to services and treatment coverage present more barriers. In particular, the lack of treatment coverage is a key obstacle that needs to be addressed in parallel to any attempts to increase TDT services. Experiences in other countries have shown that the extent of treatment coverage influences the utilisation rate of cessation services; the rate of usage has the potential to quadruple if full coverage is provided.29‒31 Finally, population-level strategies that promote cessation and encourage smokers to quit, such as price measures and pictorial warnings on tobacco products, are either not in place or are only in the early stages of implementation, adding to the challenges facing the expansion of TDT services in this region.32 Conclusion In summary, the rise in the prevalence of tobacco use in the region is alarming and calls for quick and decisive action in EMR countries, specifically the implementation of WHO-recommended strategies for tobacco control. In the short term, helping smokers to quit is highly feasible. Enabling and training HCPs, potentially through international collaborations, should help build the skills needed to deliver effective TDT measures to smokers throughout the EMR. acknowledgements KHCC is a grantee of the Mayo Clinic in the USA for conducting Global Bridges work in the EMR. References 1. Mokdad AH, Jaber S, Aziz MI, AlBuhairan F, AlGhaithi A, AlHamad NM, et al. The state of health in the Arab world, 1990-2010: An analysis of the burden of diseases, injuries, and risk factors. Lancet 2014; 383:309–20. doi: 10.1016/S0140- 6736(13)62189-3. 2. United States Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General, 2014. From: www. surgeongeneral.gov/library/reports/50-years-of-progress/ Accessed: Jan 2014. 3. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package. From: www.who.int/tobacco/mpower/mpower_report_full_2008.pdf Accessed: Jan 2014. 4. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair- Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380:2224– 60. doi: 10.1016/S0140-6736(12)61766-8. 5. Ng M, Freeman MK, Fleming TD, Robinson M, Dwyer- Lindgren L, Thomson B, et al. Smoking prevalence and cigarette consumption in 187 countries, 1980-2012. JAMA 2014; 311:183–92. doi: 10.1001/jama.2013.284692. 6. National Cancer Institute. Harms of Smoking and Health Benefits of Quitting. From: www.cancer.gov/cancertopics/ factsheet/Tobacco/cessation Accessed: Feb 2014. 7. American Cancer Society. Guide to Quitting Smoking Benefits. From: www.cancer.org/healthy/stayawayfromtobacco/ guidetoquittingsmoking/guide-to-quitting-smoking-benefits Accessed: Feb 2014. Feras I. Hawari and Rasha K. Bader Review | e447 21. Geller AC, Hayes RB, Leone F, Churchill LC, Leung K, Reed G, et al. Tobacco dependence treatment teaching by medical school clerkship preceptors: Survey responses from more than 1,000 US medical students. Prev Med 2013; 57:81–6. doi: 10.1016/j.ypmed.2013.04.006. 22. Anderson P, Jané-Llopis E. How can we increase the involvement of primary health care in the treatment of tobacco dependence? A meta-analysis. Addiction 2004; 99:299–312. doi: 10.1111/j.1360-0443.2004.00672.x. 23. Carson KV, Verbiest ME, Crone MR, Brinn MP, Esterman AJ, Assendelft WJ, et al. Training health professionals in smoking cessation. Cochrane Database Syst Rev 2012; 5:CD000214. doi: 10.1002/14651858.CD000214.pub2. 24. Rigotti NA, Bitton A, Richards AE, Reyen M, Wassum K, Raw M. An international survey of training programs for treating tobacco dependence. Addiction 2009; 104:288–96. doi: 10.1111/j.1360-0443.2008.02442.x. 25. Bollyky TJ, Glassman A; Center for Global Development. Incentives for Life: Cash-on-Delivery Aid for Tobacco Control in Developing Countries. From: www.cgdev.org/publication/ incentives-life-cash-delivery-aid-tobacco-control-developing- countries Accessed: Feb 2014. 26. Eriksen M, Mackay J, Ross H. The Tobacco Atlas. 4th ed. Atlanta, Georgia, USA: American Cancer Society, 2012. Pp. 54–7, 66–82. 27. Awraq Investments. Al-Eqbal Investment Company Equity Report. From: www.awraq.com/uploads/research/033a1e112 edd533f5ef22504ed856594740a1c88.pdf Accessed: Feb 2014. 28. Japan Tobacco International. JT completes acquisition of a leading waterpipe tobacco (Shisha) company. From: www.jti. com/media/news-releases/jt-completes-acquisition-leading- water-pipe-tobacco-company/ Accessed: Feb 2014. 29. Gollust SE, Schroeder SA, Warner KE. Helping smokers quit: Understanding the barriers to utilization of smoking cessation services. Milbank Q 2008; 86:601–27. doi: 10.1111/j.1468- 0009.2008.00536.x. 30. Curry SJ, Grothaus LC, McAfee T, Pabiniak C. Use and cost effectiveness of smoking-cessation services under four insurance plans in a health maintenance organization. N Engl J Med 1998; 339:673–9. doi: 10.1056/NEJM199809033391006. 31. Land T, Rigotti NA, Levy DE, Paskowsky M, Warner D, Kwass JA, et al. A longitudinal study of medicaid coverage for tobacco dependence treatments in Massachusetts and associated decreases in hospitalizations for cardiovascular disease. PLoS Med 2010; e1000375. doi: 10.1371/journal.pmed.1000375. 32. Borland R, Li L, Driezen P, Wilson N, Hammond D, Thompson ME, et al. Cessation assistance reported by smokers in 15 countries participating in the International Tobacco Control (ITC) policy evaluation surveys. Addiction 2012; 107:197–205. doi: 10.1111/j.1360-0443.2011.03636.x. 8. World Health Organization Framework Convention on Tobacco Control. Guidelines for implementation of Article 14. From: www.who.int/fctc/guidelines/adopted/article_14/en/ Accessed: Feb 2014. 9. Jha P, Chaloupka FJ; The World Bank. Curbing the epidemic: Governments and the economics of tobacco control. Tob Control 1999; 8:196–201. doi:10.1136/tc.8.2.196. 10. Hughes JR. Tobacco treatment specialists: A new profession. J Smok Cessat 2007; 2:2–7. doi: 10.1375/jsc.2.supp.2. 11. Centers for Disease Control and Prevention. 2000 Surgeon General’s Report: Reducing Tobacco Use. From: www. surgeongeneral.gov/library/reports/50-years-of-progress/ Accessed: Aug 2014. 12. Raw M, McNeill A, Murray R. Case studies of tobacco dependence treatment in Brazil, England, India, South Africa and Uruguay. Addiction 2010; 105:1721‒8. doi: 10.1111/j.1360- 0443.2010.03043.x. 13. National Tobacco Control Programme, India Ministry of Health & Family Welfare. Tobacco Dependence Treatment Guidelines. From: www.treatobacco.net/en/uploads/documents/Treatment %20Guidelines/India%20treatment%20guidelines%20in%20 English%202011.pdf Accessed: Feb 2014. 14. World Health Organization. WHO report on the global tobacco epidemic, 2013: Enforcing bans on tobacco advertising, promotion and sponsorship. From: www.who.int/tobacco/ global_report/2013/en/ Accessed: Jan 2014. 15. World Health Organization Regional Office for the Eastern Mediterranean. Global Adult Tobacco Survey: Egypt fact sheet. From: www.emro.who.int/images/stories/tfi/documents/ GATS%20FS%20EGY%202009.pdf Accessed: Feb 2014. 16. World Health Organization Regional Office for the Eastern Mediterranean. Global Adult Tobacco Survey: Qatar fact sheet. From: www.emro.who.int/images/stories/tfi/documents/ FACT_SHEETS/FS_GATS_Qatar_2013.pdf Accessed: Feb 2014. 17. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report: Health-Care Provider Screening for Tobacco Smoking and Advice to Quit: 17 Countries, 2008-2011. From: www.cdc.gov/mmwr/preview/mmwrhtml/mm6246a4. htm Accessed: Feb 2014. 18. Muramoto ML, Lando H. Faculty development in tobacco cessation: Training health professionals and promoting tobacco control in developing countries. Drug Alochol Rev 2009; 28:498–506. doi: 10.1111/j.1465-3362.2009.00106.x. 19. Richmond R, Zwar N, Taylor R, Hunnisett J, Hyslop F. Teaching about tobacco in medical schools: A worldwide study. Drug Alcohol Rev 2009; 28:484–97. doi: 10.1111/j.1465- 3362.2009.00105.x. 20. World Health Organization Regional Office for the Eastern Mediterranean. Global Health Professions Student Survey fact sheets and country reports. From: www.emro.who.int /tobacco/gtss-matrix/ghpss-factsheets-reports.html Accessed: Feb 2014.