Muslim Communities Learning About Second-hand Smoke in Bangladesh (MCLASS II): An effectiveness-implementation hybrid study

Breathing in other people's smoke is called passive smoking; also referred to as environmental or second-hand smoking. Second-hand smoke (SHS) contains 4,000 chemicals, and is a serious health hazard to non-smokers. SHS is estimated to cost more than 600,000 lives per year, worldwide. A large proportion of the overall burden of diseases due to SHS is due to lung diseases such as asthma, chest infections and lung cancer. Women and children are worst affected; 47% of deaths from SHS exposure occur in female adults and 28% in children. Recognising SHS as a public health threat, most countries have introduced bans on smoking in enclosed public spaces, which has significantly reduced adults' exposure to SHS. However, for most non-smoking women and children, cars and homes remain the most likely places for them to breathe in SHS. The only possible way to protect them from SHS is to make cars and homes completely smoke free.

For the last few years, we have been working with Muslim communities to develop and test a community-based intervention called, 'Smoke Free Homes' (SFH). We train Imams (Muslim faith leaders) based in mosques to encourage their congregations to make a positive change in their smoking behaviours. Imams stimulate discussions during study circles, in-between regular prayers and during Quran classes. Through our pilot work, we found that with proper support mosques are a suitable place for promoting health and Imams are willing to deliver smoke-free messages. In addition, we have also developed technology to measure Indoor Air Quality (IAQ) using a cheap and efficient home installation meter. In a pilot study, we have demonstrated that IAQ feedback can also motivate changes in smoking behaviours in homes.

Inspired by our pilot work in the UK, we now propose a large study in Bangladesh where SHS is a major public health problem and a priority for policy making in tobacco control. Through our work in Bangladesh in this area for several years, we have established collaborations with local communities and policy makers. Before carrying out the main study, we will adapt SFH to Bangladesh context. The adaptation will be informed by the findings of the interviews and discussions with community members and Imams in Dhaka. We wish to examine how effective is SFH, with or without IAQ feedback, in reducing exposure to SHS in homes. We are also interested to see if the intervention improves their lung health, general quality of life, and reduce health service use. To provide accurate answers to these important questions, we will recruit a total of 45 Mosques and 1800 households in their catchment area. We will randomly allocate mosques to three arms.
Mosques in arm 1, will receive training on SFH and their congregation will receive IAQ feedback on a sample of homes from their community. Those in arm 2, will only receive training on SFH and arm 3 mosques will have usual services. We will also use objective measurements including testing IAQ to assess whether our intervention has reduced SHS exposure in homes. Other measures will include questionnaires to record respiratory symptoms such as cough, wheeze and scales to measure quality of life. We will undertake all the measurements as described above using internationally agreed standards. Over the following six-months, we will repeat these assessments at regular intervals. In parallel, using an economic analysis we will also assess whether SFH with or without IAQ is value for money.
Subsequently, we will also assess how best to implement SFH with or without IAQ feedback and bring it to scale. For this part of the study, we will (a) estimate the likely costs and effects of scaling up the intervention, (b) develop a simple implementation monitoring tool, (c) investigate likely obstacles to and opportunities for implementing and scaling up the intervention, and (d) how best to work with communities and policy makers to overcome these obstacles and maximize such opportunities.

Second-hand smoke (SHS) is a serious health hazard costing 600,000 lives a year. Women and children in developing countries are worst affected as smoke-free laws are only partially implemented and homes remain a source of SHS exposure. There is limited evidence on interventions designed to reduce SHS exposure in homes, especially in community settings. Following a successful pilot, we plan to evaluate a community-based approach to promote smoke-free homes in Bangladesh - a country with a strong commitment to smoke-free environments but with high levels of SHS exposure in children.
We aim to assess the effectiveness of a community-based intervention - Smoke Free Homes (SFH), with or without Indoor Air Quality (IAQ) feedback, in reducing non-smokers' exposure to SHS in the home. SFH and IAQ feedback are behavioural interventions designed to discourage people from smoking indoors. SFH consists of a set of messages and activities couched within mainstream Islamic discourse, delivered by faith leaders (Imams) in places of worship (mosques). IAQ feedback consists of anonymised information on indoor air quality measured by a particulate matter (PM2.5) monitor.
Following adaptation of SFH and IAQ feedback for the Bangladeshi context, we will conduct a three-arm cluster randomised controlled-trial in Dhaka. We will randomise 45 mosques as follows: arm 1 - SFH and IAQ feedback; arm 2 - SFH alone; and arm 3 - usual services. We will recruit 1,800 households with at least one smoker. The primary outcome is change in household PM2.5 concentration. Secondary outcomes include frequency and severity of respiratory symptoms, healthcare service use and quality of life. A cost-effectiveness analysis and process evaluation will also be conducted. An implementation study will inform how best to scale up these approaches. The investigators' expertise and track record within the field, extensive links within the community and with policy makers are some of the strengths of the proposal

Non-smoking general public, researchers and policymakers in Bangladesh are the key direct beneficiaries of this project: The study will have a big impact through these beneficiaries.

(1) Despite laws against smoking in public places, non-smokers, particularly women and children, remain exposed to second-hand smoke and suffer ill-health as a result. By tackling smoking behaviours at homes, our project has the potential to shift social norms and as a result improve lung health outcomes among non-smokers in Bangladesh and beyond. It will improve the health of the most vulnerable - SHS disproportionately affects women and children with devastating health and economic consequences. If successful and taken up, our intervention would lead to a reduction in the burden of disease among the most vulnerable. Our study will be one of three MRC-funded studies assessing and demonstrating the effect of modifying smoking behaviours through community-based approaches in Bangladesh.

(2) Bangladesh's limited capacity in health research is an impediment in human and economic development. The project will lead to the development of research capacity among Bangladeshi researchers particularly in applying the Medical Research Council (MRC) Framework for Developing and Evaluating Complex interventions to their local context. There will be special focus on the development of following research skills: behavioural intervention development, risk communication, cluster randomised controlled trial methods, statistical analysis of a trial, data management, academic writing, process and economic evaluation

(3) For policy makers, lack of evidence on approaches to challenge smoking behaviours within local communities in Bangladesh is a barrier to effective tobacco control. Moreover, policies such as smoke-free laws (effective elsewhere) often fail to achieve their full potential in Bangladesh due to existing social attitudes towards smoking. Policy makers within the Ministry of Health in Bangladesh would benefit both from the new knowledge on community-based approaches to address smoking behaviours and also from a shift in social attitudes towards smoking, which may lead to more effective policy implementation. Our research is grounded within implementation science, attempting to answer questions that are highly relevant to programme managers. Being research partners, the findings will be owned by policy makers and target communities enabling the adoption, scaling up and sustainability of such intervention. Bangladesh, like many low- and middle-income countries, lacks infrastructure to provide comprehensive health promotion through their health services. In this study, we will develop knowledge on how best to support local communities in becoming aware, owning and delivering health promotion.

Beyond health, by tackling smoking behaviours, our proposal indirectly, creates opportunities for families to have more disposable income to spend on food, shelter and children's education. It allows health system to focus its efforts and limited resources on other issues. Tobacco control increases productivity and leads to long-term economic gains for the country and society. Addressing tobacco use is likely to promote gender equality and maternal health and reduce child mortality. Reduction in tobacco demand also cuts down pesticide use and deforestation leading to environmental sustainability.