Botswana Smoking Abstinence Reinforcement Trial (BSMART)

PROJECT ABSTRACT
Tobacco use is highly prevalent among people living with HIV/AIDS (PLWH) especially in southern Africa where
HIV is most heavily concentrated. Among PLWH, tobacco use impacts HIV-related co-morbidities and is the
leading cause of premature mortality from non-HIV related malignancies such as lung cancer which account for
20% of the cancer burden. Integrating an evidence-based intervention, such as Screening, Brief Intervention and
Referral to Treatment (SBIRT) into a HIV care system presents an important opportunity to establish and
evaluate a modifiable cancer prevention strategy into a low- and middle-income country (LMIC) setting where
both lay health workers (LHW) and non-physician clinicians are widely used. Botswana, where the University of
Maryland Baltimore (UMB) has worked since 2015, oversees a wide network of HIV care clinics for its citizens.
Demographic Health Surveys from sub-Saharan Africa show that smoking prevalence among PLWH ranges
12.5-44.3%. Yet, based on our pilot data the system of care is highly unprepared to meet the challenge of
integrating evidence-based smoking cessation treatment into routine HIV care. The Government of Botswana
wants more to be done to assist its citizen in smoking cessation. To meet this challenge, the Botswana Smoking
Abstinence Reinforcement Trial (BSMART) proposes to use a Type 2 hybrid effectiveness-implementation study
design to evaluate the effectiveness and implementation of a well-established SBIRT intervention consisting of
the 5As, (Ask, Advise, Assess, Assist, Arrange) delivered by trained LHW case managers, followed by referral
to treatment with varenicline (a medication demonstrated to be efficacious for smoking cessation among
PLWH1-3 and on formulary in Botswana) prescribed and monitored by trained nurse prescribers-dispensers, in
the network of outpatient HIV care facilities in Botswana. The specific aims guided by the RE-AIM Framework
and informed by an Implementation Governance Structure are to: 1) Assess Reach and Effectiveness of
BSMART; 2) Assess the Adoption and Implementation indexed by quality and consistency of intervention
delivery; 3) Assess whether the intervention becomes Maintained as part of routine practices; 4) Determine the
preliminary cost-effectiveness of BSMART.

Grant Number: 3U01CA275048-04S1
NIH Institute/Center: NIH
Principal Investigator: Manhattan Charurat