This scoping review described the knowledge gaps in local-level smoking cessation interventions in Japan, their implementation outcomes, implementation barriers and facilitators, and the use of implementation strategies. Regarding overall knowledge about the smoking cessation intervention components in Japan (RQ1), behavioral counseling and cessation medication in clinical settings were the most commonly used, and articles for community and workplace settings were quite limited. Workplaces have several advantages in implementing health promotion, including smoking cessation interventions, such as enabling access to a large number of people and encouraging sustained peer support and positive peer pressure, which have strong evidence for increasing the prevalence of smoking cessation [100]. While the number of peer-reviewed articles on interventions in workplaces was limited, much knowledge and experience were extracted from the grey literature and supplemental surveys in workplace settings. Moreover, articles on smoking cessation interventions in Japan did not fully cover the list of EBIs reported by the Surgeon General Report. For instance, there are no studies for quitlines despite of strong evidence. To accelerate the implementation of smoking cessation interventions in Japan, there is a need to improve smoking cessation treatment systems, including online treatment, and to develop and disseminate quitline systems [101].
With regard to implementation outcomes (RQ2), a few studies measured them. When an intervention failed to produce the expected effect, this could be caused by either intervention or implementation failure [37]. Measuring implementation outcomes helps us understand the mechanism of success behind implementing an intervention by understanding the implementation process. For instance, fidelity of behavioral counseling can be collected over different time points from various sources such as medical record review (e.g., whether patients were asked, advised, assessed, assisted, or arranged for follow-up) or qualitative approaches included interviews for clinicians or patients [17]. Furthermore, implementation outcomes are not measured only after the implementation. Some implementation outcomes, such as acceptability, can be measured at the pre-implementation phase to each stage of implementation as it is changeable with experience. Since there are already several established EBIs for smoking cessation, it would be beneficial to focus on implementation success by measuring implementation outcomes. None of the 18 articles extracted in this study cited or reported Proctor’s implementation outcome framework. As variations in terminology reporting limited knowledge synthesis across studies [102], future research should use a common taxonomy with conceptual definitions.
Regarding barriers and facilitators (RQ3), the most frequently reported barriers were “available resources,” “knowledge and beliefs about the intervention,” and “patient needs and resources” in clinical settings. These barriers were consistent with previous studies that reported time limitations, low priority, lack of knowledge among healthcare professionals, and providers’ perception that patients were not interested in smoking cessation as barriers to primary care [103, 104], including a scoping review in South Asian regions [105]. The most frequently reported facilitator was “relative priority.” In Japan, the MHLW and METI started awarding and certifying organizations engaged in health promotion in 2012 and 2014, respectively [27, 28]. In addition, a revised Health Promotion Law was enacted in 2018 to reduce secondhand smoking [6]. Thus, these measures at a national level could contribute to prioritizing smoking cessation interventions for organizations. In our study, “patient needs and resources” were reported as both barriers and facilitators. This may be due to differences in implementation phases and settings. While most of barriers were extracted in the implementation phase in clinical settings (e.g., healthcare providers’ hurdles in providing smoking cessation to smokers), most of the facilitators were extracted in the adoption phase in workplace settings as the triggers for introducing smoking cessation interventions in the workplace (e.g., employee complaints about secondhand smoke exposure among non-smoking employees, or requests for implementing measures to support smoking cessation). Regarding implementation strategies (RQ4), the finding that training was the most frequently utilized strategy for smoking cessation interventions in clinical settings was consistent with a previous study [17]. In addition, our study showed that training was utilized not only for behavioral counseling and cessation medication, but also for smoke-free policies, public awareness, and web-based interventions in all settings.
As EBIs have already been established for smoking cessation, it is important to accelerate their implementation. Thus, research should be conducted on methods to increase the evidence of implementation and context by organizing and accumulating barriers, facilitators, strategies, and outcomes within the implementation science framework. In addition, because a knowledge gap was identified through this study, when considering future research funding priorities, it will be possible to prioritize investment in areas where evidence is lacking, which may lead to the promotion of implementation research.
This study has important implications for smoking cessation support practitioners. The findings can be used as a starting point for practitioners to consider what outcomes to measure, what factors may facilitate or inhibit smoking cessation, and what strategies to utilize when implementing a new smoking cessation intervention. For example, when a company is considering the introduction of a new behavioral counseling and cessation medication program, it may be useful to survey the employees’ needs and modify the strategy according to the actual situation in the office, or to consider not only seminars for smokers but also involve the families of employees.
Since this study suggests that organizations conducting smoking cessation interventions have data or insight of implementation outcomes, barriers, facilitators, and strategies, it is important to create reporting tools for implementation outcomes, CFIR, and ERIC that are easy to understand and use for practitioners, encouraging them to accumulate findings in the field. However, because ERIC adopts a conceptual category of implementation strategies, it may not provide enough information for practitioners to utilize. For example, the strategy of "engage consumer" is a large concept, and its sub-items such as "involve patients/consumers and family members" also lack specifics. In our study, we extracted specific examples of “involve patients/consumers and family members,” such as peer-support smoking cessation programs in which smokers and non-smokers are paired to try to quit smoking and a smoking cessation competition by business location, by reviewing case studies and conducting surveys and interviews. Such specific descriptions may be important for practitioners when considering their actions. Therefore, it would be beneficial to include these specific examples along with reporting in the framework of implementation science. Alternatively, utilizing the ERIC compilation and behavior change technique (BCT) taxonomy [106] could be beneficial for both practitioners and researchers to accumulate evidence.
This study also provides important insight for practitioners in countries with lagging tobacco control measures. Even in countries such as Japan, where tobacco control at a national level is insufficient, it could be effective to promote the use of smoking cessation interventions by strengthening the outer setting (i.e., measures by local government, organizational encouragement of health promotion by certificates) and encouraging individual characteristics (i.e., training health workers). Although the Heath & Productivity Stock Selection and Smart Life Projects implemented in Japan do not specifically focus on smoking cessation, they are likely to increase the priority of smoking cessation measures since they are one of the prerequisites for application to them. In addition, smoking cessation treatment is an important measure that can be implemented even if national policies listed in MPOWER are behind it, and the results of this study suggest that improving provider awareness and knowledge is important, since this is a major implementation barrier.
Strengths and limitation of this study
In this study, we extracted findings that could not be extracted from peer-reviewed articles alone, by utilizing grey literature and quantitative and qualitative research. In particular, the supplemental quantitative survey was able to uncover many findings, with an average of 5.2 responses extracted per organization for facilitators and 11.3 responses per organization for implementation strategies. The number of facilitators was limited to four; however, by including the survey results, we were able to extract more facilitators. Regarding implementation strategies, although the number of articles was large, some strategies could only be extracted through the survey, suggesting that hidden knowledge has accumulated in the field. Furthermore, the interviews allowed us to understand the context of the strategies and facilitators. Combining reviews with quantitative and qualitative research, as in this study, may be useful in understanding the implementation of EBIs already in place.
This study had several limitations. First, despite our efforts to conduct a comprehensive review, the limited number of organization survey results was reflected due to low response rate. Second, although we developed detailed coding manuals for systematic analysis and coding, the results may be affected by misclassification of coding. Finally, as the study only included smoking cessation interventions conducted in Japan, the results may not be generalizable to other contexts. However, the findings of barriers and facilitators as well as implementation strategies could provide important insights for other countries where tobacco control measures at a national level are lagging, as in Japan.