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A question central to the theme of this supplement to Tobacco Control is “why seed tobacco research in developing countries?” Arguably, research done in advanced institutions can provide answers to most questions regarding the hazards of smoking and ways to combat its spread. Indeed, do we need to repeat in developing countries expensive and lengthy cohort studies about the link between smoking and cancer? Or should we investigate addiction neurobiology in every population to better understand and treat it? Obviously, there may be differences in cancer risk or addiction neurobiology between populations, but are these of a sufficient magnitude and relevance to tobacco control to justify establishing such costly research programmes in developing countries. These are justified arguments, yet the question at hand is of much broader nature.
LOCAL DATA ESSENTIAL
We have learned through the years that the smoking epidemic follows a predictable course in most populations, thus requiring fairly similar intervention strategies. Yet when we begin planning tobacco control interventions in a developing country setting, we immediately face basic questions for which few answers exist, and for which data from developed countries are inadequate, and sometimes even misleading. More so, when threatened by the potential adoption of anti-tobacco policies promoted by governments and public health advocates in developing countries, the tobacco industry often responds by highlighting the potential negative economic impact of these policies and the inadequacy of local data justifying their implementation. Examples of local data essential for the development of effective tobacco control interventions include: patterns and trends of tobacco use initiation and quitting in the society; the applicability of interventions developed in different cultures or rich societies (for example, tax increases); the toxic and addictive profiles of local tobacco use methods (for example, smokeless tobacco, waterpipe, and bidis) and the economic toll of tobacco use for the target society compared to the costs of establishing nationwide intervention programmes? These are just a few examples of the scope and depth of data required to even begin planning intervention strategies to curb tobacco use in the society, as well as to convince policymakers of the rationale of investing in such interventions.
An evidence-guided approach to tobacco control is particularly relevant to societies where limited resources necessitate rationing expenditures to areas with the most potential impact. Without negating the universal relevance of tobacco control knowledge generated in developed countries, answers to specific local questions are best generated by credible research conducted within the target societies by people native to the local environment and culture.
Evidently, the holy grail of tobacco research in developing countries lies in finding the delicate balance between required resources and potential benefits of the proposed research agendas. Projects supported by the research and capacity building initiative of the Fogarty International Center commemorated in this supplement strive to achieve this balance. As seen from contributions showcased in this supplement, countries and regions that until very recently had scarce standardised data about tobacco use, or scarce national capacity to address the tobacco problem, have taken impressive steps in these directions, thanks to this single modestly funded (by international research standards) initiative.
WIDE-RANGING GAINS FROM SEEDING TOBACCO CONTROL RESEARCH IN DEVELOPING COUNTRIES
The gains from building local research capacity and generating local data are critical, both for knowledge translation (that is, identifying cost-effective and culturally appropriate ways of applying available knowledge in the specific context of each country), and new knowledge generation (that is, addressing critical information gaps that act as barriers to the initiation and implementation of tobacco control policies). Equally important for developing countries is that successful collaborations in tobacco-control research and building of skilled local capacity can sprout new research in other health areas, thus broadening the impact of such initiatives on the public health landscape in developing countries. Indeed, as work progresses in the projects funded by the Fogarty initiative we see data generated on cardiovascular health, environmental health, social and behavioural sciences, to name but a few. Other than branching to other health research areas locally, this initiative has led to new cross-projects collaborations. An example of such emerging collaborations is the Research Assistance Matching (RAM) project developed in partnership between the Syrian Center for Tobacco Studies and the Johns Hopkins Bloomberg School of Public Health to help researchers in developing countries connect and collaborate with experts in their field. Noticeably, training of local personnel under this programme was not confined to research methods, but involved research support as well. Abiding by international standards for research involving human subjects, institutional review board approval of research protocols, and staff training and accreditation in human subjects’ protection, was a novelty for most developing countries’ researchers going into this programme. In essence, activities arising from this single initiative have in many instances laid down the foundation for the culture of standardised research and evidence-based public health in participant developing countries.
Gains of such initiatives, however, are by no means confined to the developing countries. Knowledge generated in developing countries can be relevant to large immigrant populations in developed countries, as well as to the study of emerging public health issues that may be difficult to evaluate fully within developed countries (for example, the worldwide emergence of waterpipe smoking, the export of bidis from India to the USA). Given the commitment with which many developing countries have begun implementing the World Health Organization’s Framework Convention on Tobacco Control (FCTC), research evaluating the progress of national tobacco control programmes can also provide useful information to developed countries that are slow to ratify or implement the FCTC. Another area where partnerships with developing country researchers could be especially productive is the research related to tobacco industry documents. Insights provided by these documents, enhanced by inputs of local researchers on the activities of the tobacco industry in different societies, can help to expose and thwart industry’s deception. Last but not least, in a world rushing to re-galvanise along ethnic, cultural, and ideological fortifications, such initiatives build bridges for sorely needed dialogue and understanding between people and nations. Making peace through cooperation is far less costly than any war or conflict.
The impressive successes of this programme notwithstanding, its impact is critically threatened of being short-lived if not sustained further. Given the slow process of knowledge accumulation and spread, it takes time to reach a momentum whereby new knowledge is endorsed by the public and used to influence policy. So despite the five-year length of the funding cycle of the Fogarty initiative, the fact that most of the initiated projects started from scratch means that this period is invested mainly in training, establishing operations, and generating baseline data. This limits the created research groups’ ability to influence policy as well as achieve self-sustainability. Transforming these research seeds into self-sustaining research centres/programmes that can continuously inform policy, as well as provide a model for research excellence in their respective countries/regions, will certainly require more resources, time and commitment.
While the prospects for sustainability of this programme remain in the realm of the future, the delight of friendship it has generated is an everyday reality that we intend to cherish as time goes by.
Competing interests: none declared
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