Adapting multicomponent tobacco use treatment strategies for implementation in the Lebanese primary healthcare system: a mixed-methods study.

INTRODUCTION: Tobacco use treatment (TUT) remains largely absent from Lebanon's primary healthcare system, even though smoking prevalence ranks among the highest in the region. Although Lebanon has ratified the WHO Framework Convention on Tobacco Control, TUT has not been integrated into routine care. This study describes the adaptation of evidence-based, phone-delivered TUT strategies for integration within Lebanon's primary healthcare network. METHODS: We conducted an explanatory sequential mixed-methods study. Data sources included surveys (n=107) and semistructured interviews (n=24) with healthcare providers, focus group discussions with patients who smoke (n=61) and workflow assessments of 24 primary healthcare centres. Quantitative data were analysed descriptively, and qualitative data underwent rapid framework analysis. We coded adaptations using the Framework for Reporting Adaptations and Modifications to Evidence-based Interventions (FRAME). RESULTS: Adaptations were informed by contextual determinants, including gaps in electronic health record infrastructure, patients' mental health needs, and misconceptions and social norms surrounding waterpipe use. Additional considerations included provider-level constraints, such as limited time to promote tobacco cessation (47% of providers reported having sufficient time), limited cessation training (42% reported sufficient knowledge of pharmacotherapy and 15% reported knowledge of how to prescribe cessation medications) and low confidence in counselling patients about the risks and benefits of these medications (50%). Adaptations included adding paper-based reminders to address variability in electronic health record systems; providing concise, role-specific materials and nicotine replacement therapy guidance for providers; incorporating mental health referral pathways and strengthening counselling content on the harms of waterpipe use; substituting nicotine patches with nicotine gum due to product availability; and developing instructional videos and self-help materials to support implementation. CONCLUSIONS: Tailoring implementation strategies to contextual realities in Lebanon aimed to improve the relevance, feasibility and potential uptake of TUT. This formative study provides an example of a data-driven, stakeholder-engaged approach to adapting evidence-based TUT for low-resource primary healthcare settings. TRIAL REGISTRATION NUMBER: NCT05628389.