Adaptation Process of a Culturally Tailored Smoking Cessation Intervention for People living with Severe Mental Illness in South Asia: IMPACT 4S

Introduction Despite high smoking prevalence in people living with Severe Mental Illness (SMI) from low- and middle-income countries, smoking cessation interventions adapted for this population and context are lacking. This paper describes the adaptation process of a smoking cessation intervention for people living with SMI in South Asia. Methods The adaptation process followed the first nine steps of the Escoffery framework for adapting health interventions, complemented by the Stirman adaptation classification to document the modifications. This was conducted by an interdisciplinary co-design team comprising people living with SMI, caregivers, experts in mental health, smoking cessation, and behavioral science from India, Pakistan and the UK. Stakeholders were consulted throughout. Evidence-based interventions were selected and contextual modifications to content and delivery identified. Staff were trained both in-person and online. Acceptability of the intervention was assessed through final consultations with community advisory panels. Results A UK intervention, SCIMITAR+, was selected to be adapted, drawing also on the TB & Tobacco and Smart Guide interventions from South Asia. Content and delivery adaptations focused on adding an additional “life after quitting” step, ensuring materials were understandable with culturally relevant examples and pictures, avoiding stigmatizing SMI, incorporating caregiver support, flexible scheduling of sessions alongside routine appointments, offering hybrid delivery and including female cessation advisors. Conclusion We systematically adapted a UK smoking cessation intervention for people living with SMI, tailoring it for implementation in India and Pakistan. The next steps (10 and 11 of the Escoffery framework) would be to implement and evaluate it in a pilot feasibility trial. Implications In this paper, we describe the adaptation process for a smoking cessation intervention in South Asia for people living with SMI. The co-design approach, involving people living with SMI, their caregivers, healthcare providers and experts in mental health, smoking cessation, and behavioral science, enhanced the intervention’s relevance for the new target population. There is still a significant gap in the literature explaining how such interventions are developed. This lack of detailed reporting hinders the ability to assess the appropriateness of adaptations and limits guidance for other initiatives. By addressing this gap, this paper aims to improve transparency and show how two adaptation frameworks (Escoffery adaptation framework, Stirman classification of adaptations) were used in low-resource settings, which can inform future adaptation and implementation efforts.