|Year : 2012 | Volume
| Issue : 2 | Page : 159-168
Initiating tobacco cessation services in India: challenges and opportunities
Cherian Varghese1, Jagdish Kaur2, Nimesh G Desai3, Pratima Murthy4, Savita Malhotra5, DK Subbakrishna4, Vinayak M Prasad6, Vineet G Munish7
1 World Health Organization Regional Office for the Western Pacific, Manila, Philippines
2 Directorate General of CGHS, Ministry of Health and Family Welfare, Government of India, New Delhi, India
3 Institute of Human Behaviour and Allied Sciences, Delhi, India
4 National Institute of Mental Health and Neuro Sciences, Bangalore, India
5 Post Graduate Institute of Medical Education and Research, Chandigarh, India
6 Tobacco Free Initiative, World Health Organization, Geneva, Switzerland
7 World Health Organization Country Office for India, New Delhi, India
|Date of Web Publication||24-May-2017|
National Institute of Mental Health and Neuro Sciences, Bangalore
Background: Tobacco use contributes significantly to the diseases burden in India. Very few tobacco users spontaneously quit. Therefore, beginning 2002, a network of 19 tobacco cessation clinics (TCCs) was set up over a period of time to study the feasibility of establishing tobacco cessation services.
Methods: Review of the process and operational aspects of setting up TCCs was carried out by evaluation of the records of TCCs in India. Baseline and follow-up information was recorded on a pre-designed form.
Results: During a five-year period, 34 741 subjects attended the TCCs. Baseline information was recorded in 23 320 cases. The clients were predominantly (92.5%) above 20 years, married (74.1%) and males (92.2%). All of them received simple tips for quitting tobacco; 68.9% received behavioural counselling for relapse prevention and 31% were prescribed adjunct medication. At six-week follow-up, 3255 (14%) of the tobacco users had quit and 5187 (22%) had reduced tobacco use by more than 50%. Data for three, three-monthly follow-ups was available for 12 813 patients. In this group, 26% had either quit or significantly reduced tobacco use at first follow-up (three-months), 21% at the second (six-months) and 18% at the third follow-up (nine-months) had done so.
Conclusions: It is feasible to set up effective tobacco cessation clinics in developing countries. Integration of these services into the health care delivery system still remains a challenge.
Keywords: Tobacco cessation, health services, behaviour counselling, nicotine replacement therapy, India
|How to cite this article:|
Varghese C, Kaur J, Desai NG, Murthy P, Malhotra S, Subbakrishna D K, Prasad VM, Munish VG. Initiating tobacco cessation services in India: challenges and opportunities. WHO South-East Asia J Public Health 2012;1:159-68
|How to cite this URL:|
Varghese C, Kaur J, Desai NG, Murthy P, Malhotra S, Subbakrishna D K, Prasad VM, Munish VG. Initiating tobacco cessation services in India: challenges and opportunities. WHO South-East Asia J Public Health [serial online] 2012 [cited 2019 Oct 22];1:159-68. Available from: http://www.who-seajph.org/text.asp?2012/1/2/159/206929
| Introduction|| |
Tobacco use is a major modifiable risk factor for health globally. In the South-East Asia Region (SEAR), smoking prevalence ranges from 29.8% to 63.1% among men and 0.4% to 15% among women. The practice of tobacco chewing also needs attention. Smokeless tobacco use ranges from 1.3% to 38% among men and 4.6% to 27.9% among women. India has a huge burden of tobacco-related morbidity, disability and mortality., Nearly one-third to more than half of those above 15 years use some form of tobacco.,,,, The Global Adult Tobacco Survey (GATS) in 2010 revealed that 47.9% of males and 20.3% of females, constituting 34.6% of the adult population, used tobacco in one or the other form in India.
The WHO Framework Convention on Tobacco Control (FCTC) recommends comprehensive policies for tobacco control, including cessation or treatment of tobacco dependence. Offer to help quit tobacco use is one of the six strategies for tobacco control advocated by WHO under MPOWER and technical guidelines for tobacco cessation have also been developed for different levels of health care providers. However, despite the enormous health burden resulting from tobacco use, there were no organized tobacco cessation services in India until 2001.
Global support for tobacco control policies and national data on mortality and morbidity related to tobacco use began to have its impact on policy and programming for tobacco control in India. In 2002, formal tobacco cessation facilities were set up for the first time. The purpose of the tobacco cessation clinics was to develop simple intervention models for tobacco cessation for smokers and smokeless tobacco users, to generate experience in the delivery of these interventions that can be applied in the primary care setting, and finally, to study the feasibility of implementing these interventions and their acceptability in general primary health care settings.
| Methods|| |
The first formal tobacco cessation clinics were set up in 2002, as a joint initiative of the Ministry of Health and Family Welfare, Government of India and the World Health Organization’s Country Office for India. Principal investigators from selected tertiary level health facilities were trained in tobacco cessation services in Thailand. Thirteen tobacco cessation clinics (TCC) were set up in psychiatry (3), cancer (5), surgical (2), cardiology (1), chest diseases (1) as well as in a nongovernment organizational setting (1). The TCCs were subsequently expanded to five more Regional Cancer Centres (RCC) in 2005. Another TCC has more recently been added in a general hospital setting.
The space for the TCCs was provided in the existing facilities. At a consultative meeting, organized by the Ministry of Health & Family Welfare, guidelines for assessment and intervention were evolved by consensus. The concept and operational plan was prepared by technical experts from three premier institutions, i.e. The Institute of Human Behaviour and Allied Sciences, Delhi, the National Institute of Mental Health and Neuro Sciences, Bangalore, and the Post-Graduate Institute of Medical Research, Chandigarh, supported by the WHO Country office, for India.
The staff involved in running the centers-either a psychologist, social worker or medical officer-was trained in a two-day workshop on psychosocial and pharmacological approaches to cessation. A similar workshop was held during the expansion phase. All investigators and staff were brought together annually for a review of the work and to enhance their skills in specific areas as per the need. Each clinic was supported with two personnel, a computer and a carbon monoxide monitor. The tobacco cessation approach followed at the tobacco cessation clinics is outlined in [Table 1].
A brief intake form with minimum baseline information on socio-demographic information, duration and type of tobacco use and the type of tobacco cessation intervention was developed and used in all the TCCs. Active efforts were made to recruit tobacco users for cessation at the TCCs through liaison with other medical services, community participation in camps and awareness programmes, referral by doctors, friends and relatives or by self-referral. All the TCCs maintained follow-up information for six weeks and some also maintained longer-term follow-up information.
| Results|| |
During the first five years of the setting up of the TCCs, 34 741 cases were registered across 18 TCCs. Baseline information was recorded for 23 320 cases.
| Socio-demographic characteristics|| |
Most of the clients were married (74.1%), males (92.2%), and above 21 years (82.5%). Nearly half of the respondents had more than 10 years of education. Median monthly income was ₹ 3000. Women who sought treatment at the TCCs were comparatively older than the men, less educated and with lower monthly income levels. Students constituted a very small proportion of the TCC clients [Table 2].
|Table 2: Profile of clients attending tobacco cessation clinics and six-week tobacco quit rates|
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| Tobacco use pattern|| |
A majority of those accessing tobacco intervention services were chewers (65.5%). Smokeless tobacco use was significantly associated with income below ₹ 1500 per month and education below 10 years (p<0.001). Women accessing services were more likely than men to use smokeless tobacco (83.5% and 64% respectively). Self-report of alcohol use among the smokers was relatively low (18%), almost exclusively a male phenomenon. None of the tobacco chewers reported concomitant alcohol use.
| Types of intervention|| |
All cessation service seekers were provided motivation and simple tips on how to quit tobacco. Behaviour counselling (BC) as the primary strategy for cessation was provided to 16 070(68.9%) subjects. In addition to behaviour counselling, 4713(20.2%) received medication (mostly bupropion), 2362(10.1%) received nicotine replacement therapy (NRT) and a few (175; 0.8%) got both NRT and medication. At the time of this study, varenicline was not available as a treatment option.
| Outcome at six weeks|| |
Information on six-week outcome was available for 10 471 subjects (44.9% of the entire group). Of them, 3255 (31.1%) had quit, 5187 (49.5%) reported significant improvement (reduced intake by 50% or more compared to baseline) and 2029 (8.7%) reported ‘no change’. Considering those lost to follow-up as ‘not improved’, the improved group was 36% (14% quitters and 22% who had reduced use by 50% or more).
Among men, factors associated with improved outcome at six weeks included a younger age, use of smokeless tobacco, and combined pharmacological and behavioural interventions. Among women, while outcome in general was poorer than men, combined use of pharmacotherapy and behavioural counselling was associated with a better outcome and lack of education with a poorer outcome.
| Longer-term outcome|| |
Only some of the TCCs maintained longer-term follow-up data. Three-monthly follow-up data (for nine months) was available for 12 813 clients. In this group, 26% were in the improved category at the first follow-up (three months), 21% at the second follow-up (6 months) and 18% at the third follow-up (nine months). What is striking is that of those who remained in follow-up, a significant number moved from the ‘no-change’ to the ‘improved’ category over a period of time. This indicates the need for retaining people in follow-up for chronic, relapsing conditions like tobacco dependence, in order to improve longer-term outcome.
| Discussion|| |
In 2010, smoking is expected to have caused about 930 000 adult deaths in India. Because of population growth, the absolute number of deaths in this age group is rising by about 3% per year. As per GATS India, five in ten current smokers and users of smokeless tobacco planned to quit or at least thought of quitting. In this scenario, it became important for India to institute a tobacco control programme, including expansion of facilities for tobacco cessation.
A major lesson from the study is that it is possible to establish effective tobacco cessation services in diverse health settings with optimal use of existing infrastructure and minimal support. It is also evident that follow-up is a very important component of care to ensure better outcome. There is a need to build awareness regarding the availability and benefits of tobacco cessation services. Educating the community about the benefits of tobacco cessation interventions is likely to improve retention in tobacco cessation programmes.
Several predictors of tobacco cessation have been described in earlier studies including intention to quit, recent episode of quitting, longer duration of recent quit, negative attitudes to smoking and a younger age., It has also been suggested that stopping tobacco use before the age of 40 years may be critical to improve health. In our experience, help is sought usually in the fourth decade, when many tobacco-related health problems may have already occurred. Nevertheless, our findings that younger people are more likely to be retained in treatment and have better outcomes, is an indicator to provide outreach to tobacco users at an early stage. The feasibility of using innovative technology such as mobile phones or quit tobacco helplines could be explored to improve access by youth and in hard-to-reach cases.
Healthcare givers at all levels of the healthcare delivery system must be trained in tobacco dependence treatment including behaviour counselling and pharmacotherapy. We found that physicians, in general, lacked knowledge of tobacco cessation protocols and felt uncomfortable or at a loss in their ability to handle needs of their patients for tobacco cessation. Data from the Indian Global Health Professionals Students Survey (GHPSS) between 2005-2008 among dental, medical, nursing and pharmacy students, showed high prevalence of tobacco use and a general lack of training among health professionals in patient cessation counselling techniques. Dental professionals also need to be aggressively involved in smokeless tobacco cessation.
Education of health professionals is needed to occur both within the governmental health systems as well as in the private sector. It is important to ask every patient visiting any health facility about tobacco use as it has been observed that few physicians ask their patients about tobacco use. Educating physicians in asking and assessing tobacco use among patients as well as training them in tobacco cessation on a wider scale is an urgent need. In this regard, several resources have been developed by the Ministry of Health & Family Welfare, Government of India and the WHO Country office for India. These resources include a training manual for tobacco cessation developed under the cancer control programme, a manual for dentists, a training module for doctors; these can also be used for training in tobacco cessation.,, ‘National Guidelines for Tobacco Dependence Treatment’ have also been developed which need to be widely disseminated. More detailed manuals on tobacco cessation for both doctors and nurses and other professionals have also been developed for the SEA Region.,
There has not been much research on tobacco dependence treatment or cessation in so far as smokeless tobacco is concerned. The Indian experience of offering cessation services to smokers as well as to smokeless tobacco users, especially the chewers, is unique. GATS India has also revealed that 26% of the adult population in India uses smokeless tobacco. Considering that only about 1% of smokeless tobacco users report having spontaneously quit, it is very important to address smokeless tobacco cessation in India.
Tobacco chewing is more prevalent among Indian women as compared to smoking; in some parts of India it is as high as 57%. A significant problem of tobacco use among students is recently coming to light, and a shift of use to younger persons is expected. In a study from a TCC at Chandigarh, 92% of subjects were in the 10-19 years age range and a majority (68.2%) had started tobacco use under peer pressure. The lower socio-economic stratum is underrepresented among our treatment seekers. These groups would benefit more from cost-effective interventions at the community level.
Studies in western settings, as well as the present study indicate improved quit rates with the addition of pharmacotherapy to behaviour counselling. Our experience also suggests a better outcome with the combination of these two approaches. Similar encouraging results have been reported with the combined approaches in a chest diseases tobacco cessation setting in India. The evidence for combined efficacy of pharmacotherapy and behavioural counselling in enhancing rates of tobacco cessation is now available.,,
Taking into consideration the high prevalence of tobacco use in India, community cessation intervention programmes should be integrated in the primary health care delivery services within a proper monitoring and evaluation framework. A study from Thailand reports benefits from a community pharmacist-based smoking cessation programme.
The data collected during the preliminary phase of establishment of the TCCs is extremely basic but provides some valuable insights into the kind of populations that have accessed tobacco cessation services. The sample is heterogeneous from diverse clinical settings and population groups. Although staff delivering the services received brief training in tobacco cessation intervention, there is likely to have been a great amount of variability in counselling depending on the staff’s background, training and treatment setting. Despite these limitations, the establishment of the TCCs has been the first step in providing formal tobacco cessation services in India. In a country where use of tobacco is widespread, it is critical to establish the evidence for achievement of effective tobacco cessation by use of behavioural counselling and optimal pharmacotherapy. Extending tobacco cessation services to rural populations, given the higher prevalence of tobacco use in rural populations, is imperative. Behaviour counselling is applicable and acceptable in rural settings, where access to pharmacotherapy may be limited. Studies from India have shown that health education and community awareness has helped in tobacco cessation.,
The existing TCCs are not sufficiently equipped to take care of any population-based cessation scale-up programme. It would be critical to build cessation capacity in the medical and dental college hospitals, both to provide the needed training to the students and also to cater to the cessation needs of the population. In low-resource settings, with limited access to pharmacotherapy, there is also a need to evaluate cost-effective behavioural interventions, particularly for smokeless forms of tobacco use, for further expansion of tobacco cessation activities.
The Government of India initiated the National Tobacco Control Programme in 2007-08. Taking into account the widespread use of tobacco and need for assisting tobacco users to quit, provision was made to establish tobacco cessation facilities at the district hospital level. This was a major step forward in establishing tobacco cessation facilities as near the community as possible. A psychologist and a social worker are provided at the District Tobacco Control Cell to undertake tobacco cessation activities. The Government of India has decided to make most of the TCCs self-sufficient and continue their activities in a sustainable manner from 2010-11 onwards. The focus of these RCTCs would be to build capacity of the states in tobacco cessation by conducting training of health professionals and also to focus on setting up cessation facilities in medical and dental institutions. National Guidelines for Tobacco Dependence Treatment have taken care of smokeless tobacco cessation along with the focus on smoking cessation. Training modules for doctors and health workers were also developed in 2010-11 emphasizing the “brief advice” for tobacco cessation. For the first time, tobacco cessation was also incorporated in the training modules of doctors under the Revised National Tuberculosis Control Programme (RNTCP). All medical and dental colleges, general hospitals and tuberculosis hospitals have been encouraged to set up tobacco cessation facilities as part of care giving, using existing infrastructure and resources to make these sustainable.
To conclude, tobacco cessation services established in selected tertiary level centres in India were well received and short-term outcome of subjects seeking help was encouraging. However, tobacco cessation activities clearly need to be up-scaled, and the public better informed of the availability and relevance of such interventions. Younger persons using tobacco, women users, rural populations and the economically under-privileged need to be more actively targeted.
Tobacco cessation must be offered more widely in medical settings in both urban and rural areas. The integration of tobacco cessation with existing national health programmes is a cost-effective strategy to widen the cessation services for effective outreach at the community level. The use of innovative technologies like mobile phones and setting up quit-lines can give a major impetus to the ongoing efforts of the Government of India for providing cessation facilities to a larger population, especially in the remote and rural areas. A clear and definite need for well-designed studies to examine the longer-term impact of tobacco cessation interventions in low-and middle-income settings is important for further expansion of these services.
| Acknowledgements|| |
We acknowledge the contribution of Acharya Harihar Regional Cancer Center, Cuttack (UR Parija), Bhagwan Mahaveer Cancer Hospital, Jaipur (Vivek Sharma, Rahman AU), B Barooah Cancer Institute, Assam (Joydeep Das), Cancer Institute, Chennai (Rohini Prem Kumari, E Vidhubala), Chatrapati Shahuji Maharaj Medical University, Lucknow (Ramakant B), Chittaranjan National Cancer Institute, Kolkata (Utpal Sanyal), Institute of Behavior and Allied Sciences, New Delhi (SN Gupta, Uday Singh, Deepak Kumar, Rupali Shivalkar), Indira Gandhi Institute of Cardiology, Patna (Mahabir Das), Jawaharlal Nehru Cancer Hospital and Research Center, Bhopal (Dilip Kumar Kar), MNJ Institute of Oncology and Regional Cancer Center, Hyderabad (BN Rao), National Institute of Mental Health and Neuro Sciences (Issac M, Benegal V), Bangalore, National Organization for Tobacco Eradication, Goa (Shekhar Salkar), Post Graduate Institute of Medical Research, Chandigarh (Anil Malhotra), Pramukhswami Medical College and Shree Krishna Hospital, Gujarat (Girish Mishra), Regional Cancer Center, Mizoram (Jane R Ralte), Regional Cancer Center, Thiruvananthapuram (Jayakrishnan R), Tata Memorial Hospital, Mumbai (Surendra Shastri), Vallabhbhai Patel Chest Institute, New Delhi (Raj Kumar), Ministry of Health and Family Welfare, Government of India, WHO Country Office for India., and the staff of TCC IHBAS and NIMHANS. We also gratefully acknowledge the active role played by the subsequent co-ordinators of the various TCCs towards tobacco control and cessation.
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[Table 1], [Table 2]
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