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| COMMUNITY RESEARCH |
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| Year : 2010 | Volume
: 47
| Issue : 5 | Page : 69-74 |
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Tobacco cessation services in India: Recent developments and the need for expansion
P Murthy, S Saddichha
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bangalore - 560 029, India
| Date of Web Publication | 9-Jul-2010 |
Correspondence Address:
P Murthy
Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bangalore - 560 029
India
 Source of Support: World Health Organization Country Office and the Ministry of Health and Family Welfare, Government of India, Conflict of Interest: None  | Check |
DOI: 10.4103/0019-509X.63873
Tobacco use is a major cause of preventable death and disease in India. Unfortunately, very few people in India quit tobacco use. Lack of awareness of harm, ingrained cultural attitudes, and lack of support for cessation maintains tobacco use in the community. The significant addictive property of nicotine makes quitting difficult and relapse common. Health professionals have received little training, and very few thus carry out proper assessments and interventions among tobacco users. Evidence from the developed countries suggests that brief interventions delivered by diverse health professionals are effective in tobacco cessation. Combining pharmacologic approaches with behavioral counseling produces better results than a single strategy. In India, early experiences with tobacco cessation occurred in the context of primary community education for cancer control. More recently, tobacco cessation clinics have been set up to develop models of intervention, and train health professionals in service delivery. These need to be expanded at the primary, secondary, and tertiary care levels, and cost-effective community tobacco cessation models need to be developed. Tobacco cessation forms one of the critical activities under the National Tobacco Control Program. Tobacco cessation needs to be urgently expanded by training health professionals in providing routine clinical interventions, increasing availability and subsidy on pharmacotherapy, developing wide-reaching strategies, such as quitlines and cost-effective strategies, such as group interventions.
Keywords: Expansion, health professionals, intervention, tobacco cessation, training
How to cite this article:
Murthy P, Saddichha S. Tobacco cessation services in India: Recent developments and the need for expansion. Indian J Cancer 2010;47, Suppl S1:69-74 |
Publication of the supplement was supported by the funds from the 14th World Conference on Tobacco or Health, March 8-12, 2009, Mumbai. The Guest Editors, Editors, Authors and others involved with the journal did not get any financial or non-financial benefit from the sponsors.
| » Introduction | |  |
Tobacco use is described as the single most preventable cause of morbidity and mortality globally, with the World Bank predicting over 450 million tobacco deaths in the next 50 years, if the present scenario does not change. [1] In India, 47% of males and 14% of females use tobacco, [2] and there are about 194 million users of both smokeless and smoking forms. [3] Tobacco-related mortality in India is among the highest in the world, with about 700,000 annual deaths attributable to smoking. [4] Annual oral cancer incidence in the Indian subcontinent has been estimated to be as high as 10 per 100,000 among males [5] and oral cancer rates are steadily increasing among young tobacco users. Smoking increases the risk of Mycobacterium tuberculosis infection, the risk of progression from infection to disease, and the risk of death among tuberculosis patients. [6] It is estimated that 8.3 million cases of coronary artery disease and chronic obstructive airway diseases are also attributable to tobacco each year. [7]
| » Why Tobacco Cessation? The Benefits | | |
Aggressive tobacco cessation measures result in several benefits that have been well documented. It has been estimated that if adult consumption were to decrease by 50% by the year 2020, approximately 180 million tobacco-related deaths could be avoided. [8] Not only is tobacco cessation important in its own right, but it also contributes to tobacco prevention in countries where tobacco use is considered to be a part of the cultural norm. [9] In order to reduce tobacco-related deaths and diseases, current users must quit tobacco use. Although this is a critical step in tobacco control, special efforts will be required to help current users quit tobacco use.
Both smokers and smokeless tobacco users have substantial benefits from cessation. Smokers who quit before 50 years of age reduce their risk of dying in the next 15 years to half that of a continuingsmoker. Even those who quit at 60 years of age reduce their risk of dying by 10% compared with regular smokers. Smoking cessation is known to produce an immediate decline in the blood carbon monoxide levels, normalization of pulse rate, blood pressure, and restoration of sense of taste and smell. [10] Cessation of smokeless tobacco use is associated with reduced risks of oral cancer and precancerous lesions, cardiovascular diseases, and dental problems. [11]
Risks for lung cancer, coronary heart disease, and chronic obstructive pulmonary disease are also markedly reduced by smoking cessation. If potential mothers quit smoking before becoming pregnant, or within the first trimester of pregnancy, infant birth weight is likely to be the same as nonsmokers. Even among pregnant women who quit smoking later in pregnancy, infant birth weights are higher than among women who continue to smoke. Smoking cessation also causes favorable changes in the lipid profile and body fat deposition. Smoking cessation reduces or eliminates the risk of passive smoking-induced diseases, especially in children: pneumonia, bronchitis, middle ear infections, and exacerbations of bronchial asthma. [10],[12],[13],[14]
| » Barriers to Quitting | | |
Despite these enormous gains from tobacco cessation, few persons, particularly in developing countries, give up tobacco use spontaneously. Only 5% of smokers had spontaneously given up smoking in India in 1995 [15] and in a more recent nationally representative case-control study, [16] only 2% of smokers had spontaneously quit. In order for a downward shift in tobacco use to occur, it is imperative that health professionals be at the forefront of tobacco cessation efforts. [17] Several studies in the West have shown that tobacco cessation advice provided by health professionals enhances the quit rate among their patients. [18],[19],[20],[21],[22]
A significant barrier for tobacco cessation and effective prevention is lack of knowledge of the health effects of tobacco use. Poorer knowledge of the risks of smoking has been shown to be associated with smoking initiation among school and college students. [23],[24] Deeply ingrained cultural habits also maintain tobacco use, particularly in rural areas. Another barrier is the lack of tobacco cessation advice and support. A recent study in India reported that 83% of tobacco users wanted to quit, of whom 51% were unsuccessful. [25] This commonly arises from a lack of trained health professionals to provide quitting support. In a study in Bihar, over two-thirds of medical doctors felt the need for increasing their training on tobacco cessation. [26] Health providers may also lack the motivation to undertake smoking cessation activities. Inadequate training in health care facilities and lack of resources and government funding are factors that can impede health care providers from taking up tobacco cessation activities.
Another barrier is the health professional's own use of tobacco. The Global Health Professional Students' Survey revealed that 13.5% of male medical and 11.4% of dental students used tobacco. [27] Tobacco use among practicing health professionals is also high. In a study in Kerala, 15% of male medical school faculty, 13% physicians, and 14% of medical students reported tobacco use. [28]
The lack of training and sensitization of health professionals limits the assessment and intervention of tobacco use. A few studies have been conducted in the developing countries on how often doctors ask patients about their tobacco use, what kind of advice they give them, and whether doctors feel competent to assist patients quit the habit. [29] In Bihar, most of
the doctors surveyed (60-80%) did not take tobacco history. [26] Misconceptions held by doctors can also influence intervention. In a study in Kerala, about one-third of doctors believed that smoking only becomes harmful when the number of cigarettes per day is 6 or more. [30]
| » Efforts Toward Tobacco Cessation | | |
Much of the early efforts on tobacco cessation occurred in the context of primary, community-based interventions for cancer control in the 1980s and 1990s. The efficacy of an antitobacco community education program was evaluated in Karnataka after 2 years in a case-control design. [31] Health education to the community included screening of films, exhibits, and personal contact. In the experimental area, there was a 10.2% decline in tobacco use among the males and 16.3% decline among the females, with corresponding quitter's rate of 26.5% and 36.7%, respectively. Among men, a higher proportion (30.2%) had given up chewing compared with smoking (20.4%). Education using personal and mass media communication in Kerala showed 5-year quit rates of 9.4% among the experimental group compared with 3.2% in the control group. [32] Annual age-adjusted rates of leukoplakia also decreased in the group at 8-10-year follow-up. [33],[34] Other community interventions have compared minimal and more intensive community-based approaches. A study carried out in the Vaishali District of Bihar used potential volunteer groups and individuals in the community and trained them to provide cessation activities. The intervention led to a 4% quit rate, 3% dose reduction rate, and 2% reduction in multiple habits. [35] The study concluded that community-centered mass approaches with minimal sustained intervention was more effective than a clinic- centered, intensive, individual approach.
Dependence and Relapse
One study reported that although brief advice resulted in a quit rate of 55%, the relapse rate was 23%. [36] High rates of relapse among quitters occur because of the addiction potential of tobacco. [37] Tobacco is reportedly more addictive than any other substance of abuse. [38] An improved understanding of the neurobiology of nicotine dependence has had important implications for the management of this disorder. [39]
| » What Works for Nicotine Dependence? | | |
Most meta-analytical studies evaluating tobacco cessation interventions recommend a combination of pharmacotherapy with behavioral interventions. Pharmacotherapy has been shown to double or triple quit rates. [22],[40],[41] Nicotine Replacement Therapy (NRT) is the most widely used therapy for smoking cessation and comprises a range of products with passive (transdermal patch) and instantaneous nicotine delivery (eg, gum, nasal spray, inhaler) with the rationale of providing a slow and steady supply of nicotine to achieve constant concentration levels of nicotine in order to relieve craving and withdrawal symptoms. NRT has been associated with odds ratios of 1.5-1.8 for successful quitting. A combination of NRTs appears to work better than a single NRT for smokers. The abuse potential of NRTs has been described to be low.
Non-NRT medications commonly used for treatment include varenicline, bupropion and nortryptiline. Varenicline is a novel orally administered alpha4beta2-nicotinic acetylcholine (ACh) receptor partial agonist developed specifically for smoking cessation. Varenicline demonstrated both short-term and long-term efficacy compared with placebo in a randomized controlled trial. [42] It doubles or triples the chances of quitting. Varenicline has been reported to be well tolerated and appears to attenuate the urge to smoke. [43] Most smoking cessation trials, however, have been conducted in developed countries and various strategies need to be explored in India, given the differences in educational, cultural, and economic factors.
Bupropion is an antidepressant drug. It is believed to act as an antagonist by blocking nicotine receptors in the brain and affecting the brain's reward/pleasure system. Bupropion approximately doubles the odds of success in quitting.
Nortryptiline, a second-generation tricyclic antidepressant and clonidine, an alpha-agonist antihypertensive are recommended as second-line medications. [22] These drugs have not been evaluated as extensively as the other drugs, but their lower costs make them potential pharmacotherapies in low-income countries.
Most studies of behavioral interventions worldwide reported moderate success in quitting tobacco at 6 months. This finding is seen across different professionals providing interventions in diverse settings using various modalities. Group counseling has shown to be effective. Behavioral interventions in adolescents and pregnancy seem more effective than pharmacotherapy. Technology-driven interventions, such as telephone counseling, dedicated quitlines, and mobile- and web-based technologies have recently gained popularity. Combining interventions shows promising results compared with a single intervention. [44]
Clinic-based Tobacco Cessation
In 2002, tobacco cessation clinics (TCCs) were set up in India to provide the first formal tobacco cessation intervention. Thirteen clinics were set up in oncology, cardiology, psychiatry, surgery and in NGO settings , and later expanded to 19. They were supported by the World Health Organization Country Office and the Ministry of Health and Family Welfare, Government of
India. [45] The main objectives of this initiative were to evolve treatment approaches for the management of smoking and smokeless tobacco dependence, to generate experience in the implementation of these interventions, and to study the feasibility of implementing these interventions on a large scale. In the first 5 years of the clinics, 34,741 cases were registered at these clinics and baseline information recorded for 23,320 cases. Only behavioral strategies were employed in 69% of the cases, and pharmacotherapy, primarily bupropion, and nicotine gums were used in 31% along with behavioral counseling. At 6 weeks, 14% had gradually quit and 22% had reduced their tobacco intake by 50% or more. Younger male patients, users of smokeless forms of tobacco and those receiving a combination of pharmacotherapy and behavioral counseling had relatively better outcomes at 3, 6, and 9 months. The longer the patients retained in follow-up, the greater was the movement from "not improved" to "improved" categories. [46]
Encouraging results have been published from the TCC at Delhi, comparing the effect of counseling alone with counseling and medication (bupropion). The continuous abstinence rate in the counseling group at 1, 3, 6, and 12 months was 17%, 17%, 16%, and 15%, respectively, whereas in the medication group the rates were 60%, 58%, 54%, and 53%, respectively (P<0.001 for all comparisons). [47]
The limitations of the clinic approach are that it reaches only a limited number of predominantly urban and educated users. There was heterogeneity in the treatment approaches, with a very limited use of pharmacotherapy. However, the initiative demonstrated the feasibility of setting up tobacco cessation facilities in diverse clinical settings, and evolved service models that could be extended to the community. The TCCs have since been redesignated as regional resource centers, been increasingly involved in training of health professionals and production of health education materials for tobacco cessation in multiple languages.
| » Expansion beyond Clinics | | |
Tobacco cessation is an important activity under the National Tobacco Control Program initiated by the Government of India. [48] In the pilot phase of the program, district tobacco control units were set up in 18 districts in 9 states, in 2007-2008. This was to be expanded to 12 more states. In addition to tobacco cessation, the activities included school programs, education and awareness, and training and monitoring of implementation of tobacco control laws. The tobacco cessation regional resource centers are expected to play a pivotal role in training at the district level. Associations are envisaged to include tobacco cessation activities with the cancer control program, RNTCP (Revised National Tuberculosis Control Program), noncommunicable disease control program, mental health program, and the National Rural Health Mission.
The Way Forward
Expansion of tobacco cessation program needs to be implemented along several lines and the following recommendations may be considered.
Tobacco cessation training and incorporation of tobacco education into the training curriculum
The greatest need currently is to enhance trained human resources to provide tobacco cessation. This will be possible through training health professionals at primary, secondary, and tertiary care levels as well as through professional bodies. Tobacco cessation education needs to be incorporated into the current undergraduate medical, dental, and nursing curricula. This becomes even more imperative as it is well established that most doctors who use tobacco, pick up the habit during their training and in turn become negative role models. Other health professionals, particularly those involved in primary health care delivery also need to be sensitized and trained in tobacco cessation.
Establishment of tobacco quitlines that offer free counseling and resources to quit
A tobacco quitline may be initiated where trained counsellors offer brief interventions and practical tips to handle withdrawal. Such a quitline may be funded from an additional cess on each tobacco packet/cigarette/beedi sold in the country.
Integration of tobacco cessation into existing programs
Tobacco cessation can be easily delivered by the existing health systems and programs by simply integrating "like with like" programs. For example, during DOTS (Directly Observed Treatment Short course) delivery, each health care worker could also offer some help with tobacco cessation. Similar intervention programs can be integrated into cancer and noncommunicable disease programs.
Every clinical consultation must become a teachable moment for behavioral change
Asking for tobacco and alcohol use must become a routine part of essential history taking and every clinician must use the consultation as a teachable moment for health behavior change.
Advertise the benefits of tobacco cessation and the facilities for support
A very effective method of tobacco cessation is the use of mass media to promote tobacco control advertisements and counter advertising. The use of positive messages, as has occurred with the AIDS program, works better than delivering negative messages. Mass media campaigns are an essential part of a comprehensive tobacco control program. Campaigns that encourage more people to attempt quitting should be conducted. These can be particularly effective in workplace settings, when backed up with support to quit.
Using tobacco cessation techniques not just in individual but in group and community settings
In a vast country like India, where the reach of individuals for individual or group sessions may be limited, it makes imminent sense to promote community-based cessation methods reaching a wider audience. As has been discussed earlier, such cessation methods are proven effective and also have the advantage of forming spontaneous peer groups within the community, which support an individual's decision to quit.
Brief intervention approaches should be promoted
Brief intervention is an effective strategy for tobacco cessation. Such approaches need to be promoted, because they can be delivered by a wide range of health and non-health professionals, such as dentists, nurses, social workers, and others.
Increase NRT accessibility
NRT is the most popular and cost-effective pharmacotherapy currently available and should be made easily accessible and subsidized. However, the range of pharmacotherapy must be available so that the public that can afford out-of-pocket expenses has the choice of evidence-based pharmacotherapy.
Bringing both pharmacotherapy and counseling under the national health insurance umbrella
An ideal situation would be one where both pharmacotherapy and counseling are brought under the national health insurance schemes and offered freely to those in need of it. In the absence of such a scheme, subsidies for the purchase of both medications and NRT may be considered.
Finally, tobacco control efforts are more likely to be bolstered when incorporated into existing national-, state-, and district-level health structures linked with current positions and accountability processes
The attempt to do so under the National Tobacco Control Program must be sustained and strengthened.
| » Conclusion | | |
Given the high global morbidity and mortality from tobacco use in India, there is a need to develop evidence-based, cost-effective interventions for both smoking and smokeless tobacco use. Tobacco addiction produces neurobiological and behavioral changes, and optimal approaches combining behavioral methods and pharmacotherapy need to be developed. [44]
| » Acknowledgment | | |
The primary author is the principal investigator of the TCC at NIMHANS, supported by the World Health Organization Country Office and the Ministry of Health and Family Welfare, Government of India.
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