|TOBACCO CONTROL ISSUE - ORIGINAL ARTICLE
|Year : 2014 | Volume
| Issue : 5 | Page : 54-59
Community-based tobacco cessation program among women in Mumbai, India
GA Mishra, SV Kulkarni, PV Majmudar, SD Gupta, SS Shastri
Department of Preventive Oncology, Tata Memorial Hospital, E. Borges Marg, Parel, Mumbai, Maharashtra, India
|Date of Web Publication||19-Dec-2014|
G A Mishra
Department of Preventive Oncology, Tata Memorial Hospital, E. Borges Marg, Parel, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Globally tobacco epidemic kills nearly six million people annually. Consumption of tobacco products is on the rise in low- and middle-income countries. Tobacco is addictive; hence, tobacco users need support in quitting. Aims: Providing tobacco cessation services to women in community enabling them to quit tobacco, identifying factors associated with quitting and documenting the processes involved to establish a replicable "model tobacco cessation program." Settings and Design: This is a community based tobacco cessation program of one year duration conducted among women in a low socioeconomic area of Mumbai, India. Subjects and Methods: It involved three interventions conducted at three months interval, comprised of health education, games and counseling sessions and a post intervention follow-up. Statistical Analysis: Uni and multivariate analysis was performed to find out association of various factors with quitting tobacco. Results: The average compliance in three intervention rounds was 95.2%. The mean age at initiation of tobacco was 17.3 years. Tobacco use among family members and in the community was primary reasons for initiation and addiction to tobacco was an important factor for continuation, whereas health education and counseling seemed to be largely responsible for quitting. The quit rate at the end of the programme was 33.5%. Multivariate logistic regression analysis found that women in higher age groups and women consuming tobacco at multiple locations are less likely to quit tobacco. Conclusions: Changing cultural norms associated with smokeless tobacco, strict implementation of antitobacco laws in the community and work places and providing cessation support are important measures in preventing initiation and continuation of tobacco use among women in India.
Keywords: Counseling, health education, tobacco cessation, tobacco quit rates
|How to cite this article:|
Mishra G A, Kulkarni S V, Majmudar P V, Gupta S D, Shastri S S. Community-based tobacco cessation program among women in Mumbai, India. Indian J Cancer 2014;51, Suppl S1:54-9
|How to cite this URL:|
Mishra G A, Kulkarni S V, Majmudar P V, Gupta S D, Shastri S S. Community-based tobacco cessation program among women in Mumbai, India. Indian J Cancer [serial online] 2014 [cited 2021 May 10];51, Suppl S1:54-9. Available from: https://www.indianjcancer.com/text.asp?2014/51/5/54/147474
| » Introduction|| |
Globally about six million people die due to tobacco use annually.  Approximately, 250 million adults use smokeless tobacco (SLT) in 11 countries of the World Health Organization (WHO) South-East Asia Region (SEAR). They account for 90% of global SLT users.  The prevalence of tobacco use among the adult Indian population is 34.6% (estimated urban and rural prevalence is 25.3% and 38.4%, respectively); overall 47.9% males and 20.3% females in India, 42.5% males and 18.9% females specifically in Maharashtra consume tobacco. 
Although smoking is the most common form of tobacco consumed worldwide, India has varied patterns of tobacco use.  The use of SLT is much higher (25.9%) when compared to smoking tobacco (14.0%).  Tobacco use is influenced by social, cultural, and ritual factors in India.  Consumption of SLT when compared to smoking forms is culturally accepted among women. However, with decreasing social and economic restrictions on women and with increase in spending capacity, tobacco use among women is increasing in India and even globally. 
Consumption of smoking as well as SLT causes cancers of different sites in human body, including the organs of respiratory, reproductive, urinary and gastro-intestinal systems, acute hypertension, increased risk of cardiovascular diseases and diabetes mellitus and infertility. , The benefits of quitting can be perceived immediately on discontinuing tobacco use. Both immediate and long-term health benefits include normalization of the pulse rate and blood pressure, improved respiratory function and reduction in the reproductive adverse effects.  Lack of awareness about the ill-effects of tobacco use, ingrained cultural attitudes and lack of widespread cessation facilities maintains tobacco use in the community. Utilization of tobacco cessation services by current users is an important aspect of reducing the risk of tobacco related deaths.  Accordingly, tobacco cessation is an important component of the National Tobacco Control Programme (NTCP).  Counseling is one of the best approached methods for tobacco cessation.  WHO MPOWER has recommended to offer help to quit tobacco as an important approach to counter the tobacco epidemic. 
Currently, women constitute one of the biggest target groups of the tobacco industry due to their growing spending power.  Therefore, unless effective, comprehensive and sustained initiatives are implemented to reduce tobacco use among women, prevalence of females using tobacco is likely to rise.
Until date, there are only 24 tobacco cessation clinics (TCCs) in the country, a figure largely insufficient to reach out to 275 million current tobacco users.  All TCCs are located in urban areas and some attached to major hospitals. Furthermore, people at the community level are often unaware of the existence of such facility and are hesitant to approach this specialized set-up. Hence, a TCC providing service at community level will make tobacco cessation counseling easily accessible for the masses at grass root level and also counter the stigma associated with approaching a specialized set-up.
A community-based tobacco cessation programme was planned and implemented for women in a low socioeconomic community in Mumbai. The purpose of this programme was to create awareness among women in the community regarding the ill-effects of tobacco, provide tobacco cessation counseling services to help them quit and assess outcome of such an intervention. The processes involved were documented in detail. The goal principally was to establish a model tobacco cessation programme, which could be replicated elsewhere. This programme is registered with the clinical trials.gov with registration number NCT01958255.
| » Subjects and Methods|| |
A community survey to identify women using tobacco was conducted six months prior to initiating this programme, as a part of women cancer screening by the same group of investigators. The current program involved provision of three tobacco cessation interventions at three monthly intervals, followed by a postintervention follow-up. The total duration of the program was 12 months.
Eligible women were contacted by door-to-door visit and explained the cessation programme. Informed consent was obtained from women who were interested in participating and their sociodemographic and risk factor history and information about their knowledge, attitude and practices of tobacco habits were obtained by personal interviews and recorded on a structured and pilot tested questionnaire, by trained Medical Social Workers. Women were then invited at community-based camp place for further interventions. Each of the three interventions was conducted in three sessions. First session of rapport building comprised of games or cultural activity [Figure 1]. Second session comprised of group discussion or health education programme (HEP) on tobacco and adverse effect [Figure 2]. Third session included group counseling to quit the tobacco habits with a focus on benefits of quitting, encouragement to quit, dealing with withdrawal symptoms and encouraging quitters to maintain abstinence [Figure 3].
Throughout the programme extensive efforts were made to maintain high participation rates. A post-intervention follow-up was conducted to assess the tobacco practices at the end of the programme. The main outcome measure recorded was self-reported tobacco use status. A woman was considered to have quit tobacco, if she did not use tobacco over a period of past 1-month.
The data were entered in SPSS version 18 and analyzed in STATA.
| » Results|| |
During the survey of the earlier screening project conducted in the same area, 340 women tobacco users were identified. Six months later, when the present program was initiated, it was found that 36 women (10.6%) had quit tobacco with a single round of well conducted HEP that was provided as a part of screening services. Hence, 304 women tobacco users were eligible for enrollment in the present program. In house-to-house visits of the eligible, 279, 273 (97.9%), 268 (96%), and 260 (93.2%) women were contacted during the first, second and third interventions and post intervention follow-up, respectively. 25 women could not be contacted throughout the duration of the project, despite making several attempts to trace them. The average compliance to participation in the three intervention rounds among the total enrolled eligible (i.e. 279 women) was 95.3%. The motivational stage of assessment with regards to tobacco cessation during each of the three interventional sessions and during the post intervention follow-up is shown in [Table 1].
Reasons for taking to tobacco habits
The mean and median ages at initiation of tobacco use were 17.3 years (standard deviation = 9.11) and 15 years, respectively. The main reasons for initiation of tobacco were influenced by family members using tobacco 135 (48.4%), prevalence of tobacco use in the community 93 (33.3%) and peer pressure 65 (23.3%). Among the 271 women who were ever pregnant, 242 (89.3%) consumed tobacco during pregnancy including 18 (7.4%) women who reported to have initiated tobacco use during pregnancy. Craving during pregnancy (100%) was the main reason for initiation. 173 women were working either currently or in the past. Of the 26 women working indoors, two reported presence of employees smoking at the workplace. Of the 6 (3.5%) working women who had antitobacco policy at their work place, five reported policy prohibiting smoking tobacco while one reported policy prohibiting use of any form of tobacco inside the workplace.
Economics of tobacco use
252 (90.3%) women mentioned that they purchased tobacco for self-consumption and 238 of them (85.3%) spend between Rs. 4/- and Rs. 25/- per month for tobacco. The mean and median monthly tobacco expense was Rs. 21.61/- and Rs. 20.00/-.
Place of use
About 77% used tobacco at home only, 13% at home and workplace and at multiple places by 9.8%.
Family history of tobacco consumption was present in 183 (65.6%) women. Smokeless forms when compared to smoking forms were used predominantly by the family members of the participant women.
Quit rates and attempts
The overall tobacco quit rate at the end of the programme was 33.5% (n = 260). Among the 87 women who quit tobacco, out of them 95% reported quitting tobacco because of the information received from the HEP and counseling sessions. Among the 279 enrolled women, 69 (24.7%) had unsuccessfully attempted quitting tobacco in the past. Among the women contacted, 167 (61.2% n = 273), 86 (32% n = 268), and 33 (12.7% n = 260) women made attempts to quit tobacco after the first, second and third interventions respectively. Among the 260 women contacted at the end of the study, 140 women had attempted quitting tobacco once, 66 - twice, 21 - thrice, 6- 4 times, 2- 5 times and 1 attempted quitting 6 times. Among the 87 tobacco quitters at the end of the study, 42 had attempted quitting once, 31 twice, nine thrice, two each had attempted quitting 4 and 5 times, respectively and one had attempted quitting 6 times in the past. Overall, 35.3% women (average of four rounds) had made quit attempts.
About 49 (29.3%), 22 (25.6%) and 22 (66.7%) women had experienced withdrawal symptoms after they attempted to quit tobacco after first, second and third interventions respectively, the main symptoms being dryness of mouth, constipation, craving for tobacco, oral discomfort and irritability. Some 42.3%, 39.1% and 84.2% women who had withdrawal symptoms could quit tobacco after the first, second and third interventions, respectively. Among the enrolled women, 24 never attempted quitting throughout the programme because of its addictive nature (92.5%) and because they thought it provided relief from work pressure (38%) and energy for work (34.8%).
Association of various factors
Univariate and multivariate logistic regression analysis [Table 2] was performed to find out the association of various factors with tobacco quitting. Univariate analysis showed women in higher age group, who lacked the knowledge that tobacco is injurious to health, higher duration of tobacco use, who used tobacco at multiple locations, had higher monthly expenses on tobacco and higher fragerstorm score were less likely to quit tobacco. When the significant variables of univariate were put in the multivariate logistic regression analysis, age groups and locations of tobacco consumption were significantly associated with tobacco quitting. Women with higher age groups and women consuming tobacco at multiple locations were less likely to quit tobacco.
|Table 2: Multivariate analysis showing relation of various sociodemographic and risk factor variables with tobacco quitting|
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| » Discussion|| |
In the present study, of the 340 women initially identified as tobacco users, 36 (10.6%) women quit tobacco due to the impact generated by a single session of HEP received during the cancer screening program. This shows that even a single session of an effective HEP has remarkable potential to result in tobacco cessation among women never exposed to such an elaborate information in the past. Antitobacco community education programme in Koral district of Karnataka had quit rate of 36.7% at the end of five years. 
The average compliance to participation was 95%. The satisfactory compliance rates were achieved through extensive efforts by the staff employing various strategies like sensitization of local community leaders, selecting potential places in the community where people were more likely to visit, multiple visits to the women's houses for invitation, flexible timings of the interventions etc. Repeated contact counseling is crucial for the success of cessation and prevention of relapses.  The present study ensured average compliance of 95.2% to the three interventions provided. The average participation rate in the community based group intervention programme in Tamil Nadu was 74.5%.  The participation rate for the baseline survey in a community-based smoking cessation intervention trial in Kerala was 82%. 
The mean age at initiation of tobacco in the present study was 17.3 years, compared to 18.6 years in Maharashtra.  Average age at initiation has been recorded as 15 years for smoking in a rural Kerala study,  and 23.6 years for chewing tobacco in Gujarat study.  A study from Kerala demonstrates decreasing trend in the age at initiation of tobacco use.  Tobacco use is affected by various sociocultural factors, as evident from the present study where 47.3% women initiated tobacco use emulating the family elders using tobacco, 34% influenced by the use of tobacco in the community and 22.2% due to peer pressure. In Trivandrum study among adolescent boys, common reasons for children initiating tobacco habit were peer pressure, parental tobacco habits and availability of pocket money.  Present study indicates that maximum number of tobacco quitters had initiated tobacco consumption between 10 and 19 years. A study in Gujarat showed that majority of tobacco quitters had initiated tobacco habits between age 20 and 30 years.  A study among young adults indicates those who begin earlier are less likely to quit smoking. 
The prevalence of tobacco use during pregnancy was 86.9%. The National Institutes of Health funded study found that about one-third of the pregnant women consumed tobacco in Orissa.  Six (3.5%) women who reported having antitobacco policy at workplaces consumed tobacco. Similarly, a rural workplace with presence of antitobacco policy still had 48% employees who consumed tobacco.  The mean monthly expense on tobacco in the current study was Rs. 21.61. In a workplace tobacco cessation programme, the average monthly expenditure on nonsmoking forms of tobacco was Rs. 66.65.  In the present study, 67% of tobacco users and 58.60% of quitters had family members who used tobacco. In the Gujarat study, 63.9% of tobacco users and 48.2% of quitters had history of tobacco use among family members. 
The overall tobacco quit rate among the participants contacted during the post intervention follow-up was 33.46%. The group intervention study in Tamil Nadu recorded cessation rates of 13.8% at the end of two months.  A study undertaken to review the process and operational aspects of establishment of TCCs set-up as part of NTCP resulted in 26%, 21% and 18% tobacco users either quitting or reducing the habit after three, six and nine months with behavioral counseling and pharmacotherapy interventions.  A study implemented in three regions of Kerala, resulted in 1.9%, 4.9% and 2.1% tobacco users quitting tobacco at the end of one year in those regions.  In the present study, the chief reason for quitting tobacco was motivation due to HEP and counseling. A study from Gujarat identified health problems (72.2%), preaching by local religious leaders encouraging quitting (60.2%) and familial pressure (40.7%) as important reasons for quitting. 
In the present study, 35.3% women (average of four rounds) made an attempt to quit as compared to 29% according to the Global Adult Tobacco Survey 2009-2010.  In a study from Gujarat and Andhra Pradesh, 18.3% tobacco users had attempted to quit during the past 12 months.  Among the 87 tobacco quitters at the end of the study, 48% had attempted quitting once, 36% twice, 10% thrice and 6% more than thrice. A workplace tobacco cessation in India showed that of the final 20 tobacco quitters at the end of 21% had attempted quitting once, 10% twice, 10% thrice, one had attempted quitting 7 times respectively in the past. 
In the present study, most women said that they continued tobacco use because it was a habit. A workplace tobacco cessation programme in India showed belief that tobacco would not harm them, avoiding distress caused by discontinuation of tobacco habit and relief from stress were important reasons for persistence of the habit. 
The success of tobacco cessation programme is determined by combination of the initiatives taken by the tobacco users to quit and the support system offered by family, community and the healthcare professionals. Influencing the sociocultural customs and beliefs regarding tobacco in the community is important for preventing the initiation of tobacco use. Education on tobacco related health hazards needs to be incorporated in the school and junior college curriculum. Strict implementation of antitobacco laws at public places, in the community and work places is necessary. Majority of the tobacco users also used or even initiated tobacco habit during pregnancy. This emphasizes incorporation of tobacco control and cessation practices into the antenatal care. As most women consumed mishri, available at a very low rate, it emphasizes the need of having system in place to impose taxes on all tobacco products including nonmanufactured tobacco.
| » Conclusions|| |
In a well-supported cessation program on tobacco among 260 women, 33% quit tobacco. The focus was on intense communication and support.
| » References|| |
Reddy KS, Gupta PC, editors. Report on Tobacco Control in India (New Delhi, India). New Delhi, India: Ministry of Health and Family Welfare; 2004. Government of India; Centers for Disease Control and Prevention. USA: World Health Organization.
World Health Organization. Gender, Women and the Tobacco Epidemic: Prevalence of Tobacco Use and Factors Influencing Initiation and Maintenance among Women. World Health Organization; 2010.
IARC. Tobacco Smoke and Involuntary Smoking. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. IARC; 2002. p. 83.
Smokeless Tobacco. IARC Monograph. Available from: http://www.monographs.iarc.fr/ENG/Monographs/vol89/mono89-6.pdf.
Health Benefit of Quitting Smoking. Available from: http://www.who.int/tobacco/quitting/benefits/en/. [Last accessed on 2014 Apr 08].
Kumar MS, Sarma PS, Thankappan KR. Community-based group intervention for tobacco cessation in rural Tamil Nadu, India: A cluster randomized trial. J Subst Abuse Treat 2012;43:53-60.
Anantha N, Nandakumar A, Vishwanath N, Venkatesh T, Pallad YG, Manjunath P, et al.
Efficacy of an anti-tobacco community education program in India. Cancer Causes Control 1995;6:119-29.
Mishra GA, Pimple SA, Shastri SS. An overview of the tobacco problem in India. Indian J Med Paediatr Oncol 2012;33:139-45.
Jayakrishnan R, Mathew A, Uutela A, Finne P. A community based smoking cessation intervention trial for rural Kerala, India. Asian Pac J Cancer Prev 2011;12:3191-5.
Radhakrishnan J, Aleyamma M, Antti U, Anssi A, Paul S. Multiple Approaches and Participation Rate for a Community Based Smoking Cessation Intervention Trial in Rural Kerala, India. Asia Pacific J cancer Prev. 2013;14:2891-2896
Joshi U, Modi B, Yadav S. A study on prevalence of chewing form of tobacco and existing quitting patterns in urban population of Jamnagar, Gujarat. Indian J Community Med 2010;35:105-8.
Pradeepkumar AS, Mohan S, Gopalakrishnan P, Sarma PS, Thankappan KR, Nichter M. Tobacco use in Kerala: Findings from three recent studies. Natl Med J India 2005;18:148-53.
Mohan S, Sankara Sarma P, Thankappan KR. Access to pocket money and low educational performance predict tobacco use among adolescent boys in Kerala, India. Prev Med 2005;41:685-92.
Breslau N, Peterson EL. Smoking cessation in young adults: Age at initiation of cigarette smoking and other suspected influences. Am J Public Health 1996;86:214-20.
Bloch M, Althabe F, Onyamboko M, Kaseba-Sata C, Castilla EE, Freire S, et al.
Tobacco use and secondhand smoke exposure during pregnancy: An investigative survey of women in 9 developing nations. Am J Public Health 2008;98:1833-40.
Mishra GA, Shastri SS, Uplap PA, Majmudar PV, Rane PS, Gupta SD. Establishing a model workplace tobacco cessation program in India. Indian J Occup Environ Med 2009;13:97-103.
Varghese C, Kaur J, Desai NG, Murthy P, Malhotra S, Subbakrishna DK, et al
. Initiating tobacco cessation services in India: Challenges and opportunities. WHO South East Asia J Public Health 2012;1:159-68.
Gupta PC, Mehta FS, Pindborg JJ, Aghi MB, Bhonsle RB, Daftary DK, et al.
Intervention study for primary prevention of oral cancer among 36 000 Indian tobacco users. Lancet 1986;1:1235-9.
Sarkar BK, Arora M, Gupta VK, Reddy KS. Determinants of tobacco cessation behaviour among smokers and smokeless tobacco users in the states of Gujarat and Andhra Pradesh, India. Asian Pac J Cancer Prev 2013;14:1931-5.
Mishra GA, Majmudar PV, Gupta SD, Rane PS, Uplap PA, Shastri SS. Workplace tobacco cessation program in India: A success story. Indian J Occup Environ Med 2009;13:146-53.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]