|Year : 2020 | Volume
| Issue : 4 | Page : 443-450
Preparedness of primary health care providers for tobacco cessation — Experiences from a non-communicable disease training program
Arun M Kokane, Arun Mitra
Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
|Date of Submission||26-Oct-2018|
|Date of Decision||17-Apr-2019|
|Date of Acceptance||27-May-2019|
|Date of Web Publication||02-Oct-2020|
Department of Community and Family Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Background: Tobacco use can lead to tobacco/nicotine dependence and serious health problems. Quitting smoking significantly reduces the risk of developing smoking-related diseases. In a low resource setting like India, the role of primary healthcare providers in tobacco cessation is immense. The current study was conducted with the objective of evaluating the preparedness, knowledge and attitude of the primary healthcare providers in tobacco cessation.
Methods: A cross-sectional study involving 289 trainees taking part in a non-communicable disease training in the calendar year 2015, held at All India Institute of Medical Sciences, Bhopal were interviewed with a close-ended questionnaire on the demographic profile of participants, their preparedness, and current knowledge and attitude related with tobacco cessation activities.
Results: Among the 289 trainees, majority of the study participants were staff nurses (54.7%) and medical officers (41.2%) with a mean (± Standard Deviation, range) age of 35 (±10, 22-63) years predominantly from district and sub-district hospitals (52.9%). In total, 86.9% counsel their patients regarding tobacco cessation and 13.1% use nicotine replacement therapy in aiding tobacco cessation. 174 (60.2%) participants received on-job training of various duration on tobacco control, and 96 (33.2%) did not receive any training. Preparedness toward tobacco cessation was present in 15.01% (41) of the study participants.
Conclusion: The study reveals that the majority of the healthcare providers were not prepared, and only half of the participants had favorable attitudes and practices of delivering tobacco cessation activities.
Keywords: Attitude, healthcare providers, knowledge, practice, tobacco cessation
|How to cite this article:|
Kokane AM, Mitra A. Preparedness of primary health care providers for tobacco cessation — Experiences from a non-communicable disease training program. Indian J Cancer 2020;57:443-50
|How to cite this URL:|
Kokane AM, Mitra A. Preparedness of primary health care providers for tobacco cessation — Experiences from a non-communicable disease training program. Indian J Cancer [serial online] 2020 [cited 2020 Oct 24];57:443-50. Available from: https://www.indianjcancer.com/text.asp?2020/57/4/443/297030
| » Introduction|| |
Tobacco has been implicated in the morbidity and mortality across a wide array of conditions such as non-communicable disease,,,, mental disorders,,,, and infections.,,, The World Health Organization Report on The Global Tobacco Epidemic - 2017 estimates that more than 7 million lives are lost each year due to tobacco; out of which, 6 million are due to the direct tobacco use, whereas around 890,000 are due to second-hand smoke. The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) treaty in 2005 was signed and ratified by over 168 countries. Under the ambit of the WHO FCTC, the MPOWER package is intended to assist the country-level implementation.
India is the second-largest consumer of smoking and smokeless variety of tobacco globally, and accounting for one-sixth of tobacco-related deaths. The Global Adult Tobacco Survey (GATS) conducted in India in 2009-10 revealed that about 46% of users planned to quit and more than half were planning to quit within the next 12 months. Although the proportion of adult tobacco users is on the decline from 34.6% in 2009–10 to 28.6% in (2016-17), the burden of tobacco in India remains huge. The GATS-2 (2016–17) survey revealed 61.9% cigarette smokers, 53.8% bidi smokers, and 46.2% smokeless tobacco users planned to quit tobacco. A countrywide tobacco cessation program was launched in 2016 in light of high interest of quitting tobacco among its users.
India ratified the WHO-FCTC in 2004. The government's initiatives such as a national level program for tobacco control [National Tobacco Control Programme (NTCP)], tobacco-control legislations [The Cigarettes and other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003), and setting up of Tobacco Cessation Centers (TCCs) further reinforce India's commitment in combating tobacco, which is reflected in the decline in tobacco consumption reported in second GATS 2017.
The National Program for Prevention and Control of Cancer, Diabetes, CVD, and Stroke (NPCDCS) recognizes tobacco as a major risk factor, especially in oral cancers. However, there is huge scope for improvement in the provision of tobacco cessation activities in reducing the burden of tobacco in society. In addition to the scaling up of the tobacco cessation centers in India, the healthcare providers delivering these services needs to be strengthened to meet India's growing needs. Conversely, not much is known regarding the preparedness of this personnel in providing these services to those who seek. This study is planned to assess knowledge, attitude, and practices along with the preparedness of healthcare providers and the factors associated with respect to tobacco cessation in their work settings.
| » Methodology|| |
Madhya Pradesh (MP) is the second largest state in India. It has a population of 7.27 crores; overall, the literacy rate is 69.3%. The state houses 51 district hospitals, 64 civil hospitals, 334 community health centres (CHC), 1,157 primary health centres (PHC), and 8,764 subcenters (SC). As per norms of state government, 23 doctors and 52 nursing staff are required for district hospital; 5 doctors and 6 nursing staff for CHC; 1 doctor and 1 lady health visitor (LHV) for PHC; and 1 male health worker and 1 female health worker for SC.,
In an effort to strengthen the healthcare workforce, the government of Madhya Pradesh funded a project for training of medical officers and staff nurse in non-communicable disease management, a seven-day training program at All India Institute of Medical Sciences (AIIMS) –Bhopal; in which 3–4 sessions (4–6 hours) were dedicated to tobacco deaddiction and cessation activities. This opportunity was utilized to assess the knowledge, attitude, current practices, and preparedness of healthcare providers in delivering tobacco cessation services at their workplace.
Study design and participants
It was a cross-sectional study with a universal sampling method. A total of 289 participants in 15 batches attended the NCD training in the 2015 calendar year. All those 289 were invited to participate after explaining them the purpose of the study.
After explaining them the purpose of the study, informed verbal consent was obtained in the local language (Hindi) from all the participants in every batch. Data were collected in a predesigned, pretested, and close-ended questionnaire, which were validated by performing a pilot study and was made available in bi-lingual format (Hindi and English) within the first couple of days as per the convenient time suggested by the participants.
The questionnaire contained items pertaining to the demographic profile of the participants, practices, knowledge, attitude, and preparedness related to tobacco cessation.
The preparedness was assessed through following variables; any training attended during education, attended any on-job training, ever consumed tobacco in any form, adequate knowledge, and favorable attitude toward tobacco cessation activities. Adequate knowledge and favorable practices related to tobacco cessation services were self-reported binary variables i.e., yes and no, based on the operational definitions provided in [Box 1].
Current practices of healthcare providers in delivering tobacco cessation services at their workplace were ascertained through following variables i.e., perform counseling for tobacco cessation and prescribe nicotine replacement therapy and other pharmacological therapy (such as varenicline and bupropion) to patients.
The data were entered into a Microsoft Excel spreadsheet and analyzed by using R statistical package (Version 3.4.1). The demographic profile, education status, working place, and preparedness were considered as independent variables, and favorable practices were considered as dependent variables. Chi-square test and bi-variate logistic regression were performed, and the odds ratios and their 95% confidence intervals were estimated to describe the association between the variables. The P-value of less than 0.05 was considered to be statistically significant.
Approval was obtained before conducting the present study from Institute Human Ethical Committee (IHEC) of AIIMS Bhopal vide Letter No. IHEC-LOP/2015/EF0006 dated 17th August 2015.
| » Results|| |
This study was carried out as a part of the chronic disease training program for medical officers and nursing staff working at various levels of healthcare. A total of 289 healthcare providers i.e., 120 males (41.5%) and 169 females (58.5%) participated in the study. The mean (± Standard Deviation, range) age of the study participants was 35 (±10, 22-63) years, with the majority (75%) belonging to the younger age i.e., 20-40 years. The baseline characteristics of the study population are described in [Table 1]. Approximately, 13% have consumed tobacco in any form during their lifetime, 82% have not consumed tobacco, and 5% did not respond.
It was found that the majority (86.9%) of the study participants counsel their patients regarding tobacco cessation [Figure 1]. However, only 12 (13.1%) participants reported the use of nicotine replacement therapy in aiding tobacco cessation.
|Figure 1: Current practices of health care providers in delivering tobacco cessation services at their work place. NRT = Nicotine Replacement Therapy|
Click here to view
Curriculum training on the dangers of tobacco
When inquired about being trained on the dangers of tobacco as a part of their curriculum course [MBBS, MD/MS, BSc (Nursing), MSc (Nursing), and Nursing Diploma], 51% of participant agreed to be trained as a part of the curriculum, 42% did not agree, and around 7% did not respond.
On-job training on tobacco cessation
It was found that 174 (60.2%) received on-job training of various duration on tobacco control and 96 (33.2%) did not receive any training during the job [Figure 2], while 19 (6.6%) did not respond. Of those who received on-job training, 54% received training for two or more days. It was found that about 60% of healthcare providers at each health facility underwent on-job training (PHC: 63.3%, CHC: 61.3%, sub-district hospital: 63.6%, district hospital: 58.5%). It was also interesting to find that the healthcare providers from the district hospital had the least training among all the facilites; however, this difference was not found to be statistically significant (P > 0.05).
|Figure 2: On-job training of health care providers in delivering tobacco cessation services at their work place|
Click here to view
Knowledge and attitude toward tobacco cessation
Of the 289 study participants, knowledge could be assessed for 273 (94.5%) participants. Regarding knowledge and attitude toward tobacco cessation, it was found that compared to individuals less than 30 years, participants aged between 31–40 and 51–60 years were having fewer chances of having inadequate knowledge. Similarly, compared to individuals from PHC were having lesser chances of having inadequate knowledge as compared to individuals from the district hospital (P = 0.002).
Females were more likely to have inadequate knowledge regarding tobacco cessation as compared to males (OR: 2.27, 95% CI: 1.39-3.78). Staff nurses were twice as more likely to have inadequate knowledge as compared to medical officers (OR: 2.78, 95% CI: 1.66-4.70). Individuals who underwent on-job training of one day or more days were more likely to have inadequate knowledge (OR: 3.28, 95% CI: 1.23-9.13 and OR: 2.77, 95% CI: 1.27-6.50) as compared to those who underwent a half-day training [Table 2].
|Table 2: Association between the socio-demographic characteristics of the study population and their knowledge regarding tobacco cessation (N = 273*)|
Click here to view
Individuals with the unfavorable attitude toward tobacco cessation were four times more likely to have inadequate knowledge as compared to those who had favorable knowledge. Healthcare providers who received training during their job were less likely (χ2 = 7.132, P = 0.002) to consume tobacco in their lifetime [Table 3]. The attitude of the healthcare providers (favorable and unfavorable) was checked for the association between age, gender, designation, type of facility, on-job training, and duration and was not found to be statistically significant (P > 0.05).
|Table 3: Association between training on tobacco cessation during education and consumption of tobacco|
Click here to view
Preparedness toward tobacco cessation
It was found that 15% (n = 41) of the study participants were prepared toward tobacco cessation [Table 4]. The bivariate analysis reveals that participants aged between 31 and 40 years were more likely to be prepared as compared to participants below 30 years of age. In addition, participants from the CHC were two times likely to be less prepared for tobacco cessation (OR: 2.40, 95% CI: 1.08-5.91) as compared to participants from the District Hospital. Gender, designation, educational qualification, and location were not associated with the preparedness of tobacco cessation.
|Table 4: Bivariate analysis between preparedness of tobacco cessation and socio-demographic characteristics of the study population (N = 273*)|
Click here to view
| » Discussion|| |
In spite these enormous gains from tobacco cessation, only a small fraction give up tobacco use spontaneously. Estimates show that only 2% to 5% of smokers spontaneously give up smoking in India., Primary care is an important context for promoting tobacco cessation. In a low-resource country like India, primary healthcare providers play an immense role in tobacco cessation. Healthcare professionals have an important role to play in tobacco control especially in settings such as India given that health literacy is low and that other modes of education of the public such as pictorial warnings on tobacco packaging have been ineffective. They are an integral part for achieving the National Health Policy set a goal of 30% reduction in tobacco users by 2025. The current study is aimed to identify self-reported preparedness for tobacco cessation service delivery among healthcare providers attending NCD training in MP, India.
Earlier studies in India observed that 22-48% of physicians or dentists use tobacco products., However, our study estimates a lower level of tobacco use among healthcare providers. Mony et al. studied the tobacco use, attitudes, and practices of tobacco cessation in Southern India and reported similar results (6.9%). This may be owing to various socio-demographic characteristics of the study population including the fact that there is a substantial proportion of females in the study participants. This could also be because of the response bias, which might have influenced tobacco use patterns in the study participants. Also, because this is a self-response setting and the findings were not validated through serum cotinine levels, this lower estimate may be owing to under-reporting and requires further exploration.
Regarding knowledge, the participants reported knowledge of tobacco cessation activities also was low (56.7%). Although a majority (87%) of the healthcare providers reported that they had adequate knowledge regarding counseling, only 13% reported that they have adequate knowledge regarding nicotine replacement therapy. Our estimates were lower than that of those found by previous researchers in India., This may be explained by lack of knowledge and inadequate training on tobacco cessation, 60% of those who reported on-job training reported a training duration of less than a day.
Regarding attitude, only half of the participants had favorable attitudes toward tobacco cessation and agreed that training on the dangers of tobacco use must be included in their curriculum course. This may be precipitated owing to the lack of adequate knowledge regarding the dangers of tobacco use and inadequate training regarding the cessation. It is also interesting to note that the odds of consuming tobacco were three times more in those healthcare providers who did not have any training during education as compared to those who received the education. Previous studies report the need for inclusion of tobacco cessation into academic and professional training., Our study has revealed suboptimal levels of preparedness on tobacco cessation among healthcare providers with only 15% being prepared for tobacco cessation and only a marginal fraction reporting adequate knowledge regarding prescribing pharmacological therapy. A similar cross-sectional study was done by Panda et al. in 12 districts of Andhra Pradesh and Gujarat, which reports that only one-third of patients have been screened for tobacco use, and a meager 5% have been offered advice on tobacco cessation., Many researchers across the world stress on the importance of the role of a health care provider in counselling and motivating tobacco users to quit tobacco.,,, It is also imperative that the policymakers understand the essential role of a health care provider in reducing the burden of tobacco.
Research related to tobacco among primary healthcare providers is limited in India. Although numerous studies are available on tobacco use and patterns with a majority of them conducted among medical students, few explore tobacco cessation in particular.,,, Most studies have identified insufficient formal training and some negative attitudes as key barriers to the enhanced participation of healthcare professionals in tobacco control, which are in line with our study findings.
There are many areas of focus where India needs to look to decrease the burden of tobacco as a whole. Apart from the governments commitment, it is essential to look toward the reforms in both the educational and healthcare sector. We speculate that the poor coordination among stakeholders and healthcare providers results in ineffective implementation of the Cigarettes and Other Tobacco Products Act, 2003 across the state. The theme for the World Tobacco Day 2017 was “Tobacco – a threat to development,” the state of MP has a long way to go to eliminate this threat and the same would be possible only with collective efforts across multiple sectors.
The current study has many methodological limitations. The findings of this study are subject to self-reporting response bias. In addition, in the current study, the non-response rate in certain aspects was high. One of the major limitations was that the status of consumption of tobacco was considered to be ever used rather than the current use. The behavioral and contextual barriers limiting the preparedness for tobacco cessation services of the healthcare provider required a qualitative component and was not studied. The lack of calculation of sample size limits the generalisability of the findings of this study to the population.
| » Conclusion and Recommendations|| |
The study reveals that the majority of the healthcare providers are not prepared and only about half of them have favorable practices of tobacco cessation activities. The authors recommend a re-look into the training of these healthcare providers for tobacco cessation and incorporate the training into the professional and academic curriculum.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Law MR, Morris J, Wald NJ. Environmental tobacco smoke exposure and ischaemic heart disease: An evaluation of the evidence. BMJ 1997;315:973-80.
Sasco A, Secretan M, Straif K. Tobacco smoking and cancer: A brief review of recent epidemiological evidence. Lung Cancer 2004;45:S3-9.
Johnson N. Tobacco use and oral cancer: Aglobal perspective. J Dent Educ 2001;65:328-39.
Cataldo JK, Prochaska JJ, Glantz SA. Cigarette smoking is a risk factor for Alzheimer's disease: An analysis controlling for tobacco industry affiliation. J Alzheimers Dis 2010;19:465-80.
Ziedonis D, Hitsman B, Beckham JC, et al.
Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report. Nicotine Tob Res 2008;10:1691-1715.
Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: A population-based prevalence study. JAMA 2000;284:2606-10.
Tobias MI, Templeton R, Collings S. How much do mental disorders contribute to New Zealand's tobacco epidemic? Tob Control 2008;17347-50.
Williams JM, Ziedonis D. Addressing tobacco among individuals with a mental illness or an addiction. Addict Behav 2004;29:1067-83.
Bagaitkar J, Demuth DR, Scott DA. Tobacco use increases susceptibility to bacterial infection. Tob Induc Dis 2008;4:12.
Arcavi L, Benowitz NL. Cigarette smoking and infection. Arch Intern Med 2004;164:2206-16.
Bates MN, Khalakdina A, Pai M, Chang L, Lessa F, Smith KR. Risk of tuberculosis from exposure to tobacco smoke: A systematic review and meta-analysis. Arch Intern Med 2007;167:335-42.
Fischer M, Hedberg K, Cardosi P, Plikaytis BD, Hoesly FC, Steingart KR, et al.
Tobacco smoke as a risk factor for meningococcal disease. Pediatr Infect Dis J 1997;16:979-83.
Nikogosian H. WHO Framework convention on tobacco control: A key milestone. Bull World Health Organ 2010;88:83.
Mishra GA, Pimple SA, Shastri SS. An overview of the tobacco problem in India. Indian J Med Paediatr Oncol 2012;33:139-45.
] [Full text]
Freeman B, Pankaj C, Ashima S, Sanjay S, PC G. India: steep decline in tobacco consumption in India reported in second Global Adult Tobacco Survey (GATS 2017). Available from: http://nrs.harvard.edu/urn-3:HUL. InstRepos:34853158
[Last accessed on 2020 Sep 02].
Schwartz RL, Wipfli HL, Samet JM. World no tobacco day 2011: India's progress in implementing the framework convention on tobacco control. Indian J Med Res 2011;133:455-7.
] [Full text]
R Core Team (2019). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. 2019. Available from: https://www.R-project.org/
. [Last accessed on 2020 Sep 03].
Jha P, Ranson MK, Nguyen SN, Yach D. Estimates of global and regional smoking prevalence in 1995, by age and sex. Am J Public Health 2002;92:1002-6.
Jha P, Jacob B, Gajalakshmi V, Gupta PC, Dhingra N, Kumar R, et al.
Anationally representative case–control study of smoking and death in India. N
Engl J Med 2008;358:1137-47.
Arora M, Tewari A, Nazar GP, Gupta VK, Shrivastav R. Ineffective pictorial health warnings on tobacco products: Lessons learnt from India. Indian J Public Health 2012;56:61. [Full text]
Sarkar D, Dhand R, Malhotra A, Malhotra S, Sharma B. Perceptions and attitude towards tobacco smoking among doctors in Chandigarh. Indian J Chest Dis Allied Sci 1990;32:1-9.
Saddichha S, Rekha DP, Patil BK, Murthy P, Benegal V, Isaac MK, et al.
Knowledge, attitude and practices of Indian dental surgeons towards tobacco control: Advances towards prevention. Asian Pac J Cancer Prev 2010;11:939-42.
Mony PK, Vishwanath NS, Krishnan S. Tobacco use, attitudes and cessation practices among healthcare workers of a city health department in Southern India. Journal of Family Medicine and Primary Care 2015;4:261.
Murthy P, Saddichha S. Tobacco cessation services in India: Recent developments and the need for expansion. Indian J Cancer 2010;47:69-74.
] [Full text]
Turker Y, Aydin LY, Baltaci D, Erdem O, Tanriverdi MH, Sarigüzel Y, et al.
Evaluation of post-graduate training effect on smoking cessation practice and attitudes of family physicians towards tobacco control. Int J Clin Exp Med 2014;7:2763.
Schuck K, Otten R, Kleinjan M, Bricker JB, Engels RC. School-based promotion of cessation support: Reach of proactive mailings and acceptability of treatment in smoking parents recruited into cessation support through primary schools. BMC Public Health 2013;13:381.
Panda R, Persai D, Venkatesan S. Missed opportunities for brief intervention in tobacco control in primary care: Patients' perspectives from primary health care settings in India. BMC Health Serv Res 2015;15:50.
Panda R, Jena PK. Examining physicians' preparedness for tobacco cessation services in India: Findings from primary care public health facilities in two Indian states. Australasian Med J 2013;6:115-21.
Ruhil R. Role of primary care providers in tobacco cessation, tobacco dependence treatment. Indian J Community Health 2015;27:8-12.
Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database Syst Rev 2008;CD000165.
Lancaster T, Fowler G. Training health professionals in smoking cessation. Cochrane Database Syst Rev 2000:CD000214.
Kottke TE, Battista RN, DeFriese GH, Brekke ML. Attributes of successful smoking cessation interventions in medical practice: A meta-analysis of 39 controlled trials. JAMA 1988;259:2882-9.
Prochaska JJ, Fromont SC, Hall SM. How prepared are psychiatry residents for treating nicotine dependence? Acad Psychiatry 2005;29:256-61.
Strecher VJ, OMalley MS, Villagra VG, Campbell EE, Gonzalez JJ, Irons TG, et al.
Can residents be trained to counsel patients about quitting smoking? J Gen Intern Med 1991;6:9-17.
Weintraub TA, Saitz R, Samet JH. Education of preventive medicine residents: Alcohol, tobacco, and other drug abuse. Am J Prev Med 2003;24:101-5.
Gottlieb NH, Guo JL, Blozis SA, Huang PP. Individual and contextual factors related to family practice residents' assessment and counseling for tobacco cessation. J Am Board Fam Pract 2001;14:343-51.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]