LifeFirst Supporting Wellbeing Among Adults by Stopping Tobacco Habit

Background and Significance:

About 1 million deaths are attributed to tobacco use in India each year. In 2017 there were roughly 267 million tobacco users including 199 million smokeless tobacco users, 100 million smokers, and 32 million dual users. Tobacco use is higher in rural versus urban populations (32% vs. 21%) and among men versus women (24% vs. 14%). In Mumbai, there are disparities in tobacco use based on education and occupation. Cessation is of interest to tobacco users in India. In a national survey, about 39% of smokers and 33% of smokeless tobacco users reported a quit attempt in the year preceding the survey. The challenge in India, given the magnitude of tobacco use and limited resources, is in delivering cessation supports at scale and with low cost. The problem of tobacco is multifaceted and widespread, with a lack of coordination among those engaged in tobacco cessation: community centers, NGOs and clinics. India is a signatory to the WHO Framework Convention on Tobacco Control (FCTC) and launched the National Tobacco Control Program in 2007, though the impact is limited by inconsistent enforcement across states and regions. Greater attention to and support for cessation of smokeless tobacco is also needed.

Low-resource settings require evidence-based cessation programs that can be delivered, sustained, and scaled-up at low cost. However, there are important barriers to scaling up evidence-based tobacco cessation in such settings. First, research syntheses, such as systematic reviews and meta-analyses mainly come from high-income settings and the interventions and strategies are difficult to implement in limited-resource settings such as India. Second, tobacco cessation EBPs typically include pharmacotherapy, a resource beyond the reach of most tobacco users and many healthcare systems in India. Also, most tobacco cessation EBPs focus solely on smoking, which is a mismatch for India given the high rates of smokeless, smoked, and dual tobacco use and the fact that the smokeless tobacco market in India is the world's largest. Third, EBPs are more likely to be scaled up in low- and middle-income countries (LMICs) if they are simple and inexpensive and can be used in alternative channels, such as NGOs or commercial operations, rather than relying entirely on government infrastructure and highly skilled personnel. Fourth, there is a gap in the literature regarding interventions to influence practice change among practitioners in LMICs. Together these gaps highlight a need to advance the science of adapting and implementing low-cost, scalable cessation EBPs for use in India and other LMICs.

One type of low-cost, scalable cessation support is brief advice interventions, or short engagement by providers to screen for tobacco use, offer cessation advice, and refer users to treatment resources. These interventions can typically be administered in 30 seconds to 2 minutes. Brief advice interventions are effective for both smoked and smokeless tobacco. Simple forms of these programs have been shown to have an impact of 1-3% increased cessation rates over no advice, which could translate to 7.8-23.4 million fewer tobacco users in India. Programs that have a higher level of counseling (as in this proposal) are expected to have greater impact. In a study of 19 tobacco cessation centers across India, tobacco users who received behavioral counseling demonstrated 12.5% cessation rates at six weeks post-intervention, only 5% less than those who received counseling and medication. If this level of impact was sustainable over the long-term, it could translate into 33 million fewer tobacco users. According to the 2016-2017 Global Adults Tobacco Survey (GATS) in India, only 48% of smokers and 31% of smokeless tobacco users were advised to quit by a provider, highlighting a potential role for brief advice interventions.

The use of diverse health professionals (rather than only highly credentialed individuals) is an important opportunity for brief advice interventions. India meets only 25% of the WHO benchmark for health care staffing, and available educational facilities are insufficient to grow the workforce to needed levels. To reach needed staffing levels, the number of physicians would need to increase by 151%, but the current annual growth rate is 10-14%. Task-shifting is a strategy that emphasizes moving tasks from highly credentialed workers to less credentialed (but more readily available) workers and can promote access to preventive services and health. The task-shifting model has been effectively used to deliver mental health EBPs in LMICs, showing that providers with little or no prior mental health training, and often little formal education, can deliver EBPs effectively with positive clinical outcomes. In a recent report, the Ministry of Family Health and Welfare, Government of India, recommended a task shifting approach suggesting that cessation programs be delivered by a range of health professionals, including health workers, community outreach workers, and other professionals. An important consideration for task-shifting models is the potential changes to practitioner training. For example, an EBP for autism spectrum disorder was adapted from the United Kingdom to sites in India and Pakistan. The use of non-specialists to deliver the program necessitated a change from a 2-day training for therapists to a 4-week training for non-specialists and new referral patterns and measures for non-specialist competencies.