Factors associated with successful tobacco use cessation among teachers in Bihar state, India: a mixed-method study.

Although tobacco use is declining in several countries including India (dropping from 35% in 2009-10 to 29% 2016-17 among adults)-it still poses a huge burden on India, as the world's second largest consumer of tobacco products. In Bihar state, with a prevalence of 25%, the Bihar School Teachers Study (BSTS) successfully enlisted teachers as role models for encouraging quitting and changing social norms pertaining to tobacco. The study used a mixed-methods approach to identify factors associated with teachers' quitting. Qualitative data were collected through focus groups with teachers and school principals. Quantitative data were collected through a written survey administered to school personnel post-intervention. Key findings from focus groups were that teachers and principals quit using tobacco and promoted cessation because they wanted to model positive behaviors; specific information about tobacco's harms aided cessation; and the BSTS intervention facilitated a school environment that supported quitting. Survey results indicated teachers who reported knowing people who quit using tobacco in the prior year were far more likely to quit as were teachers who reported that their school's tobacco policy was completely enforced. The combination of qualitative and quantitative data yielded important insights with strong implications for future interventions.

Feedback from vendors on gutka ban in two States of India.

BACKGROUND & OBJECTIVES: Beginning in 2012, all States in India eventually banned the sale of gutka. This study was conducted to investigate gutka vendors' knowledge on gutka ban, products covered under ban, penalties for non-compliance and action for enforcement by government agencies. METHODS: Twenty vendors were interviewed, 10 each in Mumbai (Maharashtra) and Indore (Madhya Pradesh) during May - June, 2013, one year after ban was imposed. Interviewers used a standardized questionnaire to assess vendors' knowledge of gutka ban, their attitude towards it and compliance to it in practice. RESULTS: All 20 vendors were aware that gutka sale was banned. However, despite ban, eight of the 10 vendors in Mumbai perceived sale of pan masala as legal. In Indore, all 10 vendors perceived sale of Indori Tambakoo, a local gutka variant, as legal. No vendor was sure about the quantum of fine applicable on being caught selling the banned product. Two vendors in Mumbai and nine in Indore admitted selling gutka. Five vendors in Mumbai and four in Indore supported an existing ban on gutka. INTERPRETATION & CONCLUSIONS: All vendors were aware of the ban on gutka and reason for it. Many vendors supported the ban. However, awareness of other products covered under ban and on fines in case of non-compliance was low. Law enforcement system needs to be intensified to implement ban. Notification of ban needs to be further strengthened and made unambiguous to explicitly include all smokeless tobacco products.

Scaling up a tobacco control intervention in low resource settings: a case example for school teachers in India.

Research on processes of bringing effective tobacco control interventions to scale to increase quit rates among tobacco users is uncommon. This study examines processes to bring to scale one such intervention for school teachers, i.e. Tobacco Free Teacher-Tobacco Free Society (TFT-TFS). This intervention provides a foundation for an effective and low cost approach to promote cessation through schools. The present study was conducted in the states of Bihar and Maharashtra in 2014 using quantitative and qualitative methods. Focus group discussions (FGDs) were analysed using immersion crystallization method. The data presented are from a survey of 291 principals and seven FGDs. This study examined characteristics of principals and teachers, organizational environment, external environmental factors and program characteristics to determine facilitators and barriers for successful dissemination and implementation of the TFT-TFS program. Some facilitators were, incorporation of the program in existing channels like staff meetings and trainings, certification and recognition by the department of education; while some barriers were routine time bound duties (mainly teaching) of teachers and prevalence of tobacco use among teachers and administrators. Principals and teachers expressed a need and high level of interest in the adoption and implementation of the TFT-TFS program in their schools.

Consensus on Management of Deep Vein Thrombosis with Emphasis on NOACs (Non-Vitamin K Antagonist Oral Anticoagulants): Recommendations from Inter-Disciplinary Group of Indian Experts.

It is estimated that around 2.5 lac patients are identified as having an acute venous thrombo-embolic event in India annually. This includes patients with deep vein thrombosis and pulmonary embolism, and is estimated to result in more than 3.7 lacs deaths each year in European countries. The 'Consensus on Management of Deep Vein Thrombosis with Emphasis on NOACs (Non-Vitamin K Antagonist Oral Anticoagulants): Recommendations from Inter-Disciplinary Group of Indian Experts' position paper was developed to assist clinicians and institutions with an evidence-based approach to the diagnosis and treatment of acute deep vein thrombosis patients. Key to the evaluation of patients with suspected deep vein thrombosis is the use of the clinician's clinical evaluation with the help of pre-test probability tools as well as judicious use of objective diagnostic tests. Our hope is that we have supplemented clinicians' clinical acumen, and assisted them and their health systems in developing best practice approaches to this ever-interesting population of patients. The Deep Vein Thrombosis Consensus Working Group welcomes your inputs on how improvements might be made on this paper in the future.

Experiences recruiting Indian worksites for an integrated health protection and health promotion randomized control trial in Maharashtra, India.

This article provides an overview of the recruitment strategies utilized in the Mumbai Worksites Tobacco Control Study, a cluster randomized trial testing the effectiveness of an integrated tobacco control and occupational safety and health program in Indian manufacturing worksites. From June 2012 to June 2013, 20 companies were recruited. Companies were identified using association lists, referrals, internet searches and visits to industrial areas. Four hundred eighty companies were contacted to validate information, introduce the study and seek an in-person meeting with a company representative. Eighty-three company representatives agreed to meet. Of those 83 companies, 55 agreed to a formal 'pitch meeting' with key decision makers at the company. Seventy-seven recruitment 'pitches' were given, including multiple meetings in the same companies. If the company was interested, we obtained a letter of participation and employee roster. Based on this experience, recommendations are made that can help inform future researchers and practitioners wishing to recruit Indian worksites. When compared with recruitment of US manufacturing worksites, recruitment of Indian worksites lacked current industrial lists of companies to serve as a sampling frame, and required more in-person visits, incentives for control companies and more assurances around confidentiality to allow occupational safety and health experts into their worksite.

Tracking intervention delivery in the 'Tobacco-Free Teachers/Tobacco-Free Society' program, Bihar, India.

In health education and behavior change interventions, process tracking monitors the delivery of an intervention and its receipt to the intended audience. A randomized controlled trial in the state of Bihar, India was conducted to help school teachers become tobacco free through appropriately designed intervention program and delivery system. We describe the results from process tracking of this intervention delivery. The intervention program was centred on six topics delivered in each school through 12 sessions over 6 successive months. The program deliverers recorded the process measures as total number of sessions and program-components implemented (fidelity); time spent conducting sessions (dose) and proportion of teachers attending at least one session (reach). The outcome measures (teachers' exposure to intervention messages and tobacco policy adoption) were assessed post-intervention. All 12 sessions were delivered in 33 out of 36 schools. Thirty-one schools implemented all six program components. In 18 schools, ≥95% of the teachers participated in one or more sessions. Thirty-three schools received 12 or more hours of dose. In 29 schools, 100% teachers reported exposure to all program messages. Tobacco policy was adopted by all schools. Thus, the intervention was generally delivered as planned and it had a positive impact on teachers and schools.

Long-term exposure to particulate matter and all-cause and cause-specific mortality in an analysis of multiple Asian cohorts.

BACKGROUND: Exposure to ambient air pollution is associated with a significant number of deaths. Much of the evidence associating air pollution with adverse effects is from North American and Europe, partially due to incomplete data in other regions limiting location specific examinations. The aim of the current paper is to leverage satellite derived air quality data to examine the relationship between ambient particulate matter and all-cause and cause-specific mortality in Asia. METHODS: Six cohorts from the Asia Cohort Consortium provided residential information for participants, recruited between 1991 and 2008, across six countries (Bangladesh, India, Iran, Japan, South Korea, and Taiwan). Ambient particulate material (PM2·5) levels for the year of enrolment (or 1998 if enrolled earlier) were assigned utilizing satellite and sensor-based maps. Cox proportional models were used to examine the association between ambient air pollution and all-cause and cause-specific mortality (all cancer, lung cancer, cardiovascular and lung disease). Models were additionally adjusted for urbanicity (representing urban and built characteristics) and stratified by smoking status in secondary analyses. Country-specific findings were pooled via random-effects meta-analysis. FINDINGS: More than 300,000 participants across six cohorts were included, representing more than 4-million-person years. A positive relationship was observed between a 5 µg/m (Dockery et al., 1993) increase in PM2·5 and cardiovascular mortality (HR: 1·06, 95 % CI: 0.99, 1·13). The additional adjustment for urbanicity resulted in increased associations between PM2.5 and mortality outcomes, including all-cause mortality (1·04, 95 % CI: 0·97, 1·11). Results were generally similar regardless of whether one was a current, never, or ex-smoker. INTERPRETATION: Using satellite and remote sensing technology we showed that associations between PM2.5 and all-cause and cause-specific Hazard Ratios estimated are similar to those reported for U.S. and European cohorts. FUNDING: This project was supported by the Health Effects Institute. Grant number #4963-RFA/18-5. Specific funding support for individual cohorts is described in the Acknowledgements.

Effectiveness and Tolerability of Fondaparinux vs Enoxaparin in a Population of Indian Patients with Symptomatic Deep Vein Thrombosis: A Retrospective Real-World Study.

BACKGROUND: Fondaparinux is the first approved anticoagulant drug among factor Xa inhibitors, with proven effectiveness and safety in preventing deep vein thrombosis. However, limited data are available supporting the benefit-risk profile of fondaparinux vs enoxaparin in a real-world group of Indian patients with deep vein thrombosis. OBJECTIVE: To compare the effectiveness and tolerability of fondaparinux vs enoxaparin in patients with symptomatic deep vein thrombosis in a long-term real-world setting. METHODS: Data from the electronic medical records of adult patients diagnosed with deep vein thrombosis prescribed fondaparinux (n = 503) or enoxaparin (n = 508) as monotherapy were analyzed. Effectiveness was analyzed in terms of recurrence, duration, and type of deep vein thrombosis event, and tolerability as bleeding events at initial hospitalization and follow-up visits up to 3 months duration. Appropriate statistical methods were used to determine the significance (p < 0.05) between the two groups. RESULTS: The deep vein thrombosis recurrence in the fondaparinux group was non-inferior (2.78%) when compared with enoxaparin (3.76%), with a mean duration of 47 and 48 days, respectively. The number of events and mean duration of events (in days) were not significant (p > 0.05). Major bleeding events were higher in the enoxaparin group at 3.17% than the fondaparinux group at 2.19%, and the difference was not statistically significant (p > 0.05). CONCLUSIONS: The weight-based, once-daily subcutaneous fondaparinux dose showed non-inferior effectiveness and a comparable tolerability profile when compared with the twice-daily enoxaparin dose for the management of symptomatic deep vein thrombosis.

Global oral health inequalities in incidence and outcomes for oral cancer: causes and solutions.

The mouth and oropharynx are among the ten most common sites affected by cancer worldwide, but global incidence varies widely. Five-year survival rates exceed 50% in only the best treatment centers. Causes are predominantly lifestyle-related: Tobacco, areca nut, alcohol, poor diet, viral infections, and pollution are all important etiological factors. Oral cancer is a disease of the poor and dispossessed, and reducing social inequalities requires national policies co-ordinated with wider health and social initiatives - the common risk factor approach: control of the environment; safe water; adequate food; public and professional education about early signs and symptoms; early diagnosis and intervention; evidence-based treatments appropriate to available resources; and thoughtful rehabilitation and palliative care. Reductions in inequalities, both within and between countries, are more likely to accrue from the application of existing knowledge in a whole-of-society approach. Basic research aimed at determining individual predisposition and acquired genetic determinants of carcinogenesis and tumor progression, thus allowing for targeted therapies, should be pursued opportunistically.

Performance and Stability of Pearl Millet Varieties for Grain Yield and Micronutrients in Arid and Semi-Arid Regions of India.

Pearl millet [Pennisetum glaucum (L.) R. Br.] is grown under both arid and semi-arid conditions in India, where other cereals are hard to grow. Pearl millet cultivars, hybrids, and OPVs (open pollinated varieties) are tested and released by the All India Coordinated Research Project on Pearl Millet (AICRP-PM) across three zones (A1, A, and B) that are classified based on rainfall pattern. Except in locations with extreme weather conditions, hybrids dominate pearl millet growing areas, which can be attributed to hybrid vigor and the active role of the private sector. The importance of OPVs cannot be ruled out, owing to wider adaptation, lower input cost, and timely seed availability to subsidiary farmers cultivating this crop. This study was conducted to scrutinize the presently used test locations for evaluation of pearl millet OPVs across India, identify the best OPVs across locations, and determine the variation in grain Fe and Zn contents across locations in these regions. Six varieties were evaluated across 20 locations in A1 and A (pooled as A) and B zones along with three common checks and additional three zonal adapted checks in the respective zones during the 2019 rainy season. Recorded data on yield and quality traits were analyzed using genotype main effects and genotype × environment interaction biplot method. The genotype × environment (G × E) interaction was found to be highly significant for all the grain yield and agronomic traits and for both micronutrients (iron and zinc). However, genotypic effect (G) was four (productive tillers) to 49 (grain Fe content) times that of G × E interaction effect for various traits across zones that show the flexibility of OPVs. Ananthapuramu is the ideal test site for selecting pearl millet cultivars effectively for adaptation across India, while Ananthapuramu, Perumallapalle, and Gurugram can also be used as initial testing locations. OPVs MP 599 and MP 600 are identified as ideal genotypes, because they showed higher grain and fodder yields and stability compared with other cultivars. Iron and zinc concentration showed highly significant positive correlation (across environment = 0.83; p < 0.01), indicating possibility of simultaneous effective selection for both traits. Three common checks were found to be significantly low yielders than the test entries or zonal checks in individual zones and across India, indicating the potential of genetic improvement through OPVs.

Alternative forms of tobacco use.

BACKGROUND: A review of the available scientific literature concerning forms of tobacco use other than regular cigarettes, cigars and pipes, the nature of such products, prevalence data and trends, health effects, regulatory issues and preventive measures. RESULTS: Narghile (water pipe), bidis, kreteks and other forms of oral tobacco are traditionally used in many low-income countries, and some of these are currently spreading to the Western countries. They are all linked to negative effects similar to, and often greater than, those associated with common cigarette smoking. Various potentially reduced exposure products (PREPs), including snus, targeted at smokers aware of the health risks of regular cigarettes, have recently been developed by the tobacco industry. Their pathogenic potential varies widely and is not fully known; it is in any case greater than that of pure nicotine forms (such as medicinal nicotine). Their use as cigarette substitutes should not be considered even by inveterate smokers who are unable or unwilling to quit nicotine before further independent evaluation and control. CONCLUSIONS: There is no such thing as a safe tobacco product. Like cigarettes, alternative forms of tobacco use need regulatory measures that are adapted to local situations and supplemented by preventive measures within the World Health Organization's Framework Convention for Tobacco Control.

Tobacco, education & health.

The incontrovertible scientific evidence about tobacco use causing serious health consequences is now accepted even by the tobacco industry. Research continues to enlarge the spectrum of diseases caused by tobacco use among users as well as among nonusers exposed to secondhand tobacco smoke. This review attempts to illustrate the greater risk to adverse health outcomes among the less educated due to a greater prevalence of tobacco use among them. Numerous surveys worldwide and in India show a greater prevalence of tobacco use among the less educated and illiterate. In a large population based study in Mumbai, the odds ratios for any kind of tobacco use among the illiterate as compared to the college educated were 7.4 for males and 20.3 for females after adjusting for age and occupation. School-dropouts are more likely to take up tobacco use in childhood and adolescence. Student youth taught about the dangers of tobacco use in school are less likely to initiate tobacco use. High tobacco use among the less educated and under privileged affects them in multiple ways: (i) Tobacco users in such households, because of their nicotine addiction, prefer spending a disproportionate amount of their meager income on tobacco products, often curtailing essential expenditures for food, healthcare and education for the family. (ii) Because of high tobacco use and other factors of disadvantage connected with low educational status, they suffer more from the diseases and other health impacts caused by tobacco. This higher morbidity results in high health care expenditures, which impoverish the family further. (iii) Premature death caused by tobacco use in this under- privileged section often takes away the major wage earner in the family, plunging it into even more hardship. Tobacco use is a terrible scourge particularly of the less educated, globally and in India. Tobacco use, education and health in a human population are inter-related in ways that make sufferings and deaths caused by tobacco use even more tragic than normally realized. Tobacco use works against social and economic development and should be appropriately addressed through health education and tobacco cessation services particularly in the underprivileged, illiterate population.

Tobacco control in schools of India: review from India Global School Personnel Survey 2006.

School personnel are role models for students, teachers of tobacco use prevention curricula, and key influencers for tobacco control policies in schools. With their daily interactions and strong influence on their students they represent an influential group for tobacco control. Data collected through the Global School Personnel Survey during 2006 in 180 school; of 6 regions of India have shown that a large proportion (29%) of school personnel used tobacco. The scarcity of tobacco free school policies and relevant teaching materials (non existent in 62% of schools surveyed) and lack of training among school personnel (84%) reported in this study indicate the extent of undermining the scope of prevention efforts in schools to reduce adolescent tobacco use prevalence in India. Majority of school personnel in India strongly agreed that they should receive specific training to help students avoid or stop using tobacco. Training of school personnel along with introduction of comprehensive school policies and its vigorous enforcement will help adolescent students and school personnel to adopt and maintain a tobacco free lifestyle.

Social impacts on adult use of tobacco: findings from the International Tobacco Control Project India, Wave 1 Survey.

BACKGROUND: Social impacts on tobacco use have been reported but not well quantified. This study investigated how strongly the use of smoked and smokeless tobacco may be influenced by other users who are close to the respondents. METHODS: The International Tobacco Control Project (TCP), India, used stratified multistage cluster sampling to survey individuals aged ≥15 years in four areas of India about their tobacco use and that of their close associates. The present study used logistic regression to calculate odds ratios (ORs) for tobacco use for each type of close associate. RESULTS: Among the 9780 respondents, tobacco use was significantly associated with their close associates' (father's, mother's, friends', spouse's) tobacco use in the same form. After adjusting for confounding variables, women smokers were nine times more likely to have a mother who ever smoked (OR: 9.0; 95% confidence interval [CI]: 3.3-24.7) and men smokers five times more likely (OR: 5.4; 95% CI: 2.1-14.1) than non-smokers. Men smokers were seven times more likely to have close friends who smoked (OR: 7.2; 95% CI: 5.6-9.3). Users of smokeless tobacco (SLT) were five times more likely to have friends who used SLT (OR: 5.3; 95% CI: 4.4-6.3 [men]; OR: 5.0; 95% CI: 4.3-5.9 [women]) and four times more likely to have a spouse who used SLT (OR: 4.1; 95% CI: 3.0-5.8 [men]; OR: 4.3; 95% CI: 3.6-5.3 [women]), than non-users. The ORs for the association of the individuals' tobacco use, whether smoked or smokeless, increased with the number of close friends using it in the same form. CONCLUSION: The influence of family members and friends on tobacco use needs to be appropriately addressed in tobacco-control interventions.

Validation of real-time three-dimensional echocardiography for quantifying left ventricular volumes in the presence of a left ventricular aneurysm: in vitro and in vivo studies.

OBJECTIVES: To validate the accuracy of real-time three-dimensional echocardiography (RT3DE) for quantifying aneurysmal left ventricular (LV) volumes. BACKGROUND: Conventional two-dimensional echocardiography (2DE) has limitations when applied for quantification of LV volumes in patients with LV aneurysms. METHODS: Seven aneurysmal balloons, 15 sheep (5 with chronic LV aneurysms and 10 without LV aneurysms) during 60 different hemodynamic conditions and 29 patients (13 with chronic LV aneurysms and 16 with normal LV) underwent RT3DE and 2DE. Electromagnetic flow meters and magnetic resonance imaging (MRI) served as reference standards in the animals and in the patients, respectively. Rotated apical six-plane method with multiplanar Simpson's rule and apical biplane Simpson's rule were used to determine LV volumes by RT3DE and 2DE, respectively. RESULTS: Both RT3DE and 2DE correlated well with actual volumes for aneurysmal balloons. However, a significantly smaller mean difference (MD) was found between RT3DE and actual volumes (-7 ml for RT3DE vs. 22 ml for 2DE, p = 0.0002). Excellent correlation and agreement between RT3DE and electromagnetic flow meters for LV stroke volumes for animals with aneurysms were observed, while 2DE showed lesser correlation and agreement (r = 0.97, MD = -1.0 ml vs. r = 0.76, MD = 4.4 ml). In patients with LV aneurysms, better correlation and agreement between RT3DE and MRI for LV volumes were obtained (r = 0.99, MD = -28 ml) than between 2DE and MRI (r = 0.91, MD = -49 ml). CONCLUSIONS: For geometrically asymmetric LVs associated with ventricular aneurysms, RT3DE can accurately quantify LV volumes.

Mortality experience in relation to tobacco chewing and smoking habits from a 10-year follow-up study in Ernakulam District, Kerala.

Mortality experience of a cohort of 10 287 individuals age 15 years and over selected by random sampling in Ernakulam district of Kerala was recorded in house-to-house surveys over a 10-year period. Mortality rates were analysed according to tobacco habits of chewing and smoking, taking-age and sex distribution into consideration. Tobacco chewing was practised most commonly by females and these females had significantly higher age-adjusted mortality rates than those who did not use tobacco (relative risk 1.3). Excess mortality among male bidi smokers (relative risk 1.5) was also significant and comparable to the excess mortality among cigarette smokers reported from Western countries.