Performance of WHO-Updated Cardiovascular Disease Risk Prediction Charts among Doctors: Findings from a Tertiary Care Teaching Center in Puducherry, India.

BACKGROUND: The cardiovascular disease (CVD) risk prediction charts, updated by the World Health Organization for 21 regions in 2019. These charts-lab and non-lab versions-estimate a person's overall CVD risk; the non-lab version is intended for low-resource environments. OBJECTIVES: Using the "non-lab" and "lab" versions of the WHO CVD risk prediction charts, we sought to estimate the burden of ten-year risk of a fatal or non-fatal CVD event in a tertiary care hospital of Puducherry and to assess the agreement between them. MATERIALS AND METHODS: We included 255 doctors working in a tertiary care hospital in Puducherry. Age, gender, systolic blood pressure, and smoking status are all factors used in both charts. Moreover, a lab chart requires a person's total cholesterol and diabetes mellitus status, whereas a non-lab chart requires a person's body mass index. Proportions (95% confidence intervals) were used to portray the population at various CVD risk levels. Using Cohen's Kappa, the degree of agreement between the lab and non-lab charts was assessed (k). RESULTS: The majority of the study participants had <5% risk of CVD, and none had a risk of >20% in both the charts, which shows the better health-seeking behaviour of doctors. A good level of agreement was shown by the 95.2% (95%CI = 91.7 - 97.4 ) concordance in the risk categorization between the two charts (k = 0.934). CONCLUSION: When data are available and there is strong agreement between non-lab and lab-based charts, it is practical to apply WHO-updated CVD risk prediction charts.

Cost-effectiveness of population-based screening for microalbuminuria in people with type 2 diabetes mellitus in India.

OBJECTIVES: Patients with diabetes have a higher risk of developing chronic kidney disease (CKD). Early detection of CKD through microalbuminuria screening, followed by treatment, delays the progression of CKD. We evaluated the cost-effectiveness of population-based screening of microalbuminuria among normotensive type 2 diabetes mellitus patients aged >40 years compared with no screening scenario using a decision tree combined with the Markov model. METHODS: We considered two scenarios: Scenario I - dipstick microalbuminuria followed by spot-urine albumin-creatinine ratio (ACR) and serum creatinine in sequence; Scenario II - spot urine ACR plus serum creatinine. A mathematical cohort of the target population was simulated over a lifetime horizon with an annual cycle. Data for the model were obtained from secondary resources. The incremental cost-effectiveness ratios (ICERs) were estimated for screening scenarios compared to nonscreening scenario, along with sensitivity analyses. RESULTS: The discounted ICER per quality-adjusted life years gained for annual microalbuminuria screening in the normotensive diabetic population in India were ₹ 24,114 (US$ 308) and ₹ 13,790 (US$ 176) for scenarios I and II, respectively. Annual screening by scenarios I and II resulted in a reduction of 180 and 193 end-stage renal disease (ESRD) cases per 100,000 population, respectively, resulting in a cost saving of ₹ 12.3 and 13.3 Crore spent on ESRD management over 10 years. Both scenarios were also cost-effective even at the screening frequencies of 5 and 10 yearly. CONCLUSION: Microalbuminuria screening was cost-effective at the threshold of one-time GDP per capita in India.

Cost-effectiveness of response-adapted therapy (RAT) for advanced Hodgkin's Lymphoma compared with conventional treatment in India: a Markov-model based analysis.

Cost effectiveness analysis of interim positron emission tomography (PET-2, done after 2 cycles of chemotherapy) based response adaptive therapy (RAT) approaches in advanced Hodgkin lymphoma (aHL) are not available from an Indian perspective. We used a five-year decision analytics model to assess the cost-effectiveness of the two RAT approaches [(escalation (RAT-1) or de-escalation (RAT-2)] compared with standard care (SOC) in aHL (mean age:35 years). Modelling data was derived from secondary sources and sensitivity analyses were performed to assess the robustness of the model. Net monetary benefit (NMB) gained from RAT2 in Indian rupees (INR) (INR 2,26,896) was higher than the RAT1 (INR 1,83,138) when compared with SOC. Proportion achieving the complete response after initial treatment (CR1) was the key determining factor for the RAT1/2 dominance over SOC. Despite higher initial input costs, response-adapted therapy of aHL was cost-effective by minimizing the cost incurred and disutility experienced during relapse and salvage.

Despite higher initial costs, response-adapted therapy based on the interim PET scan after 2 cycles of chemotherapy was more cost-effective when compared to standard therapy with 6 cycles of ABVD in patients with advanced Hodgkin's lymphoma. Among the RAT approaches, de-escalation (RAT-2) had better cost-effectiveness than the escalation approach (RAT-1).

Continued tobacco use among tobacco-related head and neck cancer patients seeking care in a tertiary care facility, South India.

INTRODUCTION: Continued tobacco use in cancer patients leads to decreased treatment efficacy and safety, decreased survival, decreased quality of life, and an increased risk of cancer recurrence and primary tumours at other sites. OBJECTIVE: To determine the prevalence of continued tobacco usage during the first 6 months of diagnosis among tobacco-related head and neck cancer patients seeking care from a tertiary care centre and the factors associated with it. METHODS: A facility-based cohort study was conducted at a tertiary care centre in Puducherry, India. Newly diagnosed head and neck cancer patients aged > 18 years with a history of tobacco use were interviewed to gather information on their socio-demographic, clinical characteristics, and tobacco usage. All participants were interviewed again at the 3rd month and at the 6th month during their follow-up visit. The data were entered in EpiData v3.1 and analysed using STATA v14. Multivariable logistic regression analysis was done with continued tobacco use as the dependent variable and variables that were found significantly associated with continued tobacco use in univariate analysis. RESULTS: Out of 220 study participants at baseline, 157(71 %; 95 % CI: 65.1-77.1) were using tobacco at the time of diagnosis. Out of these 157 participants, 80(50.9 %; 95 % CI; 43.1-58.7) continued to use tobacco at the 3rd month, 63(40.1 %: 95 % CI: 32.6-47.9) continued to use tobacco at the 6th month. The characteristics significantly associated with continued tobacco use are age (less than 39 years and more than 70 years), primary school education, nuclear family, and living alone, smoking tobacco, and increased duration of tobacco use. CONCLUSION: Two-fifths of head and neck cancer patients with a history of tobacco use continued to use tobacco at the 6th month after diagnosis of cancer. Awareness of effects of tobacco use and the benefits of tobacco cessation needs to be created among cancer patients.

Comparative assessment of implementation of Cigarette and Other Tobacco Products Act in three States of India: A pre-post study.

BACKGROUND OBJECTIVES: The Cigarette and Other Tobacco Products Act (COTPA) limits the sale of tobacco products, promotion and advertising and packaging of tobacco products in India. Periodic monitoring of the level of compliance with all sections of COTPA is obligatory to assess the effectiveness of the act. METHODS: This pre-post study aimed to assess the change in the level of compliance with different sections of COTPA in selected States. A total of 3849 and 2176 samples were assessed during the study in November 2020 and October 2021, respectively; using the EpiData Software. RESULTS: Average compliance with section 4 of COTPA was highest in Puducherry during baseline [51.88%, prevalence ratio (PR)=0.72, 95% confidence interval (CI): 0.51-1.02] and in Telangana during endline assessment (66.1%, PR=0.6, 95% CI: 0.48-0.74). A visible change with section 5 of COTPA was observed in Telangana (40.08 to 93.12%, PR=0.04, 95% CI: 0.02-0.07). Compliance with section 6a of COTPA decreased in Puducherry (81.34 to 71.83%, PR=1.84, 95% CI: 1.14-2.95) and increased for Meghalaya and Telangana. The average compliance with sections 7, 8 and 9 (for Puducherry 51.09 vs . 48.8%, Meghalaya 54.94 vs . 46.18% and Telangana 73 vs . 51.91%, respectively) decreased in all States. An increase in average compliance was observed with sections 4 and 5 ( P =0.19 and 0.11, respectively) and a decrease with sections 7, 8 and 9 ( P =0.02) of COTPA in all three States. For sections 6a ( P =0.06) and 6b ( P =0.01), a mixed response was noted. INTERPRETATION CONCLUSIONS: The findings of this study suggest that the level of compliance with sections 4 and 5 of COTPA increased because they are strictly monitored compared to sections 7-9, which are less enforced by the States. There is a need to monitor sections 7-9 (pack warning) to fulfill the objectives related to the World Health Organization (WHO) Framework Convention on Tobacco Control.

Perception of Threat and Efficacy in Contracting COVID-19 Infection among Tobacco Users - A Cross-sectional Analytical Study from Four Indian States.

BACKGROUND: To trigger quit intention and practice of preventive measures for COVID-19 among tobacco users; it is imperative for them to be well aware of the fact that they are at higher risk of COVID-19 infection and should be at higher efficacy to practice preventive measures for the disease as compared to nonusers of tobacco. OBJECTIVES: This community-based cross-sectional analytical study was conducted from April 2020 to May 2020 among 1203 adult participants to compare the threat and efficacy perception among users and nonusers of tobacco. MATERIALS AND METHODS: Perception of threat was assessed using three questions on perceived threat and one question on perceived susceptibility; whereas perception of efficacy was assessed using four questions each on self-efficacy and response efficacy through telephonic interview. RESULTS: There was no significant difference in the overall threat perception among users and nonusers of tobacco. However, state-wise analysis showed that tobacco users had higher perception of threat for SARS-CoV-2 infection in all the states except Telangana. The overall perception of efficacy among tobacco users was significantly higher as compared to nonusers of tobacco. CONCLUSION: The study calls for active collaboration between tobacco control enthusiasts and the Government to promote awareness of a higher risk of COVID-19 disease among tobacco users. In essence, the study's implications extend beyond COVID-19 and can guide targeted efforts to promote awareness, behavior change, and collaboration in the context of other infectious diseases among tobacco users.

Performance of WHO updated cardiovascular disease risk prediction charts in a low-resource setting - Findings from a community-based survey in Puducherry, India.

BACKGROUND AND AIM: The World Health Organization has revised the cardiovascular disease (CVD) risk prediction charts in 2019 for each of the 21 Global Burden of Disease regions. These charts (non-lab and lab versions) estimate the total CVD risk in an individual, of which the non-lab is for low-resource settings. We aimed to estimate the burden of ten-year risk of fatal or non-fatal CVD event in the district of Puducherry in India using 'non-lab' and 'lab' versions of WHO CVD risk prediction charts, and to evaluate the agreement between them. METHODS AND RESULTS: We included 710 individuals aged 40-69 years who participated in a district wide non-communicable diseases survey conducted in Puducherry, India, during 2019-20. Both charts use information on age, gender, systolic blood pressure and smoking status. Additionally, lab-chart requires individual's status on diabetes mellitus and total cholesterol while non-lab requires body mass index. Population in different CVD risk levels was presented using proportions (95% confidence intervals). Agreement between lab and non-lab charts was evaluated using Cohen's Kappa (k). The lab and non-lab charts estimated 3% (95% CI: 1.7-4.2) and none of the population respectively, to have high risk (≥20%) for fatal or non-fatal CVD event over the next ten years. Both the charts showed 89.4% (95% CI:87.2%-91.7%) concordance in CVD risk prediction indicating a good level of agreement (k = 0.653). CONCLUSION: WHO updated CVD risk prediction charts are feasible to apply when data is available and there is good agreement between non-lab and lab based charts.

Metabolic Syndrome and Its Associated Factors Among Faculty Members in a Tertiary Care Teaching Hospital, Puducherry: A Cross-Sectional Analytical Study.

Background: Settings-based approach has received lot of attention under WHO renewed strategy of health promotion. It advocates regular screening/health check-ups of employees to maintain a healthy workplace. This study aimed to assess prevalence of metabolic syndrome (MetS) among faculty members and its association with selected sociodemographic, behavioral and biochemical parameters, and to determine the 10-year fatal or nonfatal cardiovascular risk using WHO-ISH risk chart. Methodology: A cross-sectional study was conducted among 252 teaching faculty members using standardized international protocols to measure behavioral risk factors (smoking, alcohol consumption, diet pattern, physical activity, sleep, and stress), physical characteristics (weight, height, waist and hip circumferences, and blood pressure), and biochemical parameters (fasting glucose and lipid profile). Risk factor profiling was done using WHO/ISH risk prediction chart. Results: Among 252 participants (males: 172 and females: 80), 58 (24.1%) were with MetS. Prevalence was higher in males (24.6%) than females (22.6%). The younger doctors (≤40 years) had lesser prevalence of MetS compared with the elderly (>40 years) doctors (20.3% vs. 26%). Age and diet pattern were found to be independently associated with MetS. The risk of having a cardiovascular event in 10 years was <5% (low risk) for 87.5% of study participants. Conclusion: Although we included doctors who are probably the most health-conscious population, we have found that one in four have a chance of having MetS. There is a need for periodic screening program and lifestyle modification strategies to control the burden of MetS among doctors.

Serum biomarkers of maternal morbidity and adverse outcome in severe pre-eclampsia.

OBJECTIVE: To evaluate the association of maternal serum biomarkers of myocardial damage, oxidative stress and angiogenic imbalance with maternal adverse outcomes in women with severe pre-eclampsia. METHODS: This was a prospective cohort study, where maternal serum biomarkers were evaluated in women admitted with severe pre-eclampsia to a tertiary care centre between March 2019 and February 2020. Serum markers included brain naturetic peptide (BNP), cardiac troponin-T (cTnT), cystatin-C (cys-C), soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF), Total Anti-Oxidant status (TAO) and malondialdehyde (MAO). Main outcome measures were adverse maternal outcomes defined as eclampsia, pulmonary oedema, acute kidney injury, placental abruption and HELLP syndrome. RESULTS: Adverse maternal outcomes occurred in 93(37.2%, 95% CI: 31.2%-43.6%) of the 250 women with severe pre-eclampsia included in the study, including 21 with pulmonary oedema, 25 with acute kidney injury and 36 with eclampsia. BNP levels were higher among women who developed pulmonary oedema (55.4 pg/mL vs 42.0 pg/mL, p = 0.008). TAO levels were higher in women who developed eclampsia (4.6 mM, IQR 3.1-5.7, p < 0.001) and acute kidney injury (4.1 mM, IQR 3.2-6.3, p = 0.002) compared to those who did not develop any complications (2.93 mM, IQR 2.3-4.1). CONCLUSIONS: Even though the endothelial dysfunction and oxidative stress biomarkers were associated with development of preeclampsia, it may have limited utility in identifying women who might develop adverse outcomes.

COTPA implementation status: An observational study in South Indian city.

Background & objectives: The World Health Organization (WHO) document released on the World No Tobacco Day, 2020, mentions that tobacco kills over 22,000 people worldwide every day either from its use or second-hand smoke exposure, which is one person every 4 sec. In 2003, the Cigarettes and Other Tobacco Products Act (COTPA) was enacted by the Indian government to control/regulate use of tobacco and tobacco products. Despite various amendments to this law, there has not been any appreciable decrease in tobacco use. The objective of this study was to assess the compliance level with sections 4-10 of COTPA in urban Puducherry in South India. Methods: Random sample survey of 13 wards was carried out in selected parts of the city of Puducherry. The estimated sample size was minimum 160 public places and point of sales (PoS) each. A pre-tested checklist was used to obtain information on compliance with COTPA. Statistical and spatial analysis was performed using STATA v12.0 and QGIS v2.14.21, respectively. Results: Eight per cent of public places, 0 per cent of PoS, 1.7 per cent of educational institutions and 48 per cent of tobacco packages were found compliant with COTPA specifications. The compliance in public places varied from 0 (bus stops) to 55 per cent (religious places). Interpretation & conclusions: The overall compliance with COTPA was found to be very low in urban Puducherry. In order to ensure proper implementation of the laws, effective enforcement with periodic monitoring of various sections of COTPA are needed.

Evidence on article 5.3 of FCTC (tobacco industry interference in tobacco control activities) in India- a qualitative scoping study.

BACKGROUND: The Tobacco Industry (henceforth TI) yearns to portray itself as being "socially responsible" and fights for the decision-making positions; that are it used to deter, delay or dilute tobacco control measures. There is little documented evidence of Tobacco Industry Interference (henceforth TII) from India, the scope of their interference and challenges faced by the experts for effective tobacco control. This research study seeks to cover this significant gap in the literature on the TI of India. METHODS: A cross-sectional qualitative research design, based upon in-depth interviews (N = 26), was used to explore the key stakeholders' opinions regarding TII in India. The interviews used a set of questions to collect information about the participant's roles and responsibilities in tobacco control, the nature of TII faced by the participants, means of influence by TI, barriers and challenges to tobacco control efforts. RESULTS: Most of the respondents were engaged in tobacco control, training, advocacy and awareness generation activities for 5-10 years or more. The respondents defined the TI and its scope as per their experience with the help of the power ranking methodology. Most of them perceived TI as 'manufacturers' while others consider them as 'advertisers', 'public relation companies', 'wholesalers', 'vendors', and 'Government firms with TI stocks. The research team identified six significant domains: influencing the policy and administrative decisions, Interference in the implementation of tobacco control laws and activities, false propaganda and hiding the truth, manipulating front action groups (FAG), rampant tobacco advertising and promotion activities and others under which TII activities were classified. Most respondents believed that TI players were interfering in the policy decisions, implementing the tobacco control laws and activities and manipulating the FAG. A detailed taxonomic classification of the TII strategies that emerged from our analysis was linked to article 5.3 of FCTC. CONCLUSIONS: The study documented a significant level of TII in different domains, with stakeholders acting at various hierarchical levels. Thus providing insight into the tactics of the TI in order to enable stakeholders to anticipate and pre-empt the kinds of alliances the TI may attempt to build; stimulating academicians and researchers to undertake in-depth analysis into various strategies and therefore underscoring the need to ensuring transparency in official interaction with the TI and its representatives.

Pricing of tobacco products: Pre and post GST implementation.

There is ample evidence stating that any taxation policy that effectively increases the real price of tobacco products reduces its use. In the past, several countries have documented instances; wherein the intended effects of tobacco taxation were undermined by aggressive pricing strategies of the industry. However, there is a dearth of such evidence in Indian context. Hence, the current study was conducted to ascertain the changes in the retail price of locally available tobacco products during pre and post GST period in India. This cross-sectional analytical study was conducted among all available tobacco products in the states of Meghalaya, Odisha, Puducherry and Telangana. The information on maximum retail price (MRP) pre and post GST implementation on tobacco products was gathered from the owners of Point of Sale (PoS), vendors and retailers of various tobacco products. The results showed that of the total 154 brands observed pre and post GST implementation, 33.12% [95%CI 25.75-41.15] did not exhibit any increase in their price. The proportion of tobacco product brands with decrease/no change in price was a higher in Meghalaya (PR = 44; 95%CI: 6.32-306.3), Odisha (PR = 23; 95%CI: 3.25-162.7) and Puducherry (PR = 1.48; 95%CI: 0.1-22.84) as compared to Telangana. As compared to cigarettes, smokeless tobacco (PR = 1.84; 95%CI 1.16-2.89) and bidi (PR = 1.74; 95%CI: 0.78-3.9) had more number of brands with a decrease/no change in price post GST implementation. Moreover, four new brands of smokeless tobacco were introduced into the market following GST implementation. The study clearly suggests a departure from the outcomes envisaged by taxation policy on tobacco products in the country. Given the importance of price as a determinant in tobacco use especially among youth, there is an urgent need for strengthening our tax regime for tobacco products.

National level E-Resource Centre for Tobacco Control (E-RCTC): One stop solution to information on tobacco control in India.

The existing information on tobacco control, though highly valuable, is lying scattered at different sources. Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh in collaboration and technical support of International Union against TB and Lung Diseases (The Union) undertook an initiative to start a national level E-Resource Centre for Tobacco Control (E-RCTC) with an aim to provide relevant information on tobacco control under one roof thereby countering the misleading facts on tobacco control which exist on various web engines. The national level E-Resource Centre for Tobacco Control was developed in three stages. In the span of less than 3 years, the portal is open in public domain with over 2,36,019 visitors from around 80+ countries (as on 23rd July 2020), and growing. The portal showcases an array of valuable and vital information related to tobacco control initiatives under various heads like: Policies and Legislations, Circulars and Orders, National Tobacco Control Programme (NTCP), Publications and IEC Materials. India's first national level Resource Centre for Tobacco Control has proved to be a much-needed step in the country for facilitating speedy implementation of World Health Organization- Framework Convention on Tobacco Control (WHO-FCTC), MPOWER and other tobacco control interventions. Even with its limitations like absence of an interactive mechanism among a few others, the Resource Centre is nothing less than a storehouse of knowledge as it showcases content that are immensely helpful for the tobacco control community. Constant efforts are being made to improve the national level E-Resource Centre for Tobacco Control website and minimize the drawbacks.

Depiction of tobacco in Indian mass media: A content analysis.

BACKGROUND: Although exposure to tobacco content on mass media is a well-grounded source for early initiation, less is known on how tobacco is portrayed in mass media. OBJECTIVES: To determine the proportion of tobacco appearances and the percentage of pro or anti-tobacco messages in the selected print, electronic and internet based Indian mass media. METHODS: The content analysis was conducted among selected categories of: top two daily newspapers in terms of readership, topmost Television channel in terms of viewership and top five trending videos on YouTube. The tobacco appearances in newspaper, television (five minute interval) and YouTube (one minute interval) were recorded and coded as pro or anti-tobacco messages. RESULTS: Tobacco appearances were present in 0.3% of 9373 [95% CI: 0.2-0.5] advertisements reviewed in Newspapers; all of which were pro-tobacco messages. Among the total 1512 intervals watched on Television, 18.1% [95% CI: 16.2-20.1] had tobacco appearance. There were a total of 289 tobacco incidents in television of which 92.4% were pro-tobacco messages. Out of the total 900 videos watched on YouTube, 11.44% [95% CI: 9.49-13.65] had tobacco appearance. Among the 206 tobacco incidents present in YouTube, 98.5% were pro-tobacco messages. CONCLUSIONS: The study documented considerable extent of pro-tobacco depictions in Indian mass media.

Tobacco consumption trends and correlates of successful cessation in Indian females: Findings of Global Adult Tobacco Surveys.

BACKGROUND: Female gender is being affected disproportionately by tobacco use. The correlates of tobacco use among women are different from men, which has not been studied in India. To develop gender-sensitive interventions and policies in tobacco control, it's essential to ascertain the factors that affect tobacco consumption and successful cessation among Indian women. METHODS: This secondary data analysis was done for females respondents aged >15 years using the data generated from the GATS-1 (2009-2010) and GATS-II (2016-2017). The primary dependent variables included interest in quitting smoking/SLT, attempt to quit smoking/SLT, successful quitting. The independent variables were broadly categorized as a community, household, and individual level. Simple descriptive analysis using % age relative change was used to calculate the change in tobacco consumption between two rounds of GATS, whereas; bivariate and multivariable logistic regression were used to calculate the unadjusted and adjusted odds ratio for cessation related variables (GATS-2). RESULTS: There was a 29.5% relative reduction in the prevalence of tobacco use in round-2 among females. A maximum reduction in the prevalence was observed in the 15-29 years (-51.3%), those not exposed the media advertisements (-19.9%). While unadjusted OR depicted that unmarried women, young age, asked by health workers about tobacco use, and advice given by them increased the interest in quitting smoking, none of them emerged to be significant on a multivariable logistic regression except the advice given by the health care provider. Successful cessation (>6 months) of SLT products is possible in urban areas, with decreased exposure to media advertisements. CONCLUSION: There is an urgent need for gender-sensitive policies in tobacco control and the integration of these policies with relevant national health programs. This shall help to synergize efforts and obtain better outcomes that would support the overarching goal of tobacco-free India.

Prevalence and factors associated with the sale of loose cigarettes at Point of Sale: A cross-sectional analytical study from four Indian states.

BACKGROUND: The Framework Convention on Tobacco Control (FCTC) has established that sale of loose cigarettes increases the affordability and accessibility of tobacco for minors. Acknowledging this threat to public health, the Department of Consumer Affairs, Government of India amended the Legal Metrology Act to prohibit sale of loose cigarettes. Regardless, over 70% of the total cigarette sale in the country is in the form of loose cigarettes majority of which is being sold at unrecognized, unrecorded and unregulated informal sector of economy. However, there is a paucity of studies examining the factors associated with sale of loose cigarettes and further research is warranted in the country to know the dynamics of this issue. OBJECTIVE: To determine the prevalence and the factors associated with the sale of loose cigarettes at Point of Sale (PoS) in the selected four Indian states. METHODS: A community based cross-sectional analytical study was conducted among a total of 2044 PoS in the project states of Meghalaya, Odisha, Puducherry and Telangana using purposive sampling technique. The characteristics of tobacco vendors and the status of loose cigarettes sale were collected using a structured and pre-tested checklist. Proportion for prevalence estimate, bivariate and multivariable log binomial regression analysis were done. RESULTS: The prevalence of loose cigarette sale was 93.05% [95% CI: 91.89-94.1]. Sale of loose cigarette showed a significant association with area (aPR 1.03; 95% CI: 1-1.06; p = 0.025), sale of tobacco products to minors (aPR 1.07; 95% CI: 1.04-1.11; p < 0.001), sale of smoking aids to customers (aPR 1.05; 95% CI: 1.01-1.09; p = 0.02), sale of flavored chewable tobacco (aPR 1.08; 95% CI: 1.03-1.12; p = 0.001) and presence of pack warning (aPR 1.18; 95% CI: 1.11-1.25; p < 0.001). CONCLUSION: Our findings infer an open disregard for the laws specific to sale of loose cigarettes at PoS. The factors associated with the sale of loose cigarette needs to be addressed through prompt implementation of the tobacco control laws and suitable policy formulation.

Communicating risk: Status of health warning labels on various tobacco products in Indian market.

BACKGROUND: Owing to the role of tobacco packaging as a strong medium of communication, display of health warnings on tobacco packs effectively impart health risks of tobacco consumption to those currently using or contemplating the use of tobacco. METHODS: This community based cross-sectional analytical study was conducted among 2044 tobacco product packs, each collected from a different PoS, to estimate the non-compliance of section 7, 8 & 9 of COTPA among various tobacco products and its association with the PoS characteristics. Data were collected by observation of PoS by field investigators and then purchase of a unique product from each vendor followed by a brief interview of the tobacco vendor. RESULTS: The study documented an absence of health warning label on 15.51% [95% CI: 13.99-17.13] of the total 2044 tobacco products collected. The non-compliance to 'quality of health warning picture' was lowest 5.96% [95% CI: 4.91-7.16] among the tobacco products with a health warning label. The multivariate regression model revealed that absence of health warning on tobacco product packs were higher among the PoS in rural area (aPR 1.38; 95% CI: 1.16-1.65; p < 0.001) and among street/mobile vendors (aPR 1.65; 95% CI: 1.22-2.24; p = 0.001). The PoS not displaying tobacco products (aPR 1.36; 95% CI: 1.08-1.72; p = 0.01), selling flavored chewable tobacco (aPR 1.67; 95% CI: 1.24-2.27; p = 0.001), not selling loose cigarettes (aPR 2.93; 95% CI: 1.94-4.43; p < 0.001) and with vendors not enquiring age proof (aPR 10.69; 95% CI: 1.59-72.09; p < 0.001) had higher proportion of tobacco products without health warning labels. A greater proportion of smokeless/local variety tobacco products (aPR 18.06; 95% CI: 12.31-26.51; p < 0.001) had absence of health warning label. CONCLUSION: The data provided by us have clear policy implications. We recommend regular enforcement activities to monitor the presence of health warning labels on tobacco product packs along and accurate printing of the same with adherence to the Ministry of Health and Family Welfare templates.

Profile of risk factors for Non-Communicable Diseases (NCDs) in a highly urbanized district of India: Findings from Puducherry district-wide STEPS Survey, 2019-20.

INTRODUCTION: Rapid urbanization and industrialization drives the rising burden of Non-Communicable Diseases (NCDs) worldwide that are characterized by uptake of unhealthy lifestyle such as tobacco and alcohol use, physical inactivity and unhealthy diet. In India, the prevalence of various NCDs and its risk factors shows wide variations across geographic regions necessitating region-specific evidence for population-based prevention and control of NCDs. OBJECTIVE: To estimate the prevalence of behavioral and biological risk factors of NCDs among adult population (18-69 years) in the Puducherry district located in Southern part of India. METHODOLOGY: We surveyed adults using the World Health Organization (WHO) prescribed STEPwise approach to NCD surveillance (STEPS) during February 2019 to February 2020. A total of 2560 individuals were selected from urban and rural areas (50 clusters in each) through multi-stage cluster random sampling method. STEPS instrument was used to assess behavioral and physical measurements. Fasting blood sample was collected to estimate biochemical risk factors (Diabetes, Hypercholesterolemia) of NCDs. RESULTS: Among men, alcohol use 40.4% (95% CI: 37.4-43.4) was almost twice higher compared to tobacco use 24.4% (95% CI: 21.7-26.9). Nearly half of the population was physically inactive 45.8% (95% CI: 43.8-47.8) and obese 46.1% (95% CI: 44-48.1). Hypertension and diabetes mellitus were present among one-third 33.6% (95% CI: 31.6-35.5) and one-fourth 26.7% (95% CI: 24.1-29.1) of the population which were significantly higher among men (37.1% vs 30.8% and 31.6% vs 23.2% respectively). Physical inactivity and overweight/obesity increased with increasing education levels. Tobacco and alcohol use was more common among men, whereas physical inactivity with obesity and hypercholesterolemia was higher among women. CONCLUSION: We found high prevalence of various NCDs and its risk factors among the adult population of Puducherry district.

Extent of contraception methods practised by unmet need couples after counselling: a cross-sectional follow-up study in Puducherry, South India.

BACKGROUND: Information is paucity about the extent of contraception practise among the unmet need eligible couples after counselling. OBJECTIVE: To assess the prevalence and associated factors of unmet need for family planning (FP), the extent to which they practise desired contraception methods after baseline counselling and the reasons for not practicing it. METHODS: A community-based cross-sectional analytical study was conducted between 2016 and 2019 among 2228 currently married couples with periodic follow ups of unmet need group. Baseline data on unmet need were collected based on the National Family Health Survey questionnaire. Individual and couple counselling were performed through informing choice and the support for decision making was based on the unmet need reasons with follow-ups. The data were analysed using Stata software version 12.0 (StataCorp, College Station, TX). RESULTS: The total study population was 1924. The prevalence of unmet need for FP was 7.1% (137) with 2.9% (55) of unmet need for spacing and 4.3% (82) of limiting births. Age groups between 18 and 24 [adjusted odds ratio (AOR) = 4.463], 25-29 (AOR = 2.339), not having a child (AOR = 0.250), having one child (AOR = 2.369) and having lower socioeconomic status (AOR = 0.155) were significantly associated with unmet need. During the follow-ups, 37.2% (29/78) received who desired limiting births, while 43.6% (34/78) changed to spacing methods. In fact, the main reason for not adopting limiting births is the fear of post-operative surgery-related health problems. CONCLUSIONS: This study emphasizes the need for follow-up counselling for guiding contraceptive use and recorded that majority of the unmet need couples started practicing contraception methods during the follow-ups. Besides, change in desired contraception methods was observed.

Postpartum depression and its risk factors in women with a potentially life-threatening complication.

OBJECTIVE: To assess the incidence of postpartum depression (PPD) and its risk factors in women with potentially life-threatening complications. METHODS: Eight hundred and ninety women admitted to a tertiary center in South India with potentially life-threatening complications were recruited for the study. Within seven days of delivery, women underwent mental health assessments using the EPDS and PHQ-9 scale. Counseling was provided and follow-up assessment carried out at 3 months postpartum. Bivariate and multivariate analysis was done to assess the association of risk factors to depression. RESULTS: PPD was observed in 21% of the study cohort. Women with no formal education (OR -2.66, 95% CI: 1.10- 6.40) and those who had a stillbirth (OR 2.48, 95%CI: 1.57-3.93) were found to be associated with PPD after adjusting for other factors. Occurrence of an obstetric near-miss event did not increase the risk of depression. Most women recovered with postnatal counseling, with only three requiring medication at the end of 3 months. CONCLUSION: One in five women who develop potentially life-threatening complications developed PPD. A strategy of screening focused on this high-risk group, especially in low resource settings, can lead to early recognition and treatment. This in turn can lead to a reduction in the long-term morbidity associated with PPD.