Feasibility randomised controlled trial of face-to-face counselling and mobile phone messages compared to usual care for smokeless tobacco cessation in Indian primary care: Project CERTAIN.

INTRODUCTION: Smokeless tobacco (SLT) use in low- and middle-income countries (LMICs) has adverse health consequences. We hypothesize that it is feasible to test an intervention of mobile phone messages and face-to-face counselling session for SLT cessation in India. METHODS: We conducted an exploratory, individual parallel two group, randomised controlled trial (RCT), with baseline -and end-point (three months from randomisation) assessments in urban primary health centres in Odisha, India. A total of 250 current (i.e., users in the last three months) SLT users or dual users (i.e., smokers and SLT users) were recruited to the trial (125 in each group). Participants were randomised to either routine care, face-to-face counselling, and reminder mobile messages or routine care only. The primary outcomes were to assess the feasibility of running a full RCT including recruitment, compliance, and retention. RESULTS: A total seven (77.8%) out of nine primary care centres took part in the trial. Out of the 315 SLT users invited to participate, 250 provided consent and were randomised [79.4% (95% CI: 74.5, 83.7)]. Out of the 250 randomised SLT users, 238 [95% (95% CI: 91.8, 97.5)] were followed up at three months (117 in the intervention group and 121 in the control group). Of the participants in the intervention group, 74 (63.8%) reported that they received the mobile messages. CONCLUSIONS: This exploratory trial demonstrated the feasibility of delivering and evaluating an intervention of mobile phone messages and face-to-face counselling for SLT users in Indian primary care in a full randomised trial. IMPLICATIONS: This study found that combining mobile messages with face-to-face counselling for smokeless tobacco users visiting primary health care settings in India is feasible in terms of recruitment of users, compliance with the intervention, and retention of study participants within the trial.The biochemically verified smokeless tobacco abstinence rate was higher in the intervention group compared with the control groupThere was poor agreement between self-reported tobacco cessation and the measured salivary cotinine in smokeless tobacco users.The findings support the feasibility and acceptability of the intervention signalling the need for a larger clinical trial to test effectiveness of the intervention.

Validation of Mobile Messages for an mHealth Intervention for Smokeless Tobacco Cessation in India.

BACKGROUND: With the growth in use of mobile messages for behaviour change, the need to incorporate personal needs and cultural characteristics of target users has been promoted. The study aimed to describe the findings of content validation of mobile messages designed to promote smokeless tobacco cessation in primary care. METHODS: This study used a concurrent mixed-method approach with 13 patients who were tobacco users at urban primary care clinics. The clarity and appeal of 32 messages were rated on a Likert scale from 1 to 10. A mean clarity and appeal score per message was generated. A 5-item discussion guide was used for in-depth interviews and data was analysed using framework analysis. RESULTS: Participants found the content of the messages useful, and preferred shorter and audio formatted messages. The clarity scores for the messages ranged from 7.9 to 9.4 with an average score of 8.7 (SD 0.5). The appeal scores ranged from 7.3 to 9.2, with an average score of 8.5 (SD 0.6). CONCLUSIONS: Twenty-six from a total of 32 messages were found appropriate and finalised for use. This methodology can be used when developing contextually relevant mobile message interventions in other low resource settings.

Designing a mobile health smokeless tobacco cessation intervention in Odisha, India: User and provider perspectives.

Objective: There is limited evidence on the development of mobile health (mHealth) interventions for smokeless tobacco (SLT) cessation, despite its widespread use in South Asia. This formative qualitative study explored the perceptions of tobacco users and healthcare providers (HCPs) regarding developing a mHealth intervention for SLT cessation. Methods: This was a qualitative study using in-depth interviews (IDIs) with tobacco users (n = 26) and primary care physicians (PCPs) (n = 5) and focus group discussions (FGDs) with counsellors (n = 2) in four urban primary health centres (UPHCs) in Berhampur, Odisha from February to March 2020. The data were coded and analysed by two researchers using a framework analysis method. The discussion guides and initial codes were developed based on the Transtheoretical Model (TTM) of behaviour change. Results: The results were elaborated under four themes: (1) Current scenario of SLT use; (2) Barriers and facilitators for quitting SLT; (3) Barriers and facilitators for mHealth counselling; and (4) Design and delivery of the proposed intervention. SLT use was prevalent in the community regardless of sociodemographic factors. Peer factors accounted for both tobacco consumption as well as considering cessation. Participants considered mobile message counselling helpful and acceptable. Not having a mobile phone and illiteracy were identified as barriers while ease of access and rising popularity of social media applications were considered facilitators to the use of mHealth for quitting tobacco. Participants preferred messages that were pictorial, short and simple, in the local language, and tailored to individual's needs. Conclusions: This is the first study that provides evidence within the Indian context that the text messaging platform may be used for delivering an SLT cessation intervention. The integration of a theoretical basis and research findings from target users can guide future intervention development.

Exploratory randomised trial of face-to-face and mobile phone counselling against usual care for tobacco cessation in Indian primary care: a randomised controlled trial protocol for project CERTAIN.

INTRODUCTION: Despite widespread use of smokeless tobacco products by people within the Indian subcontinent, there is little awareness among Indians of its health hazards when compared with smoked tobacco. We hypothesise that mobile phone counselling will be feasible and effective for smokeless tobacco cessation intervention in India. This paper presents the protocol of the development and conduct of an exploratory trial before progression to a full randomised controlled trial. METHODS AND ANALYSIS: An exploratory randomised controlled trial will be conducted in urban primary health centres in the state of Odisha, India. A total of 250 smokeless tobacco users will be recruited to the study (125 in each arm). Participants in the intervention arm will receive routine care together with a face-to-face counselling intervention followed by advice and reminder mobile messages. The control arm will receive routine care, delivered by a primary care physician based on 'Ask' and 'Advice'. All participants will be followed up for 3 months from the first counselling session. The primary outcome of this trial is to assess the feasibility to carry out a full randomised controlled trial. ETHICS AND DISSEMINATION: Ethical approvals were obtained from the Institutional Ethics Committee of Public Health Foundation of India, Health Ministry's Screening Committee, Odisha State Ethics Board and also from University College London Research Ethics Committee, UK. The study findings will be published in a peer-reviewed scientific journal. TRIAL REGISTRATION NUMBER: CTRI/2019/05/019484.

Does behavioral intervention affect intention to quit? : A quasi-experimental study from primary healthcare settings in India.

INTRODUCTION: Tobacco is the leading cause of death and disease in India. This study examines the effect of training intervention in behavioral counseling on intention to quit tobacco in primary healthcare settings in India. The intervention included training to improve behavioral counseling practices of primary care physicians (PCPs) based on the 5As approach to increase patients' motivation to quit tobacco. METHODS: A quasi-experimental design was used for the study. The intervention consists of training of primary care physicians in the behavioral intervention in tobacco cessation. The intervention was conducted in twelve districts of two states in India (Rajasthan and Odisha) in 2016-2017. Four districts were randomly sampled for the study. A total of 1314 participants (intervention and control) were recruited for the study in the baseline and end-line surveys, respectively. Intention to quit in 30 days was the primary outcome measure. Difference-in-difference (DiD) logistic regression models were used separately for smokers and smokeless tobacco users to estimate the odds of intention to quit. Analysis was done in STATA Version 14. RESULTS: The intervention and time variable had a significantly positive influence on the intention to quit tobacco among smokers. Smokers in the intervention districts had higher odds of intention to quit (OR=9.82; 95% CI: 1.67-57.72) compared to smokers in the control districts. Smokeless tobacco (SLT) users had higher odds of intention to quit (OR=3.06; 95% CI: 1.35-6.98) in the end-line survey compared to baseline survey. CONCLUSIONS: Our findings indicate that building capacity in behavioral intervention in primary care settings can help increase the intention to quit among smokers. The observed difference in intention to quit between smokers and SLT users suggests the need of tailored counseling interventions for SLT users. There is a need for further research to design and evaluate training and behavioral interventions for SLT and dual (smoking and SLT) users in primary care settings in low- and middle-income countries.

Incremental Benefits of Multiple Tobacco Control Interventions: A Factorial Randomized Control Trial.

Tobacco control requires a comprehensive approach. The present study aims to examine the incremental effectiveness of health systems intervention when combined with other interventions in enhancing knowledge and practices of physicians in tobacco cessation. METHODS: A randomized control trial was conducted among 437 physicians in 12 districts of two states of India in 2011-13. The interventions consisted of Health Systems (H), Community (C) and Youth intervention (Y). Administrative Blocks /Mandals were randomly assigned to one of the three interventions (HC /HCY/HY) and control units. The health system intervention consisted of training physicians and developing a system of patient support and supervision for tobacco cessation. The primary outcome was change in knowledge and practices of physicians in tobacco cessation. Logistic regression model was applied to assess the impact of single and combination of interventions. RESULTS: An increase in knowledge was observed on effects of tobacco on adverse birth outcomes, advice on NRT and, information provided on chronic disease management among physicians in HC, HY and HCY intervention units compared to control units from pre-intervention to post-intervention. Statistically significant change was observed in knowledge of physicians on effects of tobacco on adverse birth outcomes in HC (OR- 4.75, p-0.02) and HCY (OR- 5.08, p-0.04) intervention units. CONCLUSIONS: HCY intervention was most effective in enhancing knowledge and practices of physicians in tobacco cessation. Our study suggests that individual tobacco control interventions when combined together has an incremental effect and increases the likelihood of provision of tobacco cessation services in primary care. 
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Health system preparedness in noncommunicable diseases: Findings from two states Odisha and Kerala in India.

INTRODUCTION: "Non-communicable diseases (NCDs) are the raging reality of today's world and have moved up the priority list of most countries worldwide including India. The government of India has launched programs such as National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular disease, and Stroke, but little is known about preparedness of health system to address NCDs. METHODS: A qualitative study was conducted in the states of Odisha and Kerala to document the government stakeholder perspectives of health system preparedness for NCDs. RESULTS: The study revealed that both the states have a NCD preparedness structure but need strengthening at various levels. The present human resource is inadequate, over-burdened, and requires specific skills. The lack of workforce adversely affects the service delivery mechanism. The study highlighted that there is a gap in the timely release of funds and also lack of evidence-based application if the information that is made available. CONCLUSION: There is a clear need to fill the gaps and strengthen the identified areas at various levels to address the increasing NCD burden. There is also a need to more in-depth and large-scale studies on such issues which act as external monitoring mechanisms thereby assisting the policy makers and program managers in with relevant and scientific evidence to bring reforms in the health system.

A quasi-experimental intervention to assess the effectiveness of a physician-delivered tobacco cessation intervention in India: A detailed study protocol.

INTRODUCTION: Tobacco cessation is the most important, cost-effective preventive maintenance that clinicians can offer study participants who use tobacco. There is lack of preparedness among primary care physicians in delivering cessation interventions. There are also limited studies which record the effectiveness of cessation interventions in the Indian context. This study is designed to evaluate the effectiveness of brief and intensive tobacco cessation interventions delivered by trained primary care providers in two states of India. METHODS AND ANALYSIS: A quasi-experimental study design has been adopted for the study with around 20 primary care practices, selected from four districts of two states in India (Odisha and Rajasthan). Brief (3A) and Intensive tobacco (5A) cessation intervention services will be provided to two groups of tobacco users, respectively. Both groups will be followed up for 6 months to determine the effectiveness of the cessation interventions. The cost-effectiveness of the services will also be documented at the end of the study. The entire study will be completed in 24 months, of which the final 6 months will be reserved for study participant follow-up and quit rate evaluation. When comparing the two groups, differences between proportions will be assessed by chi-square test and differences between means with t-test. The conventional significance level of 0.05 will be used in all analyses in order to reject the null hypothesis of no difference between groups. We will use difference-in-differences methods to assess the impact of the interventions on physicians' behavior to deliver tobacco cessation in their clinical practice. CONCLUSION: The study is in participant recruitment phase.

Examining Implementation of Tobacco Control Policy at the District Level: A Case Study Analysis from a High Burden State in India.

Introduction. While extensive scientific evidence exists on the tobacco epidemic, a lack of understanding of both policies and their appropriate way of implementation continues to hinder effective tobacco control. This is especially so in the developing countries such as India. The present study aims to understand current implementation practices and the challenges faced in mainstreaming tobacco control policy and program. Methods. We chose a qualitative study design to conduct the case analysis. A total of 42 in-depth interviews were undertaken with seven district officials in six districts of Andhra Pradesh. A conceptual framework was developed by applying grounded theory for analysis. Analysis was undertaken using case analysis approach. Results and Discussion. Our study revealed that most program managers were unfamiliar with the comprehensive tobacco control policy. Respondents have an ambiguous opinion regarding integration of tobacco control program into existing health and development programs. Respondents perceive lack of resources, low prioritization of tobacco control, and lack of monitoring and evaluation of smoke-free laws as limiting factors affecting implementation of tobacco control policy. Conclusion. The findings of this study highlighted the need for a systematic, organized action plan for effective implementation of tobacco control policy and program.

A Delphi study for setting up tobacco research and practice network in India.

BACKGROUND: There are key gaps in the production and dissemination of evidence-based tobacco control research in developing countries. In India, limited research has been made to address and understand the function, constitution, thematic areas of research of a research and practice network in tobacco control. This study aimed to identify priority areas that were agreed by stakeholders for building tobacco research and practice network in India. METHODS: This study used the well-established Delphi survey, which involves asking experts a recurring progression of questions through a series of questionnaires. The study was conducted in two rounds in the year 2013-14. Experts working in tobacco control participated in the study. In Round II, respondents rated agreement using a five-point Likert scale. Interquartile Range (IQR) was used to calculate the strength of the consensus. RESULTS: Experts expressed strong consensus on tobacco cessation and economic research as a focus areas for tobacco research network in India. Lack of funding was stated as a barrier impeding formation of tobacco research network in India by majority of respondents. A strong consensus was achieved on the fact that network can be sustained financially by Government funds (IQR = 1). Information sharing and capacity building of young researchers were the two major benefits as stated by respondents which achieved strong consensus. CONCLUSIONS: This study produced the first national stakeholder-informed priority area for developing tobacco research and practice network in India. The consensus priorities highlight the most important and urgent needs in developing research and practice network in tobacco control.

Preparedness of frontline health workers for tobacco cessation: An exploratory study from two states of India.

BACKGROUND: The 5As approach is a clinic-based approach and has been developed for primary health care providers who are uniquely positioned to interact with tobacco users. The 5As stands for: Ask about tobacco use at every visit, advise tobacco users to quit, assess readiness to quit, assist quit attempts through counseling and pharmacotherapy and arrange follow-up to prevent relapse. The present study explores whether auxiliary nurse midwives (ANMs) adhere to the 3As from the recommended 5As model for tobacco cessation. MATERIALS AND METHODS: The study was a cross-sectional study conducted among 501 ANMs in the state of Gujarat and Andhra Pradesh. Descriptive analysis and chi-square test were employed to test the differences in knowledge levels and practices of ANMs. Bivariate logistic regression was used to examine the association between each predictor variable separately and the outcome variables after adjusting for age and location. Data was analyzed using SPSS version 17 software. RESULTS: Majority of ANMs reported that they were aware of respiratory illnesses, tuberculosis, lung and oral cancer as conditions caused due to tobacco consumption. Awareness of adverse reproductive and child health effects associated with tobacco use was very low. Only about one third of respondents informed all patients about harmful effects. Only 16% of ANMs reported having ever received any on-job training related to tobacco control. ANMs who reported receiving training in tobacco control were about two times more likely to provide information on health effects of tobacco as compared to those who reported not being trained in tobacco control in the state of Gujarat. CONCLUSIONS: A majority of ANMs ask patients about tobacco use but provide advice only to patients suffering from specific diseases. A context-specific capacity building package needs to be designed to equip ANMs in recommended 5As approach in tobacco cessation.

Self-reported Practices and Attitudes of Community Health Workers (Accredited Social Health Activist) in Tobacco Control - Findings from two states in India.

BACKGROUND: The 1978 declaration (Alma-Ata declaration) made at the International Conference on Primary Health Care, meeting in Alma-Ata highlighted the critical role played by Community Health Workers (CHWs) to link communities to the health system. The flagship program of Government of India proposed introduction of CHWs namely Accredited Social Health Activist (ASHA). As a link between community and health system ASHA is in a unique position to generate awareness on tobacco-related issues. However, there is limited evidence on practices of ASHAs in tobacco control in India. The present study explores whether CHWs such as ASHAs can be utilized as a resource for informing and educating community on tobacco and its harmful effects. The study captured perceptions and practices of ASHAs regarding tobacco control. METHODS: The study was a cross-sectional study conducted among 512 ASHAs in six intervention districts each in Gujarat and Andhra Pradesh. The study settings (i.e., health facilities and villages) were selected through systematic random sampling. The study participants were selected through simple random sampling. Responses were captured through self-administered questionnaire. Logistic regression model was applied to measure associations between variables such as knowledge level of ASHAs and information provided on different tobacco-related diseases by them in both the states, with statistical significance based on the Chi-square test. RESULTS: Our findings indicate that ASHAs linked tobacco usage to diseases such as respiratory problems, lung cancer, tuberculosis, and oral disease. Only one-third of ASHAs reported informing all patients about the harmful health effects of tobacco, whereas more than half of them reported providing information only to patients suffering from specific illness. ASHAs who reported having received training in tobacco control were about Two times more likely to give information on effects of tobacco on respiratory diseases (odds ratio [OR]-1.5; confidence interval [CI]: 1.1-2.4) and adverse reproductive outcomes (OR-2.1; CI: 1.1-20.2). CONCLUSIONS: Study findings reflect suboptimal engagement of ASHAs in providing information pertaining to specific tobacco-related diseases. There is an urgent need to sensitize and train ASHAs in appropriate tobacco control practices.

Physician and patient concordance of report of tobacco cessation intervention in primary care in India.

BACKGROUND: Tobacco cessation interventions by physicians hold promise in improving quit rates. The 5As intervention ('Ask', 'Advise', 'Assess', 'Assist' and 'Arrange') is an evidence-based approach for tobacco cessation. However, little is known about adherence with the tobacco cessation interventions in primary care in India. In the present study we assessed physicians' adherence with the 5As intervention and explored physician and patient concordance on the report of 5As intervention for tobacco cessation. METHODS: We used data from two cross-sectional surveys conducted in 12 districts of Andhra Pradesh and Gujarat in India. The surveys were administered simultaneously to both patients attending, and physicians working in health facilities providing primary care. Health facilities were selected by systematic random sampling and patients were recruited by simple random sampling. Common health facilities where both surveys were performed were identified, and individual patients were matched to their physicians through a unique matching code to obtain the two study samples. RESULTS: Slight agreement was observed between the physician and patient responses on 'Ask' and 'Arrange' component of the 5As intervention. The 'Advise', 'Assess' and 'Assist' components showed low agreement. Slightly higher levels of agreement were seen on all components of the 5As, except 'Advise', for those patients who had made an attempt to quit. CONCLUSIONS: Our study suggests an urgent need for revising current strategies in order to strengthen the 'Advise', 'Assess', and 'Assist' interventions in tobacco cessation in primary care settings. Patient surveys should be used routinely in assessing fidelity and provider adherence for large scale behavioral health programs.

Missed opportunities for brief intervention in tobacco control in primary care: patients' perspectives from primary health care settings in India.

BACKGROUND: World Health Organization has called for tobacco cessation to be integrated into primary care. Primary Health Centres (PHC) offer opportunities for tobacco-use screening and brief cessation advice but data on such activities in developing countries such as India are limited. The aim of this study was to investigate screening and brief intervention practices of health service providers in primary care. METHODS: This cross-sectional study was conducted in 2012 among 1,549 patients aged over 18 years visiting PHCs in 12 districts of two Indian states- Andhra Pradesh and Gujarat. Responses were collected using an interviewer-administered questionnaire. Information was obtained on participants' tobacco use status, reason(s) for seeking medical care, whether participants had been screened for and advised to quit tobacco use. The primary outcome was whether patients were screened during their visit to the PHC. Data analysis was performed using multi-level logistic regression. RESULTS: Less than one-third (447) of patients were screened for tobacco use during their visit to the PHC. People presenting with respiratory complaints were 84% more likely (OR: 1.84; 95% CI: 1.30 to 2.62) to be screened for tobacco use when compared to those with general ailments. Number of quit attempts in the past 12 months was strongly associated with the outcome of being screened for tobacco use, indicating that people who had more than 5 quit attempts were two times more likely to be screened for tobacco use than those who had never attempted to quit tobacco (OR: 1.99; 95% CI: 1.03 to 3.8). Among the 447 patients who were screened for tobacco use, only 136 reported to have been counselled and merely 67 patients received suggestions on ways to quit tobacco. CONCLUSION: Our results show that opportunities for screening and providing tobacco use cessation advice were largely missed by the health service providers. Our study suggests that there is an urgent need to incorporate tobacco cessation interventions as part of standard practice so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and counselling to quit tobacco.

System level approaches for mainstreaming tobacco control into existing health programs in India: Perspectives from the field.

INTRODUCTION: India is the second largest consumer of tobacco in the world, and varieties of both smoked and smokeless tobacco products are widely available. The national program for tobacco control is run like a vertical stand-alone program. There is a lack of understanding of existing opportunities and barriers within the health programs that influence the integration of tobacco control messages into them. The present formative research identifies such opportunities and barriers. METHODS: We conducted a multi-step, mixed methodological study of primary care personnel and policy-makers in two Indian states of Andhra Pradesh and Gujarat. The primary purpose of our study was to investigate health worker and policy-maker perceptions on the integration of tobacco control intervention. We systematically collected data in three steps: In Step I, we conducted in-depth interviews (IDIs) and focus group discussions with primary care health personnel, Step II consists of a quantitative survey among health care providers (n = 1457) to test knowledge, attitudes and practices in tobacco control and Step III we conducted 75 IDIs with program heads and policy-makers to evaluate the relative congruence of their views on integration of the tobacco control program. RESULTS: Majority of the health care providers recognized tobacco use as a major health problem. There was a general consensus for the need of training for effective dissemination of information from health care providers to patients. Almost 92% of the respondents opined that integration of tobacco control with other health programs will be highly effective to downscale the tobacco epidemic. CONCLUSIONS: Our findings suggest the need for integration of tobacco control program into existing health programs. Integration of tobacco control strategies into the health care system within primary and secondary care will be more effective and counseling for tobacco cessation should be available for population at large.

Does receipt of 5As services have implications for patients' satisfaction in India?

BACKGROUND: The 5As model for behavior change counseling is an evidence-based counseling approach. This study aims to explore the relationship between patient satisfaction with counseling services and 5As interventions in tobacco cessation. We also investigated the impact of satisfaction with counseling services on patients' intention to quit and recommendation of those services to other tobacco users. METHODS: Two cross-sectional surveys were administered among patients and physicians working in primary health care facilities in 12 districts of two states in India. Health facilities and patients were recruited by systematic random and simple random sampling respectively. We limited our analyses to only those patients who were asked about their tobacco consumption. We used multivariable logistic regression to investigate associations between individual components of 5As interventions and patients' satisfaction with the counseling services. RESULTS: Patients who reported that they were 'advised' to quit (OR: 9.56; 95% CI: 1.89-48.28), 'assessed' for readiness to quit (OR 2.1, 95% CI: 1.07-4.15) and offered cessation 'assistance' (OR 2.2, 95% CI: 1.17-4.29) were more satisfied with the counseling services. Patients who were satisfied with the counseling services were five times more likely to have an intention to quit tobacco (OR: 5.45, 95% CI: 3.59 to 8.27) and four times as likely to recommend counseling to other tobacco users (OR 3.83; 95% CI:2.46 -5.96). CONCLUSIONS: Incorporating 5As interventions in the delivery of primary care would likely increase patients' satisfaction with physicians' delivered counseling services. Patients' recommendation of counseling services will aid in demand generation for cessation services in primary care.

Factors determining intention to quit tobacco: exploring patient responses visiting public health facilities in India.

INTRODUCTION: Intention to quit and setting a quit date are key steps in the process towards improving quit rates and are thus an integral part of tobacco cessation efforts. The present study examined various motivating factors of "intention to quit" and "setting a quit date" in patients visiting public health facilities in two states of India. METHODS: A total of 1569 tobacco-users visiting public health facilities in 12 districts of the states of Andhra Pradesh and Gujarat were assessed through an interviewer-administered questionnaire. Bivariate and multivariable logistic regression was performed to assess the effect of socio-demographic characteristics, nicotine dependence, previous quit attempts and motivational factors on "intention to quit within 30 days" and "setting a quit date". RESULTS: Only 12% of patients intended to quit tobacco within 30 days and about 11% of them were ready to set a quit date. Respondents aged above 25 years were 53% less likely to quit tobacco within 30 days when compared to those below 25 years (95% Confidence Intervals [CI]: 0.22 to 0.99). Smokeless tobacco users were associated with an odds ratio (OR) of 2.05 (95% CI: 1.15 to 3.65) for "setting a quit date" when compared to smokers. Those with 1 to 5 previous quit attempts (in the past twelve months) were associated with an OR of 2.2 (95% CI: 1.38 to 3.51) for "intention to quit" and 2.46 (95% CI: 1.52 to 3.96) for "setting a quit date". "Concern for personal health" and "setting an example for children" were associated with ORs of 3.42 (95% CI: 1.35 to 8.65) and 2.5 (95% CI: 1.03 to 6.03) respectively for "setting a quit date". CONCLUSIONS: This study is amongst the first in India to explore factors associated with the "intention to quit" and "setting a quit date" among patients visiting public health facilities. Our findings suggest that socio-economic and individual-level factors are important factors depicting intention to quit and setting a quit date. We recommend the need for well-defined studies to understand the long term effects of factors influencing tobacco cessation for patients visiting public health facilities in India.

Examining physicians' preparedness for tobacco cessation services in India: Findings from primary care public health facilities in two Indian states.

BACKGROUND: A total of 275 million tobacco users live throughout India and are in need of tobacco cessation services. However, the preparation of physicians to deliver this service at primary care health facilities remains unknown. AIMS: The study aimed to examine the primary care physicians' preparedness to deliver tobacco cessation services in two Indian states. METHOD: Researchers surveyed physicians working in primary care public health facilities, primarily in rural areas using a semistructured interview schedule. Physicians' preparedness was defined in the study as those possessing knowledge of tobacco cessation methods and exhibiting a positive attitude towards the benefits of tobacco cessation counselling as well as being willing to be part of tobacco prevention or cessation program. RESULTS: Overall only 17% of physicians demonstrated adequate preparation to provide tobacco cessation services at primary care health facilities in both the States. The findings revealed minimal tobacco cessation training during formal medical education (21.3%) and on-the-job training (18.9%). Factors, like sex and age of service provider, type of health facility, location of health facility and number of patients attended by the service provider, failed to show significance during bivariate and regression analysis. Preparedness was significantly predicted by state health system. CONCLUSION: The study highlights a lack of preparedness of primary care physicians to deliver tobacco cessation services. Both the curriculum in medical school and on-the-job training require an addition of a learning component on tobacco cessation. The addition of this component will enable existing primary care facilities to deliver tobacco cessation services.