Implementation of an evidence-based tobacco control intervention for school teachers in India: Evaluating the effects of a capacity-building strategy.

Background: Tobacco-Free Teachers, Tobacco-Free Society (TFT-TFS) is an evidence-based intervention that promotes tobacco use cessation among teachers and tobacco control policies among schools in India. This study tested an implementation model to build Bihar Department of Education (DOE) capacity to support and deliver TFT-TFS within schools, leveraging DOE training infrastructure. Method: We used a training-of-trainers (TOT) "cascade" implementation strategy to embed the TFT-TFS program into the Bihar DOE infrastructure. We trained 46 Cluster Coordinators to train and support Headmasters to implement TFT-TFS in their schools over one academic year. We selected three school districts, representing approximately 46 clusters and 219 schools. We used the RE-AIM framework to assess program adoption (Headmaster participation in at least one of six TFT-TFS trainings), implementation (of four core program components), and reach (teachers' participation in three or more group discussions). Using a non-inferiority design, we hypothesized that program adoption, implementation, and reach would not be inferior to the high standards demonstrated when TFT-TFS was originally tested in the Bihar School Teachers Study. We used self-reported checklists to measure outcomes and SPSS Version 25 to analyze data. Results: For adoption, 94% of Headmasters attended the first training, although participation declined by the sixth training. Among the 112 schools out of 219 with complete Headmaster checklist data, all met our minimum criteria for implementing TFT-TFS. Over 99% of schools posted a school tobacco control policy and distributed quit booklets. However, only 69% of schools met our criteria for program reach. Conclusions: This study outlines the processes for taking a tobacco control intervention to scale and implementing it through the Bihar DOE infrastructure. These findings provide a foundation for other Indian states and low- and middle-income countries to implement tobacco control and other health programs for schoolteachers. Trial registration: NCT05346991. Plain Language Summary: Each year in India, more than 1.2 million people die from tobacco-related causes, and India has the world's highest oral cancer burden. The world needs more evidence on how to bring cost-effective tobacco control interventions to scale, especially in low- and middle-income countries (LMICs). To address this gap, from 2017 to 2021, we examined the process of scaling up Tobacco-Free Teachers, Tobacco-Free Society (TFT-TFS), an evidence-based intervention promoting tobacco use cessation among teachers and tobacco control policies in schools. Our study tested an implementation model aimed at building the Bihar State Department of Education (DOE) capacity to support and deliver TFT-TFS. We used a training-of-trainers model to embed TFT-TFS into Bihar DOE infrastructure, training 46 Cluster Coordinators to in turn train and support Headmasters to implement TFT-TFS over one academic year. We hypothesized that program adoption, implementation, and reach would not be inferior to the high standards demonstrated when we originally tested TFT-TFS through the Bihar School Teachers Study (2013-2017). For adoption, 94% of Headmasters attended the first training, although participation declined by the sixth training. Of 112 schools (out of 219 with complete Headmaster checklist data), all met our minimum criteria for implementing TFT-TFS. Over 99% of schools posted a school tobacco control policy and distributed quit booklets. However, only 69% of schools met our criteria for program reach. Study findings offer other Indian states and LMICs lessons to implement tobacco control and other health programs for schoolteachers within educational systems.

Behavioral Interventions for Smokeless Tobacco Cessation.

INTRODUCTION: Consumption of smokeless tobacco (SLT) is on the rise (especially in the World Health Organization South-East Asian region) and has numerous repercussions over the consumer's health. This article reviews studies performed for SLT cessation using behavioral interventions, worldwide till 2017. METHODS: A systematic review by PICO (Problem, intervention, comparison, outcome) of behavioral intervention-based SLT cessation studies with minimum 6 months' follow-up, reporting outcomes in terms of risk ratios (RRs) and 95% confidence interval (CI), published between 1992 and 2017 was performed. This was followed by a meta-analysis of the outcomes of these studies by deriving the pooled estimates by the random effects model, for those on adults and youth, categorized according to the type of country where the study was performed, that is, in terms of developed or developing. Publication bias among the included studies was assessed by the Begg's test. RESULTS: Nineteen eligible studies comprising 24 498 participants, from all over the world were included. Behavioral interventions showed overall efficacy in SLT cessation in adults (RR = 1.63, 95% CI = 1.32 to 1.94) both in the developed (RR = 1.39, 95% CI = 1.16 to 1.63) and developing (RR = 2.79, 95% CI = 2.32 to 3.25) countries. However, these interventions did not prove effective for SLT cessation among youth overall (RR = 1.07, 95% CI = 0.73 to 1.41), either in the developed (RR = 1.39, 95% CI = 0.58 to 2.21) or in the developing (RR = 0.87, 95% CI = 0.68 to 1.07) countries. Publication bias was noted in all the studies among adults (p = .22) and youth (p = .05). CONCLUSION: Behavioral interventions as a single modality are effective in SLT cessation, both in the developed and developing countries. Health care providers should be sensitized to provide the same. IMPLICATIONS: A recent literature survey by Cochrane reviewed studies on interventions for SLT, including behavioral interventions, which included only those from the developed countries. The current analysis provides a broader, global update on the same by including studies performed both in the developed and developing countries (specifically the South-East Asian region-the high burden countries of SLT products).

Events of alternative splicing in head and neck cancer via RNA sequencing - an update.

BACKGROUND: Alternative splicing (AS) is a regulatory mechanism used to create many forms of mature messengers RNAs (mRNAs) from the same gene. Sequencing of RNA (RNA-Seq) is an advanced technology, which has been utilized by different studies to find AS mechanisms in head and neck cancer (HNC). Hitherto, there is no available review that could inform us of the major findings from these studies. Hence, we aim to perform a systematic literature search following PRISMA guidelines to study AS events in HNC identified through RNA-Seq studies. RESULTS: A total of five records were identified that utilized RNA-Seq data for identifying AS events in HNC. Five software was used in these records to identify AS events. Two genes influenced by AS i.e. MLL3 and RPS9 were found to be common in 4 out of 5 records. Likewise, 38 genes were identified to be similar in at least 3 records. CONCLUSIONS: Alternative splicing in HNC is a multifaceted regulatory mechanism of gene expression. It can be studied via RNA-Seq using different bioinformatics tools. Genes MLL3, as well as RPS9, were repeatedly found to be associated with HNC, however needs further functional validation.

SLTChemDB: A database of chemical compounds present in Smokeless tobacco products.

Smokeless tobacco (SLT), a cause of potentially preventable diseases, has a diverse chemical composition encompassing toxicants as well as potent carcinogens. Though the chemical profile of SLT products has been analyzed earlier, this information is not available in a comprehensive and easily accessible format. Hence, there is an imperative felt need to develop a one-stop information source providing inclusive information on SLT products. SLTChemDB is the first such database that makes available detailed information on various properties of chemical compounds identified across different brands of SLT products. The primary information for the database was extracted through extensive literature search, which was further curated from popular chemical web servers and databases. At present, SLTChemDB contains comprehensive information on 233 unique chemical compounds and 82 SLT products. The database has been made user-friendly with facility for systematic search and filters. SLTChemDB would provide the initial data on chemical compounds in SLT products to various tobacco testing laboratories. The database also highlights research gaps and thus, would be a guide for researchers interested in chemistry and toxicology of SLT products. With regular update of information in the database, it shall be a valuable evidence base for policymakers to formulate stringent policies for SLT control.

Regulation of toxic contents of smokeless tobacco products.

Effective regulation of contents of tobacco products is one of the primary milestones to reduce negative health effects associated with the use of smokeless tobacco (SLT) products. As per the available sources, testing of some SLT products has been done on ad hoc basis, but there is a lack of comprehensive and periodic analysis of these products. In addition, the available results indicate huge variations among the levels of pH, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone, N-nitrosonornicotine, benzo[a]pyrene, heavy metals and nicotine within different products as well as within different brands of the same product. This review was aimed to throw light on the variations and gaps in testing of SLT products and emphasize the need for strong policy regulation for monitoring the chemical constituents of these products.

Setting research priorities in smokeless tobacco control: A retrospective review.

BACKGROUND & OBJECTIVES: Smokeless tobacco (SLT) has become a global menace; India being one of the high-burden countries contributes about 67 per cent of its users. Although research is ongoing on various aspects of SLT use and its effects, there is a need to identify the still under-researched areas in this field. This study was aimed at delineating the quantum of research on various topics of SLT, with intent to delineate research gaps for guiding future research priorities. METHODS: Data about research in SLT were collected from PubMed database using 'smokeless tobacco' as a keyword and applying Medical Subject Headings (MeSH) terms filter. Data were extracted in XML (Extensible Markup Language) format and parsed into database to extract necessary fields such as PubMed IDs, authors' names, affiliations and MeSH terms. Quantum of research in various aspects of SLT was identified for individual MeSH terms and compared for global and Indian data. RESULTS: Data analysis of 2857 records revealed that maximum number of articles was devoted to adverse effects (35.6%) followed by epidemiology (32.4%). In comparison, India contributed only 11.7 per cent of records with maximum number of articles on the topics of epidemiology (26%) and adverse effects (45.8%). Higher proportion of research was published on epidemiology, aetiology and prevention and control at global level, while adverse effects of SLT were researched more in Indian studies as compared to global data. INTERPRETATION & CONCLUSIONS: The present analysis highlighted the paucity of research studies on important topics such as economics and alternative strategies of SLT control, both on the global and regional levels.

Implementation of Article 20 of the World Health Organization Framework Convention on Tobacco Control.

BACKGROUND & OBJECTIVES: Article 20 of the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) deals with surveillance and research on all tobacco products including smokeless tobacco (SLT). Here we describe the availability of indicators related to SLT among 180 Parties to the convention (countries ratifying the WHO FCTC are referred as Parties to the Convention). METHODS: Data on SLT use among adults and adolescents and SLT-related economic and health indicators among Parties were obtained through rigorous literature search. Data analysis for high-burden parties was done using SPSS. RESULTS: Nearly 92 per cent (166) of the Parties reported SLT use prevalence among adults or adolescents at national or subnational level, of these nearly one-fifth of the Parties (20.5%) were high-burden Parties. Comparable SLT tax incidence rate was available for 19.4 per cent (n=35) Parties, and SLT attributable morbidity and mortality risks of major diseases were available for only five per cent (n=10) of Parties. INTERPRETATION & CONCLUSIONS: SLT use is a global epidemic widespread among Parties to the Convention. There are a data gap and dearth of research on SLT-related issues. Parties need to monitor SLT use and related health and economic indicators regularly at periodic intervals.

Dohra- a mixture of potent carcinogens.

BACKGROUND & OBJECTIVES: Dohra is a areca nut preparation used with or without tobacco in a few of the areas of Uttar Pradesh (UP), India. There is evidence that it causes potentially malignant disorders and oral cancer. This study was undertaken to provide information on dohra by searching through literature and also through a survey in three areas of Uttar Pradesh (UP), India. METHODS: The information on dohra was collected through literature search, study tour to different areas of UP, where group discussions with dohra vendors and with community members of different age group were done to obtain information. RESULTS: Dohra was prepared by the users for their personal use or prepared by small-scale industry for sale. It was available mostly in betel shops or any other store/kiosks and was also available in special dohra shops. Dohra was available in both dry and wet form. Its common constituents were areca nut, catechu (Acacia catechu), edible lime, peppermint (Mentha piperita), cardamom (Elettaria cardamomum) and some flavoring agents. Dohra was consumed as such or with tobacco. INTERPRETATION & CONCLUSIONS: Different varieties of Dohra were available such as sukha dohra, sukha mulethi dohra and geela dohra. Different processing methods for producing dohra existed. As dohra increases the risk of cancer, it needs to be banned or it should be sold in packets with the details of its constituents and also statutory warning about its adverse health effects.

Smokeless tobacco cessation interventions: A systematic review.

BACKGROUND & OBJECTIVES: Smokeless tobacco (SLT) consumption is a global health issue with about 350 million users and numerous adverse health consequences like oral cancer and myocardial disorders. Hence, cessation of SLT use is as essential as smoking cessation. An update on the available literature on SLT cessation intervention studies is provided here. METHODS: Through an extensive literature search on SLT cessation intervention studies, using keywords such as smokeless tobacco, cessation, interventions, quitlines, brief advice, nicotine replacement therapy, nicotine gum, nicotine lozenge, nicotine patch, bupropion, varenicline, mHealth, etc., 59 eligible studies were selected. Furthermore, efficacy of the interventions was assessed from the reported risk ratios (RRs) [confidence intervals (CIs)] and quit rates. RESULTS: Studies were conducted in Scandinavia, India, United Kingdom, Pakistan and the United States of America, with variable follow up periods of one month to 10 years. Behavioural interventions alone showed high efficacy in SLT cessation; most studies were conducted among adults and showed positive effects, i.e. RR [CI] 0.87 [0.7, 1.09] to 3.84 [2.33, 6.33], quit rate between 9-51.5 per cent, at six months. Regular telephone support/quitlines also proved beneficial. Among pharmacological modalities, nicotine lozenges and varenicline proved efficacious in SLT cessation. INTERPRETATION & CONCLUSIONS: Globally, there is limited information available on SLT cessation intervention trials, research on which must be encouraged, especially in the low-resource, high SLT burden countries; behavioural interventions are most suitable for such settings. Appropriate training/sensitization of healthcare professionals, and school-based SLT use prevention and cessation programmes need to be encouraged.

Signature of genetic associations in oral cancer.

Oral cancer etiology is complex and controlled by multi-factorial events including genetic events. Candidate gene studies, genome-wide association studies, and next-generation sequencing identified various chromosomal loci to be associated with oral cancer. There is no available review that could give us the comprehensive picture of genetic loci identified to be associated with oral cancer by candidate gene studies-based, genome-wide association studies-based, and next-generation sequencing-based approaches. A systematic literature search was performed in the PubMed database to identify the loci associated with oral cancer by exclusive candidate gene studies-based, genome-wide association studies-based, and next-generation sequencing-based study approaches. The information of loci associated with oral cancer is made online through the resource "ORNATE." Next, screening of the loci validated by candidate gene studies and next-generation sequencing approach or by two independent studies within candidate gene studies or next-generation sequencing approaches were performed. A total of 264 loci were identified to be associated with oral cancer by candidate gene studies, genome-wide association studies, and next-generation sequencing approaches. In total, 28 loci, that is, 14q32.33 (AKT1), 5q22.2 (APC), 11q22.3 (ATM), 2q33.1 (CASP8), 11q13.3 (CCND1), 16q22.1 (CDH1), 9p21.3 (CDKN2A), 1q31.1 (COX-2), 7p11.2 (EGFR), 22q13.2 (EP300), 4q35.2 (FAT1), 4q31.3 (FBXW7), 4p16.3 (FGFR3), 1p13.3 (GSTM1-GSTT1), 11q13.2 (GSTP1), 11p15.5 (H-RAS), 3p25.3 (hOGG1), 1q32.1 (IL-10), 4q13.3 (IL-8), 12p12.1 (KRAS), 12q15 (MDM2), 12q13.12 (MLL2), 9q34.3 (NOTCH1), 17p13.1 (p53), 3q26.32 (PIK3CA), 10q23.31 (PTEN), 13q14.2 (RB1), and 5q14.2 (XRCC4), were validated to be associated with oral cancer. "ORNATE" gives a snapshot of genetic loci associated with oral cancer. All 28 loci were validated to be linked to oral cancer for which further fine-mapping followed by gene-by-gene and gene-environment interaction studies is needed to confirm their involvement in modifying oral cancer.

Widespread inequalities in smoking & smokeless tobacco consumption across wealth quintiles in States of India: Need for targeted interventions.

BACKGROUND & OBJECTIVES: India is a large country with each State having distinct social, cultural and economic characteristics. Tobacco epidemic is not uniform across the country. There are wide variations in tobacco consumption across age, sex, regions and socio-economic classes. This study was conducted to understand the wide inequalities in patterns of smoking and smokeless tobacco consumption across various States of India. METHODS: Analysis was conducted on Global Adult Tobacco Survey, India (2009-2010) data. Prevalence of both forms of tobacco use and its association with socio-economic determinants was assessed across States and Union Territories of India. Wealth indices were calculated using socio-economic data of the survey. Concentration index of inequality and one way ANOVA assessed economic inequality in tobacco consumption and variation of tobacco consumption across quintiles. Multiple logistic regression was done for tobacco consumption and wealth index adjusting for age, sex, area, education and occupation. RESULTS: Overall prevalence of smoking and smokeless tobacco consumption was 13.9 per cent (14.6, 13.3) and 25.8 per cent (26.6, 25.0), respectively. Prevalence of current smoking varied from 1.6 per cent (richest quintile in Odisha) to 42.2 per cent (poorest quintile in Meghalaya). Prevalence of current smokeless tobacco consumption varied from 1.7 per cent (richest quintile in Jammu and Kashmir) to 59.4 per cent (poorest quintile in Mizoram). Decreasing odds of tobacco consumption with increasing wealth was observed in most of the States. Reverse trend of tobacco consumption was observed in Nagaland. Significant difference in odds of smoking and smokeless tobacco consumption with wealth quintiles was observed. Concentration index of inequality was significant for smoking tobacco -0.7 (-0.62 to-0.78) and not significant for smokeless tobacco consumption -0.15 (0.01 to-0.33) INTERPRETATION & CONCLUSIONS: The findings of our analysis indicate that tobacco control policy and public health interventions need to consider widespread socio-economic inequities in tobacco consumption across the States in India.

Socioeconomic inequality in the prevalence of smoking and smokeless tobacco use in India.

BACKGROUND: Tobacco consumption has been identified as the single biggest cause of inequality in morbidity and mortality. Understanding pattern of socioeconomic equalities in tobacco consumption in India will help in designing targeted public health control measures. MATERIALS AND METHODS: Nationally representative data from the India Global Adult Tobacco Survey (GATS) conducted in 2009-2010 was analyzed. The survey provided information on 69,030 respondents aged 15 years and above. Data were analyzed according to regions for estimating prevalence of current tobacco consumption (both smoking and smokeless) across wealth quintiles. Multiple logistic regression analysis predicted the impact of socioeconomic determinants on both forms of current tobacco consumption adjusting for other socio-demographic variables. RESULTS: Trends of smoking and smokeless tobacco consumption across wealth quintiles were significant in different regions of India. Higher prevalence of smoking and smokeless tobacco consumption was observed in the medium wealth quintiles. Risk of tobacco consumption among the poorest compared to the richest quintile was 1.6 times higher for smoking and 3.1 times higher for smokeless forms. Declining odds ratios of both forms of tobacco consumption with rising education were visible across regions. Poverty was a strong predictor in north and south Indian region for smoking and in all regions for smokeless tobacco use. CONCLUSIONS: Poverty and poor education are strong risk factors for both forms of tobacco consumption in India. Public health policies, therefore, need to be targeted towards the poor and uneducated.

Linking Global Youth Tobacco Survey 2003 and 2006 data to tobacco control policy in India.

BACKGROUND: India made 2 important policy statements regarding tobacco control in the past decade. First, the India Tobacco Control Act (ITCA) was signed into law in 2003 with the goal to reduce tobacco consumption and protect citizens from exposure to secondhand smoke (SHS). Second, in 2005, India ratified the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). During this same period, India conducted the Global Youth Tobacco Survey (GYTS) in 2003 and 2006 in an effort to track tobacco use among adolescents. METHODS: The GYTS is a school-based survey of students aged 13-15 years. Representative national estimates for India in 2003 and 2006 were used in this study. RESULTS: In 2006, 3.8% of students currently smoked cigarettes and 11.9% currently used other tobacco products. These rates were not significantly different than those observed in 2003. Over the same period, exposure to SHS at home and in public places significantly decreased, whereas exposure to pro-tobacco ads on billboards and the ability to purchase cigarettes in a store did not change significantly. CONCLUSIONS: The ITCA and the WHO FCTC have had mixed impacts on the tobacco control effort for adolescents in India. The positive impacts have been the reduction in exposure to SHS, both at home and in public places. The negative impacts are seen with the lack of change in pro-tobacco advertising and ability to purchase cigarettes in stores. The Government of India needs to consider new and stronger provisions of the ITCA and include strong enforcement measures.

Tobacco use among students and school personnel in India.

BACKGROUND: Tobacco usage is addictive and causative for several diseases and premature death. Concerted efforts by the individual and society are needed for control and for surveillance. The habit is initiated during early youth and this age group requires constant monitoring and timely appropriate action to curtail usage. The WHO FCTC has recommended actions to monitor and limit the tobacco use in young age groups. One of the actions is to examine the prevalence of tobacco habits in school children 13-15 years of age and of personnel employed in schools. METHODS: WHO & CDC designed the study systems for Global Youth Tobacco Survey (GYTS) and Global School Personnel Survey (GSPS). In 2006 we conducted GYTS and GSPS in several parts of the country. The schools were chosen by strict sampling procedure and a well structured, self-administered questionnaire was used to obtain information on tobacco usage from 13 to 15 year old students of chosen schools and personnel of these schools. RESULTS: Current use of any tobacco product was 14.1% among students (17.3% boys, 9.8% girls) and among school personnel it was 29.2%(35.0% males and 13.7% females). The prevalence was highest among male students in North East (34%) and the lowest was 4.9% among female students of western states. Cigarettes and Bidi smoking were more prevalent among boys. Smokeless tobacco use prevalence rate varied between 20% and 4.5% among boys and between 21.5% and 1.6% among girl students. Among male school personnel, the prevalence varied from 57.9% in NE to 25.7% in South. Among females 26.5% were tobacco users in the NE and in Western region it was 6.6%. CONCLUSION: It is essential to adopt forceful strategies, which are area specific, in order to undo the harm inflicted by tobacco use upon the individuals &society. Periodic surveys for surveillance of trends are essential to evaluate the outcome of programmes among students and school personnels.

Linking Global Youth Tobacco Survey (GYTS) data to the WHO framework convention on tobacco control: the case for India.

India ratified the WHO Framework Convention on Tobacco Control (WHO FCTC) on February 27, 2005. The WHO FCTC is the world's first public health treaty that aims to promote and protect public health and reduce the devastating health and economic impacts of tobacco. Post ratification, each member state as part of general obligation has agreed to develop, implement, periodically update and review comprehensive multisectoral national tobacco control strategies, plans and programmes in accordance with this Convention and the protocols to which it is a Party. The Global Youth Tobacco Survey (GYTS) was developed to track tobacco use among young people across countries and the GYTS surveillance system intends to enhance the capacity of countries to design, implement, and evaluate tobacco control and prevention programs. The South-East Asia Region of WHO has developed the "Regional Strategy for Utilization of the GYTS" to meet this need for countries in the Region. In 2003, India has passed its national tobacco control legislation (India Tobacco Control Act [ITCA]), which includes provisions designed to reduce tobacco consumption and protect citizens from exposure to second hand smoke. Data in the GYTS (India) report can be used as a baseline measure for future evaluation of the tobacco control programs implemented by the Ministry of Health and Family Welfare, Government of India. India has to upscale some provisions of its National Law to accommodate all of the requirements of FCTC. Using determinants measured by GYTS in India, the government can monitor the impact of enforcing various provisions of the ITCA and the progress made in achieving the goals of the WHO FCTC and the Regional Strategies. Effective enforcement of the provisions of ITCA will show in the receding numbers of tobacco use prevalence figures and reduction in the expenditures associated with tobacco use in India.