Complementary and Alternative Medicine/Therapy for Tobacco Cessation in India: A Secondary Analysis of GATS-1 and 2.

Background: India has nearly 267 million adult tobacco users, with a slowly improving quitting rate. Among the many approaches to quitting the habit, such as counseling, nicotine replacement therapy, nicotine patch or gum, and prescribed allopathic medicines. Complementary and alternative medicine/therapy (CAM), a thousand-year-old practice in India, may also prove to be a potential method in tobacco cessation; however, there is scarce literature on the extent of use of CAM among tobacco users who attempt to quit the habit. Therefore, this study attempts to examine the potential of CAM as a strategy for tobacco control in India. Material and Methods: We undertook a secondary analysis of the data from both rounds of the Global Adult Tobacco Survey (GATS 2009 and 2016). The dependent variable included in the analysis was the use of traditional medicine as a method for quitting tobacco in three types of users-smokers, smokeless tobacco users, and dual users. The prevalence of CAM use was reported, and Chi-square test was applied to find the factors significantly associated with the use of CAM among tobacco users considering a P value of 0.05 to be statistically significant. Results: The overall prevalence of traditional medicine use for GATS-1 was observed to be more among dual users (4%), while for GATS-2, it was highest among smokers (3%). For both rounds of the GATS survey, the use of traditional medicine was found to be higher among males, rural residents, users with no education or less than primary education, and the eastern region. Conclusions: CAM has a promising potential for supporting tobacco cessation provided a concerted effort is undertaken to standardize pharmacopeia and establish robust clinical evidence. In addition, there is a need to create awareness, build the capacity of healthcare providers, and foster academic-industrial research in indigenous Ayurveda, Yoga, Naturopathy, Unani, Siddha, and Homeopathy (AYUSH) systems.

Development of a multi-component tobacco cessation training package utilizing multiple approaches of intervention development for health care providers and patients attending non-communicable disease clinics of Punjab, India.

Background: Providing patients with personalized tobacco cessation counseling that is culturally sensitive, and disease-specific from healthcare providers (HCPs) as part of their routine consultations is an approach that could be incorporated, using existing healthcare systems such as the Non-Communicable Disease (NCD) clinics. This paper describes the development of a multi-component culturally tailored, patient-centric, disease-specific tobacco cessation package utilizing multiple approaches of intervention development for healthcare providers and patients attending these clinics in Punjab, India, along with a proposed framework for implementation. Methods: The proposed intervention package was developed in 6 stages. These included a review of literature for identifying successful cessation interventions for ethnic minority groups, co-production of the package with all stakeholders involved via a series of consultative meetings and workshops, understanding contextual factors of the state and 'factor-in' these in the package, pre-test of the package among HCPs and tobacco users using in-depth interviews, micro detailing and expansion of the package by drawing on existing theories of the Cascade Model and Trans-Theoretical Model and developing an evolving analysis plan through real-world implementation at two pilot districts by undertaking a randomized controlled trial, assessing implementer's experiences using a mixed-method with a primary focus on qualitative and economic evaluation of intervention package. Results: A multi-component package consisting of a booklet (for HCPs), disease-specific pamphlets and short text messages (for patients; bilingual), and an implementation framework was developed using the 6-step process. A major finding from the in-depth interviews was the need for a specific capacity-building training program on tobacco cessation. Therefore, using this as an opportunity, we trained the in-service human resource and associated program managers at the state and district-level training workshops. Based on the feedback, training objectives were set and supported with copies of intervention package components. In addition, the role and function of each stakeholder were defined in the proposed framework. Conclusion: Consideration of tobacco users' socio-cultural and patient-centric approach makes a robust strategy while developing and implementing an intervention providing an enlarged scope to improve care services for diversified socio-cultural communities.

Banning Loose Cigarettes and Other Tobacco Products in India: A Policy Analysis.

BACKGROUND: Sale of single cigarettes (also known as singles or loosies) is a key driver for early initiation of smoking and is a leading contributor to the smoking epidemic in India. Sale of singles additionally deter implementation of tobacco control strategies of pictorial health warnings including plain packaging and defeat effective taxation and promote illicit trade. We review India's tobacco control policy responses towards banning singles and other products sold as loose tobacco and identify opportunities for future policy intervention especially in the context of the ongoing COVID-19 pandemic. METHODS: Existing national and sub-national policy documents were analyzed for their content since the inception of the tobacco control laws in the country. RESULTS: There are no effective provisions at national level to ban loose tobacco products in India. However, the implementation of multiple legislative and regulatory measures (Acts/circulars/letters/notifications/orders/court judgements) in 16 Indian states and jurisdictions provide sufficient legal framework to substantiate its complete ban pan India. While the majority of state governments have adopted state level measures, Rajasthan had issued specific directive to all the 33 districts banning loose cigarettes and other tobacco products. Himachal Pradesh introduced the most unique and comprehensive legislation, for banning the sale of cigarettes and beedis (Dated November 7, 2016). The most recent notification in the state of Maharashtra (September 24, 2020) is the first to leverage powers using a mix of national and state legislations including the legislation addressing the rapidly emerging challenge of managing COVID-19. CONCLUSION: A robust national policy which supports strong provision to deter tobacco companies, their distribution network and vendors from selling singles or loose tobacco products is urgently needed. Such policy should be backed by cautionary messaging for consumers as well. Eliminating singles and loose tobacco sale will help in blunting tobacco use prevalence besides curbing spread of infectious diseases like COVID-19 pandemic.

E-cigarette retailer storefront availability following a nationwide prohibition of e-cigarettes in India: A multicentric compliance assessment.

INTRODUCTION: This study aimed to assess the availability of retailer storefronts that continued to sell electronic nicotine/non-nicotine delivery systems (ENDS/ENNDS) in India, and characterise such retailers following the promulgation of 2019 Indian Ordinance and Act (Ordinance/Act) that prohibit ENDS/ENNDS nationwide. METHODS: Discreet observations were conducted of retailer storefronts across different socioeconomic zones in nine major cities of India (Bengaluru, Chandigarh, Dehradun, Delhi, Indore, Kolkata, Ludhiana, Raipur, and Ranchi) from 28 November 2019 to 22 January 2020 to identify the availability of ENDS/ENNDS (i.e. electronic cigarettes, e-cigarette liquid, e-cigarette accessories, heated tobacco products (HTPs), and HTPs accessories). We report the number and proportion (%) of retailers that sold ENDS/ENNDS. Other characteristics of the retailers are also described, including indirect evaluation of the retailer's awareness of the Ordinance/Act. RESULTS: Of the 199 retailer storefronts visited, 37 (18.6%) sold ENDS/ENNDS and, therefore, did not comply with the Ordinance/Act. The highest availability of non-compliant retailers was in Kolkata (n=26; 83.9%). The majority of the non-compliant retailers were tobacco retailers (n=35; 94.6%), sold e-cigarettes (n=22; 59.5%), and e-cigarette accessories (n=24; 64.9%). Although many of the non-compliant retailers displayed their ENDS/ENNDS products (n=33; 89.2%) and did not feature health warnings related to ENDS/ENNDS (n=32; 86.5%) in the stores, nearly 90% (n=33) were aware of the Ordinance/Act. CONCLUSIONS: Despite a nationwide ban, ENDS/ENNDS are still available in major cities in India, and concentrated in a particular city. Indian authorities should focus on law enforcement to ensure that the prohibition is effectively implemented.

Fuelling the tuberculosis epidemic: The role of tobacco control in ending the TB emergency.

BACKGROUND: Ending the TB epidemic by 2030 is among the key targets for countries to achieve Sustainable Development Goals. In current times we are grappling with dual burden of tuberculosis as well as tobacco use. METHODS: There is sufficient evidence to establish that tobacco smoking significantly spikes up the risk of acquiring, developing and death among tuberculosis patients. Active or passive exposure to tobacco smoke is significantly associated with tuberculosis infection and tuberculosis disease, independent of a large number of other potential confounders. RESULTS: Despite having substantial evidence about the impact of tobacco control measures, particularly tobacco cessation, on TB outcomes, the integration of TB and tobacco control still remains far-off. CONCLUSION: It is high time when TB control programs must begin to address tobacco control as a potential preventive intervention to combat colliding epidemics of tobacco and tuberculosis. This white paper discusses about the role of tobacco control in reaching the ambitious goal of ending TB epidemic by 2030.

Capacity Building through Operational Research Training in Tobacco Control: Experiences and Lesson Learned.

BACKGROUND: Several competing priorities with health and development sector currently deter research, and as a result of which evidence does not drive policy- or decision-making. There is limited operational research (OR) within the India's National Tobacco Control Programme, as it is in other middle- and low-income countries, primarily due to limited capacity and skills in undertaking OR and lack of dedicated funding. Few models of OR have been developed to meet the needs of different settings; however, they were found to be costly and time-consuming. OBJECTIVE: To elucidate a cost-effective and less resource arduous training model for building capacity in OR focused on tobacco control. MATERIALS AND METHODS: This 5½-day partly funded course enrolled 15 participants across the country and nine facilitators. The facilitator-participants interactions were initiated 2 weeks before the course, which enabled them to develop possible research questions and a plan for data analysis. RESULTS: This article presents the new OR model along with experiences of the participants which will provide useful insights on lessons learned for planning similar courses in the future. While we faced several challenges in the process and the outputs were modest, several lessons were learned which will be instrumental in the future courses that we are planning to conduct. CONCLUSION: This low cost and less time intensive model can be applied in similar settings across range of public health issues.

Open access tools for quality-assured and efficient data entry in a large, state-wide tobacco survey in India.

BACKGROUND: A large state-wide tobacco survey was conducted using modified version of pretested, globally validated Global Adult Tobacco Survey (GATS) questionnaire in 2015-22016 in Tamil Nadu, India. Due to resource constrains, data collection was carrid out using paper-based questionnaires (unlike the GATS-India, 2009-2010, which used hand-held computer devices) while data entry was done using open access tools. The objective of this paper is to describe the process of data entry and assess its quality assurance and efficiency. METHODS: In EpiData language, a variable is referred to as 'field' and a questionnaire (set of fields) as 'record'. EpiData software was used for double data entry with adequate checks followed by validation. Teamviewer was used for remote training and trouble shooting. The EpiData databases (one each for each district and each zone in Chennai city) were housed in shared Dropbox folders, which enabled secure sharing of files and automatic back-up. Each database for a district/zone had separate file for data entry of household level and individual level questionnaire. RESULTS: Of 32,945 households, there were 111,363 individuals aged ≥15 years. The average proportion of records with data entry errors for a district/zone in household level and individual level file was 4% and 24%, respectively. These are the errors that would have gone unnoticed if single entry was used. The median (inter-quartile range) time taken for double data entry for a single household level and individual level questionnaire was 30 (24, 40) s and 86 (64, 126) s, respectively. CONCLUSION: Efficient and quality-assured near-real-time data entry in a large sub-national tobacco survey was performed using innovative, resource-efficient use of open access tools.

Effect of a brief smoking cessation intervention on adult tobacco smokers with pulmonary tuberculosis: A cluster randomized controlled trial from North India.

BACKGROUND: An association between smoking and poor tuberculosis (TB) treatment outcomes has been globally established. Various smoking cessation interventions (SCIs) have been proven worldwide to curb smoking behavior. There is a need for evidence to assess if SCI increases the chance of successful treatment outcome among TB patients. OBJECTIVES: To assess the effectiveness of a brief SCI; The Ask, Brief, Cessation support (ABC) package, on treatment outcomes and smoking cessation in smear-positive adult pulmonary TB patients. METHODS: A cluster, randomized controlled trial was conducted wherein 17 designated microscopic centers of Chandigarh, India were randomly assigned using a computer-generated randomization sequence to receive SCI within directly observed treatment, short (DOTS) services, or existing standard of care. Eligible and consenting smokers (15 + years) registered as smear-positive pulmonary TB for DOTS (n = 156) between January and June 2013 were enrolled. Smoking cessation (self-reported) was assessed at intervals till the end of treatment. End TB treatment outcomes were extracted from patient records. RESULTS: Treatment success was lower in intervention arm (83.6%) as compared control arm (88.2%), but the difference was statistically insignificant (P = 0.427). Smoking cessation was higher in intervention arm (80.2%) compared to comparison arm (57.5%) (adjusted incidence risk ratio = 1.56; 95% confidence interval = 1.24-1.93; P < 0.0001). CONCLUSIONS: SCI is effective in inducing smoking cessation among TB patients. No association of SCI with TB treatment outcomes could be detected.

Opening gambit: Strategic options to initiate the tobacco endgame.

Endgame strategies to rapidly hasten the decline of tobacco are already well within reach; a few plausible policy options are outlined herein for policy practitioners, tobacco control advocates, and public health specialists. The implementation of these measures which already exist within the gamut of existing legislation requires the galvanization of political will. The options we essay include liquidating existing public investments in tobacco, holding tobacco companies accountable within the jurisdictions of their operations, fixing liability for injury and the imposition of realistic costs on insurance providers.

Low-Cost Air Quality Monitoring Methods to Assess Compliance With Smoke-Free Regulations: A Multi-Center Study in Six Low- and Middle-Income Countries.

INTRODUCTION: Many low- and middle-income countries (LMICs) have enacted legislation banning smoking in public places, yet enforcement remains challenging. The aim of this study was to assess the feasibility of using a validated low-cost methodology (the Dylos DC1700) to provide objective evidence of smoke-free (SF) law compliance in hospitality venues in urban LMIC settings, where outdoor air pollution levels are generally high. METHODS: Teams measured indoor fine particulate matter (PM2.5) concentrations and systematically observed smoking behavior and SF signage in a convenience sample of hospitality venues (bars, restaurants, cafes, and hotels) covered by existing SF legislation in Mexico, Pakistan, Indonesia, Chad, Bangladesh, and India. Outdoor air PM2.5 was also measured on each sampling day. RESULTS: Data were collected from 626 venues. Smoking was observed during almost one-third of visits with substantial differences between countries-from 5% in India to 72% in Chad. After excluding venues where other combustion sources were observed, secondhand smoke (SHS) derived PM2.5 was calculated by subtracting outdoor ambient PM2.5 concentrations from indoor measurements and was, on average, 34 µg/m(3) in venues with observed smoking-compared to an average value of 0 µg/m(3) in venues where smoking was not observed (P < .001). In over one-quarter of venues where smoking was observed the difference between indoor and outdoor PM2.5 concentrations exceeded 64 µg/m(3). CONCLUSIONS: This study suggests that low-cost air quality monitoring is a viable method for improving knowledge about environmental SHS and can provide indicative data on compliance with local and national SF legislation in hospitality venues in LMICs. IMPLICATIONS: Air quality monitoring can provide objective scientific data on SHS and air quality levels in venues to assess the effectiveness of SF laws and identify required improvements. Equipment costs and high outdoor air pollution levels have hitherto limited application in LMICs. This study tested the feasibility of using a validated low-cost methodology in hospitality venues in six LMIC urban settings and suggests this is a viable method for improving knowledge about SHS exposure and can provide indicative data on compliance with SF legislation.

Unravelling India's tobacco epidemic--priorities and recommendations for the second round of Global Adult Tobacco Survey (GATS).

The Global Adult Tobacco Survey, or GATS, has proved to be an invaluable tool for policymakers. In India, it highlighted the alarming rates of prevalence of use and risks both nationally and at state level. However, a rapid analysis of GATS-India shows that there are limitations in methods (sampling, questionnaire, measures undertaken to ensure data quality and management), which may impact the estimates of prevalence. This review discusses these potential weaknesses and recommends measures that can be adopted in the next round of surveys to overcome the limitations.

Smoking trends among women in India: Analysis of nationally representative surveys (1993-2009).

BACKGROUND: There is growing concern among policy makers with respect to alarming growth in smoking prevalence among women in the developing countries. METHODS: USING DISAGGREGATED DATA FROM FIVE NATIONALLY REPRESENTATIVE SURVEYS: Global Adult Tobacco Survey 2010, National Family Health Survey-III (NFHS-III) 2004-2005, NFHS-II 1998-1999, National Sample Survey (NSS) 52(nd) Round 1995-1996, NSS 50(th) Round 1993-1994 we analysed female smoking trend from 1993-2009. Tobacco use among females was monitored for almost two decades focusing on gender, literacy, and state-specific trends among respondents aged >15 years. RESULTS: Smoking use among women has doubled from 1.4% to 2.9% (P < 0.001) during the period 2005-2010. The prevalence of smoking increased with decrease in per capita State Gross Domestic Product and literacy status for both men and women. CONCLUSION: As the overall smoking prevalence grows, female smoking is growing at a faster rate than smoking among males, which is an emerging concern for tobacco control in India and requires the attention of policymakers.

How good is compliance with smoke-free legislation in India? Results of 38 subnational surveys.

BACKGROUND: India has been implementing smoke-free legislation since 2008 prohibiting smoking in public places. This study aimed to assess the level of compliance with smoke-free legislation (defined as the presence of no-smoking signage and the absence of active smoking, smoking aids, cigarette butts/bidi ends and smoking smell) and the role of enforcement systems in Indian jurisdictions. METHODS: This was a cross-sectional, retrospective review of reports and primary data sheets of surveys conducted in 38 selected jurisdictions across India in 2012-2013. RESULTS: Of 20 455 public places (in 38 jurisdictions), 10 377 (51%) demonstrated full compliance with smoke-free law. Educational institutions and healthcare facilities performed well at 65% and 62%, respectively, while eateries and frequently visited other public places (such as bus stands, railway stations, shopping malls, stadia, cinema halls etc.) performed poorly at 37% and 27%, respectively. Absence of no-smoking signage was the largest contributor to non-compliance across all types of public places. Enforcement systems were present in all jurisdictions, but no associations could be demonstrated between these and smoke-free compliance. CONCLUSION: Smoke-free compliance in public places in India was suboptimal and was mainly related to the absence of no-smoking signage. This warrants further pragmatic and innovative ways to improve the situation.

How compliant are tobacco vendors to india's tobacco control legislation on Ban of advertisments at point of sale? A three jurisdictions review.

BACKGROUND: Section 5 of India's tobacco control legislation "Cigarettes and Other Tobacco Products Act (COTPA), 2003"comprehensively prohibits all kinds of tobacco advertisement, promotion and sponsorship (TAPS), but permits advertisments at the point-of-sale (POS) under certain conditions. This provision has been exploited by the tobacco companies to promote their products. OBJECTIVE: To measure compliance with the provisions of Section 5 of Indian tobacco control legislation (COTPA, 2003) at point of sale. MATERIALS AND METHODS: A cross-sectional survey using an observation checklist was conducted in 1860 POS across three jurisdictions (Chennai city, District Vadodara and District Mohali) in India. RESULTS: The most common mode of advertisement of tobacco products was product showcasing (51.1%), followed by dangles (49.6%), stickers (33.8%) and boards (27.1%). More than one fourth of POS were found violating legal provisions for displaying advertisement boards in one or other forms (oversized, extended to full body lenth of POS, displayed brandname/ packshot and promotional messages). Advertisement boards (16.3%) without health warnings were also found and wherever found, more than 90% health warning were not as per the specification in respect to size, font and background color. CONCLUSIONS: Point of sale advertising is aggressively used by the tobacco industry to promote their products. There is an urgent need of effective implementation of a comprehensive ban on tobacco product advertisement, promotion and sponsorship at point of sale.

Effective smoke-free policies in achieving a high level of compliance with smoke-free law: experiences from a district of North India.

BACKGROUND: Compliance survey of smoke-free law is an effective means of measuring progress towards a smoke-free society. They also help policy makers to take action where strengthening measures are required. India has a comprehensive tobacco control law known as Cigarettes and Other Tobacco Products Act (COTPA 2003) which prohibits smoking in public places and requires display of 'No smoking' signages with proper specifications at conspicuous points. However, its implementation and enforcement are still a matter of concern. AIMS AND OBJECTIVES: To ascertain the level of compliance with smoke-free law in public places of a district of North India. METHODOLOGY: A cross sectional study was conducted in the months of November-December 2011 in district SAS Nagar Mohali of North India. The public places including hotels/restaurants/bars/shopping malls, government offices, educational institutions, healthcare facilities and transit stations were surveyed. The study tool was adapted from the guide on 'Assessing compliance with smoke-free law' developed jointly by the Campaign for Tobacco Free Kids, Johns Hopkins Bloomberg School of Public Health and International Union against Tuberculosis and Lung Disease. RESULTS: The overall compliance rate towards section 4 of COTPA was 92.3%. No active smoking was observed in 94.2% of the public places. In 90% of the public places 'No Smoking' signage were displayed as per COTPA. Health and educational institutions had maximum compliance with the smoke-free law while transit sites showed the least compliance. CONCLUSIONS: Compliance to the smoke-free law was high in the study.

Promoting tobacco cessation by integrating 'brief advice' in tuberculosis control programme.

BACKGROUND: There is an enormous health burden caused by the co-prevalence of tuberculosis (TB) and tobacco use in India. This intervention study was undertaken in district Vadodara, Gujarat, India to promote tobacco cessation by integrating 'brief advice' for tobacco cessation in TB patients who were tobacco users and registered for treatment under TB control programme, based on the tested strategies advocated by World Health Organization (WHO) and the International Union against Tuberculosis and Lung Diseases (The Union). MATERIALS AND METHODS: Brief advice for tobacco cessation based on five A's, advocated by the WHO and the UNION was incorporated into the on-going TB Control programme in India in the year 2010. The tools were developed for education, training and capturing data. All the registered TB patients receiving directly observed treatment short-course (DOTS) who used tobacco in any form were offered brief advice during routine interaction for treatment. RESULTS: A total of 46.3% of TB patients, predominantly males (89.6% males and 10.3% females) were current users of tobacco; 39.1% used smokeless tobacco, 35.9% were smokers and 25% were dual users, that is, smoked as well as used smokeless tobacco. At the end of treatment, of the 67.3% patients who were offered brief advice, quit tobacco use, 18.2% re-lapsed while 14.5% were lost to follow-up. CONCLUSION: A significant numbers of TB patients use tobacco with adverse impact on TB control programmes. Our study shows that it is feasible to introduce 'brief advice' strategy as a cost effective intervention for tobacco cessation among TB patients with careful monitoring.

Assessing compliance to smoke-free legislation: results of a sub-national survey in Himachal Pradesh, India.

INTRODUCTION: Exposure to second-hand smoke (SHS) is a serious public health concern. The Indian smoke-free legislation 'Prohibition of Smoking in Public Places Rules, 2008' prohibits smoking in public places, including workplaces. OBJECTIVE: To measure the status of compliance to legal provisions that protects the public against harms of SHS exposure, identifies the potential areas of violations and informs policy makers for strengthening enforcement measures. DESIGN: A cross-sectional survey in 1401 public places across 11 district headquarters in Himachal Pradesh, India, using a compliance guide developed by partners of the Bloomberg initiatives to reduce tobacco use. RESULTS: In 1401 public places across 11 district headquarters, 42.8% public places had signage; in 84.2% public places, no smoking was observed and in 83.7%, there was absence of smoking accessories such as ashtray, matchbox and lighter . Tobacco litter like cigarette butts was absent in 64.7% of the public places. Overall, at the state level, there was more than 80% compliance on at least three of the five indicators. Among all categories of public places, educational institutions and offices demonstrated highest compliance, whereas most frequently visited public places, eateries and accommodation facilities had least compliance. CONCLUSIONS: The compliance to 'Prohibition of Smoking in Public Places Rules, 2008' was variable in various district headquarters of Himachal Pradesh. This study identified the potential areas of violations that need attention from enforcement agencies and policymakers.