Integration of a Tobacco Cessation Program into a Rural Community-Based Maternal and Child Health Program in India: A Stakeholders' Perspective on Task Shifting.

INTRODUCTION: According to the Global Adult Tobacco Survey-2, India, 7.5% of pregnant women are tobacco users with a high prevalence of smokeless tobacco use in rural India. Although pregnant women may receive advice to quit tobacco, lack of knowledge on providing cessation support among healthcare workers results in missed opportunities. Community Health Workers (CHWs) play a significant role in maternal and child health (MCH) programs. Thus, task-shifting for providing cessation support by CHWs was planned and the perceptions and attitudes of concerned stakeholders were explored. AIMS AND METHODS: A pre-implementation qualitative study was conducted in four states of India within existing rural, community-based MCH program settings. Implementation research frameworks were used to develop data collection tools and for inductive and deductive thematic analysis. In-depth interviews were conducted with stakeholders (n = 28) like coordinators, pregnant women, and village functionaries of the government health system. Four focus groups were conducted with female CHWs (n = 24). RESULTS: Stakeholders intended to adopt the intervention as objectives of the cessation intervention were aligned with the aims of the MCH program. CHWs related to their role in task-shifting and understood the context for implementing the intervention within the MCH program. Pregnant women expressed openness to receiving cessation support from CHWs acting as a facilitator for task-shifting. Barriers anticipated were the additional workload and time required for CHWs to implement the intervention. CONCLUSIONS: Task-shifting to female CHWs for screening tobacco users, providing brief advice and cessation support within the MCH program was perceived to be acceptable, adoptable, and feasible. IMPLICATIONS: The study builds insight into the process of developing a grounded approach for the integration of tobacco cessation intervention into a rural, community-based antenatal care setting by task shifting to female CHWs for providing cessation support to pregnant women. The study fills gaps in the literature related to establishing tobacco cessation interventions for pregnant women. The delineated efforts in integration of the intervention and task shifting can be replicated in other developing countries, especially in rural communities within South Asian and Southeast Asian regions having cultural practices, community-based healthcare structures, and tobacco consumption patterns that are comparable to India.

Why do Adolescents Initiate and Continue Using Tobacco and Areca Nut?: A Qualitative Study Tracing Pathways of Use Among School-Going Adolescents in Mumbai, India.

BACKGROUND: Tobacco and areca-nut use among adolescents has been reported from different parts of India. Multiple factors influence initiation of tobacco use among adolescents. Initiation of one product gradually extends to multiple products. Studies on initiation lack documentation of the pathways and experiences post-initiation, which is required to holistically understand behavior patterns of adolescents for planning timely intervention. This study was conducted to trace pathways and identify factors influencing the initiation and continuation of tobacco and areca-nut among adolescents. METHODS: In this two-staged study, we conducted 14 focus group discussions (FGDs) with 166 adolescents studying in grades 7-9 (11-18 years) from six municipal schools in Mumbai, India. They had self-reported areca-nut or smoked or smokeless tobacco (SLT) use. Pathways of initiation were traced through in-depth interviews for 60 adolescents. RESULTS: Four multi-linear pathways of use were identified: (1) areca-nut only, (2) areca-nut to tobacco, (3) initiation with SLT, and (4) initiation with smoking. Raw or sweetened areca-nut, betel leaf, gutka, masheri, mawa, hookah, cigarette, bidi, and e-cigarettes were products reported to be used. Curiosity, easy access to tobacco products and normalization of tobacco use influenced initiation. Areca-nut acted as a precursor to tobacco use. CONCLUSION: Tracing pathways in tobacco use helped to understand reasons for initiation, influences in continuation of use, and experiences of significance to the adolescents. Experiences of adolescents play a critical role in shaping the pathways of tobacco use. Understanding the pathways and influencers will further help to build effective health promotion communication, policies for sale to minors, and school-based cessation interventions. IMPLICATIONS: Findings of the study provide an insight into unknown areas of information regarding products used by adolescents, their patterns of consumption, perceptions, and their pathways of initiation and continuation of primary and secondary products. This will help in developing specific public health awareness messages, policies regarding packaging and sale of areca-nut to children and interventions targeted for the adolescents and their specific products of use not just in India but for the South-East Asia region as areca-nut and tobacco use among adolescents is common in the region. The exercise of tracing the pathways provides basis for cessation counseling among adolescents.

Adapting and Evaluating a Brief Advice Tobacco Cessation Intervention in High-reach, Low-resource Settings in India: Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: About 1.35 million deaths annually are attributed to tobacco use in India. The main challenge, given the magnitude of tobacco use and limited resources, is delivering cessation support at scale, low cost, and through a coordinated cross-system effort; one such example being brief advice interventions. However, highly credentialed staff to identify and counsel tobacco users are scarce. Task-shifting is an important opportunity for scaling these interventions. OBJECTIVE: The LifeFirst SWASTH (Supporting Wellbeing among Adults by Stopping Tobacco Habit) program-adapted from the LifeFirst program (developed by the Narotam Sekhsaria Foundation, Mumbai, India)-is a tobacco cessation program focusing on lower-socioeconomic status patients in Mumbai receiving private health care. This parallel-arm, cluster randomized controlled trial investigates whether the LifeFirst SWASTH program increases tobacco cessation rates in low-resource, high-reach health care settings in Mumbai. METHODS: This study will target tuberculosis-specific nongovernmental organizations (NGOs), dental clinics, and NGOs implementing general health programs serving lower-socioeconomic status patients. Intervention arm patients will receive a pamphlet explaining tobacco's harmful effects. Practitioners will be trained to deliver brief cessation advice, and interested patients will be referred to a Narotam Sekhsaria Foundation counselor for free telephone counseling for 6 months. Control arm patients will receive the same pamphlet but not brief advice or counseling. Practitioners will have a customized mobile app to facilitate intervention delivery. Practitioners will also have access to a peer network through WhatsApp. The primary outcome is a 30-day point prevalence abstinence from tobacco. Secondary outcomes for patients and practitioners relate to intervention implementation. RESULTS: The study was funded in June 2020. Due to the COVID-19 pandemic, the study experienced some delays, and practitioner recruitment commenced in November 2023. As of July 2024, all practitioners have been recruited, and practitioner recruitment and training are complete. Furthermore, 36% (1687/4688) of patients have been recruited. CONCLUSIONS: It is hypothesized that those patients who participated in the LifeFirst SWASTH program will be more likely to have been abstinent from tobacco for 30 consecutive days by the end of 6 months or at least decreased their tobacco use. LifeFirst SWASTH, if found to be effective in terms of cessation outcomes and implementation, has the potential to be scaled to other settings in India and other low- and middle-income countries. The study will be conducted in low-resource settings and will reach many patients, which will increase the impact if scaled. It will use task-shifting and an app that can be tailored to different settings, also enabling scalability. Findings will build the literature for translating evidence-based interventions from high-income countries to low- and middle-income countries and from high- to low-resource settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT05234983; https://clinicaltrials.gov/study/NCT05234983. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/57236.

Adolescents and E-cigarettes in India: A Qualitative Study of Perceptions and Practices.

PURPOSE: Global Youth Tobacco Survey-4, India conducted in 2019 showed 'ever use' of e-cigarettes among adolescents to be 2.8%. However, there is dearth of qualitative data on adolescent use of e-cigarettes in the country. This study was conducted to explore and gain better understanding on adolescents' perceptions and practices about e-cigarette use. METHODS: In-depth interviews were conducted with 24 adolescents who self-reported use of e-cigarettes. The participants were recruited from ten municipal schools of Mumbai, India that cater to students from lower socio-economic background. Participants were from 7th to 9th grades, and aged 11-16 years. Data from in-depth interviews were analyzed using inductive thematic analysis. RESULTS: Adolescents referred to 'e-cigarette' as 'pen-hookah.'  E-cigarettes were perceived as relatively harmless compared to regular hookahs and conventional cigarettes. Initiation was influenced by a friend, peer, or sibling. A variety of flavors, the after-taste, the ability to perform playful tricks with smoke, and fun-time spent with friends were cited as reasons for continued use. Social media influenced both initiation and continuation. Most adolescents' regular use was with a group of friends; the device was shared with or obtained from friends or siblings. Adolescents were unclear about the presence of nicotine in refill liquids and the harmful health effects. CONCLUSION: Increasing awareness among adolescents about the harms of e-cigarettes is urgently required through comprehensive tobacco-prevention programs. More research is needed to examine the role of flavors in increasing acceptability of e-cigarettes and how it affects perceived harmfulness of tobacco products.

Factors Influencing Implementation of a Workplace Tobacco Cessation Intervention in India: A Qualitative Exploration.

BACKGROUND: Tobacco use is projected to cause more than 8 million deaths annually worldwide by 2030 and is currently linked to 1 million annual deaths in India. Very few workplaces provide tobacco cessation as a part of occupational health in India. In this study, we examined promoters and barriers to implementing an evidence-based tobacco cessation program in a workplace setting in India. METHODS: In-depth interviews were conducted with all facilitators (two program coordinators and four counselors) of a workplace tobacco cessation intervention covering implementation efforts in five organizations, including three manufacturing units and two corporate settings. FINDINGS: The identified promoters for implementation of the program were as follows: (a) workplaces that provided access to many individuals, (b) high prevalence of tobacco use that made the intervention relevant, (c) core components (awareness sessions, face-to-face counseling and 6-months follow-up) that were adaptable, (d) engagement of the management in planning and execution of the intervention, (e) employees' support to each other to quit tobacco, (f) training the medical unit within the workplace to provide limited advice, and (g) efforts to advocate tobacco-free policies within the setting. Barriers centered around (a) lack of ownership from the workplace management, (b) schedules of counselors not matching with employees, (c) nonavailability of employees because of workload, and (d) lack of privacy for counseling. CONCLUSION/IMPLICATIONS FOR PRACTICE: This study provided practical insights into the aspects of planning, engaging, executing and the process of implementation of a tobacco cessation intervention in a workplace setting. It provided guidance for an intervention within occupational health units in similar settings.