Integration of tobacco cessation and tuberculosis management by NGOs in urban India: a mixed-methods study

Incorporating neglected non-communicable diseases into the national health program-A review

Poor nations are already facing the heat of double burden of communicable and non-communicable diseases (NCDs), often known as chronic illnesses, which are characterized by a protracted course and are multifactorial in causation. In addition to this, neglected non-communicable diseases (NNCD) in the form of gout, sickle cell disease, accidents and many more are likely to be one of the biggest public health challenges soon. Nearly three-quarters (31.4 million) of all NCD-related fatalities occur in developing nations. In terms of morbidity and mortality, the "BIG FOUR" NCDs-diabetes, cancer, chronic respiratory diseases, and cardiovascular diseases-are widely acknowledged as the main contributors to global health loss. However, other NCDs account for 55% of the global burden of NCDs and are frequently neglected in terms of premature death, increased Disability Adjusted Life Years (DALY), and decreased Quality-Adjusted Life Year (QALY). We have briefly discussed the disease burden of a few significant, yet neglected NCDs in this paper.

Feasibility of tobacco cessation intervention at non-communicable diseases clinics: A qualitative study from a North Indian State

BACKGROUND

One of the 'best buys' for preventing Non-Communicable Diseases (NCDs) is to reduce tobacco use. The synergy scenario of NCDs with tobacco use necessitates converging interventions under two vertical programs to address co-morbidities and other collateral benefits. The current study was undertaken with an objective to ascertain the feasibility of integrating a tobacco cessation package into NCD clinics, especially from the perspective of healthcare providers, along with potential drivers and barriers impacting its implementation.

METHODS

A disease-specific, patient-centric, and culturally-sensitive tobacco cessation intervention package was developed (published elsewhere) for the Health Care Providers (HCPs) and patients attending the NCD clinics of Punjab, India. The HCPs received training on how to deliver the package. Between January to April 2020, we conducted a total of 45 in-depth interviews [medical officers (n = 12), counselors (n = 13), program officers (n = 10), and nurses (n = 10)] within the trained cohort across various districts of Punjab until no new information emerged. The interview data wereanalyzed deductively based on six focus areas concerning feasibility studies (acceptability, demand, adaptation, practicality, implementation, and integration) using the 7- step Framework method of qualitative analysis and put under preset themes.

RESULTS

The respondent's Mean ± SD age was 39.2± 9.2 years, and years of service in the current position were 5.5 ± 3.7 years. The study participants emphasized the role of HCPs in cessation support (theme: appropriateness and suitability), use of motivational interviewing, 5A's & 5R's protocol learned during the training & tailoring the cessation advice (theme: actual use of intervention activities); preferred face-to-face counseling using regional images, metaphors, language, case vignettes in package (theme: the extent of delivery to intended participants). Besides, they also highlighted various roadblocks and facilitators during implementation at four levels, viz. HCP, facility, patient, and community (theme: barriers and favorable factors); suggested various adaptations to keep the HCPs motivated along with the development of integrated standard operating procedures (SOPs), digitalization of the intervention package, involvement of grassroots level workers (theme: modifications required); the establishment of an inter-programmatic referral system, and a strong politico-administrative commitment (theme: integrational perspectives).

CONCLUSION

The findings suggest that implementing a tobacco cessation intervention package through the existing NCD clinics is feasible, and it forges synergies to obtain mutual benefits. Therefore, an integrated approach at the primary & secondary levels needs to be adopted to strengthen the existing healthcare systems.

Health workers' perceptions on where and how to integrate tobacco use cessation services into tuberculosis treatment; a qualitative exploratory study in Uganda

Background

Tobacco use is associated with exacerbation of tuberculosis (TB) and poor TB treatment outcomes. Integrating tobacco use cessation within TB treatment could improve healing among TB patients. The aim was to explore perceptions of health workers on where and how to integrate tobacco use cessation services into TB treatment programs in Uganda.

Methods

Between March and April 2019, nine focus group discussions (FGDs) and eight key informant interviews were conducted among health workers attending to patients with tuberculosis on a routine basis in nine facilities from the central, eastern, northern and western parts of Uganda. These facilities were high volume health centres, general hospitals and referral hospitals. The FGD sessions and interviews were tape recorded, transcribed verbatim and analysed using content analysis and the Chronic Care Model as a framework.

Results

Respondents highlighted that just like TB prevention starts in the community and TB treatment goes beyond health facility stay, integration of tobacco cessation should be started when people are still healthy and extended to those who have been healed as they go back to communities. There was need to coordinate with different organizations like peers, the media and TB treatment supporters. TB patients needed regular follow up and self-management support for both TB and tobacco cessation. Patients needed to be empowered to know their condition and their caretakers needed to be involved. Effective referral between primary health facilities and specialist facilities was needed. Clinical information systems should identify relevant people for proactive care and follow up. In order to achieve effective integration, the health system needed to be strengthened especially health worker training and provision of more space in some of the facilities.

Conclusions

Tobacco cessation activities should be provided in a continuum starting in the community before the TB patients get to hospital, during the patients’ interface with hospital treatment and be given in the community after TB patients have been discharged. This requires collaboration between those who carry out health education in communities, the TB treatment supporters and the health workers who treat patients in health facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11502-4.

A study to evaluate availability of tobacco cessation services in Bengaluru, India

BACKGROUND

In India, 28.6 % of the population use tobacco products.

OBJECTIVE AND METHODS

To evaluate the availability of tobacco cessation services in 101 hospitals in Bengaluru.

RESULTS

Only 4 out of 101 hospitals evaluated had a separate Tobacco Cessation Clinic; 24 % provided minimal services for people with addiction related problems; 28 % had at least one resident counsellor; additional 10 % had a visiting counsellor. All four of them provided counselling and medication.

CONCLUSIONS

Availability of tobacco cessation services in Bengaluru is minimal. It is important to upscale availability of cessation services both for tobacco and other substance use.

Effects of cigarette smoke on the administration of isoniazid and rifampicin to macrophages infected with Mycobacterium tuberculosis

BACKGROUND

Smoking is a cause behind many diseases, including tuberculosis, and it is a risk factor for tuberculosis infection and mortality. Moreover, smoking is associated with a poor tuberculosis treatment outcome.

OBJECTIVES

In this study, we focus on the effects of cigarette smoke on an infected cell culture treated with anti-tuberculosis drugs.

MATERIALS AND METHODS

Cytotoxicity on THP-1, J774A.1 and MH-S cell lines and growth of Mycobacterium tuberculosis exposed to a reference or a commercial cigarette was evaluated. THP-1 cell line was exposed to cigarette smoke, infected with Mycobacterium tuberculosis and treated with anti-tuberculosis drugs. Apoptosis and death cell were also tested on M. bovis BCG infected cells. Minimal inhibitory concentrations of anti-tuberculosis drugs were analyzed.

RESULTS

All cells lines showed viability values higher than 80% when exposed to cigarette smoke extract. However, THP-1 cell line infected with M. bovis BCG and exposed to Marlboro cigarette smoke showed up to a 54% reduction of apoptotic cells than cells unexposed to smoke. M. tuberculosis exposed to Marlboro cigarette smoke for 11 days had an optical density 16% lower than unexposed bacteria. When cells were infected with M. tuberculosis, the intracellular recovery of CFUs showed up to a 0.66 log reduction in cells exposed to cigarette smoke extract because of a potential impairment in the phagocytosis. Macrophages treated with drugs showed up to a 2.55 log reduction in the intracellular load burden compared with non-treated ones. Despite poor treatment outcome on TB smoker patients, minimal inhibitory concentration of rifampicin increased only 2-fold in M. tuberculosis exposed to cigarette smoke.

CONCLUSION

Smoking interferes with tuberculosis treatment impairing the immunity of the host.

Tobacco use and nicotine dependence among newly diagnosed pulmonary tuberculosis patients in Ballabgarh tuberculosis unit, Haryana

Introduction:

This study was conducted to estimate the burden of tobacco use and nicotine dependence among newly diagnosed pulmonary tuberculosis patients to help inform effective implementation of tobacco cessation strategies among tuberculosis patients to improve treatment outcomes.

Materials and Methods:

This was a cross-sectional study conducted among 211 consecutive newly diagnosed pulmonary tuberculosis patients between July 2018 till January 2019 at Ballabgarh tuberculosis unit (TU) in Faridabad district of Haryana, India. All participants were administered a pre-tested questionnaire to assess tobacco use and the Fagerstrom test for nicotine dependence (FTND) to assess nicotine dependence. Current tobacco users were defined as those who smoked in the past 7 days. Nicotine dependence was classified as low, moderate, or high for the FTND score of 0-3, 4-6, and 7-10, respectively.

Results:

Majority of the participants (71.1%) were male, aged 26–50 years (45.5%), and married (65.4%). Fifty (23.7%, CI: 18.0–29.4) participants were currently using tobacco; 29 (13.7%, CI: 9.1–18.4) reported smoking tobacco while 23 (10.9%, CI: 6.7–15.1) reported using smokeless tobacco. In the last month, the proportion of patients who attempted to quit smoking and smokeless tobacco was 31% and 26.1%, respectively. 86.2% of the smokers and 69.6% smokeless tobacco users reported moderate to a high level of nicotine dependence.

Conclusion:

High prevalence of tobacco use, a higher level of nicotine dependence and inability to quit despite an attempt among a large number of tuberculosis patients, necessitates the inclusion of routine tobacco cessation advice and nicotine replacement therapy in tuberculosis care.

A narrative review of facilitators and barriers to smoking cessation and tobacco-dependence treatment in patients with tuberculosis in low- and middle-income countries

INTRODUCTION

Smoking is a substantial cause of premature death in patients with tuberculosis (TB), particularly in low- and middle-income countries (LMICs) with high TB prevalence. The importance of incorporating smoking cessation and tobacco-dependence treatment (TDT) into TB care is highlighted in the most recent TB care guidelines. Our objective is to identify the likely key facilitators of and barriers to smoking cessation for patients with TB in LMICs.

METHODS

A systematic search of studies with English-language abstracts published between January 2000 and May 2019 was undertaken in the EMBASE, MEDLINE, EBSCO, ProQuest, Cochrane and Web of Science databases. Data extraction was followed by study-quality assessment and a descriptive and narrative synthesis of findings.

RESULTS

Out of 267 potentially eligible articles, 36 satisfied the inclusion criteria. Methodological quality of non-randomized studies was variable; low risk of bias was assessed in most randomized controlled studies. Identified facilitators included brief, repeated interventions, personalized behavioural counselling, offer of pharmacotherapy, smoke-free homes and a reasonable awareness of smoking-associated risks. Barriers included craving for a cigarette, low level of education, unemployment, easy access to tobacco in the hospital setting, lack of knowledge about quit strategies, and limited space and privacy at the clinics. Findings show that the risk of smoking relapse could be reduced through consistent follow-up upon completion of TB therapy and receiving a disease-specific smoking cessation message.

CONCLUSIONS

Raising awareness of smoking-related health risks in patients with TB and implementing guideline-recommended standardized TDT within national TB programmes could increase smoking cessation rates in this high-risk population.

Outcomes of a smoking cessation intervention at follow-up after 5 years among tuberculosis patients in China

INTRODUCTION

Smoking cessation should be part of tuberculosis (TB) treatment, but a cessation service is not available as part of a routine TB service in most low- and middle-income countries. WHO and The International Union Against Tuberculosis and Lung Disease (The Union) issued a guideline and China implemented a pilot project 5 years ago. This study aimed to determine changes in smoking status among TB patients at 5 years after completion of anti-TB treatment to observe long-term outcome of a smoking cessation project whose baseline characteristics were associated with a relapse of smoking behavior.

METHODS

A prospective longitudinal study was conducted 5 years after completion of anti-TB treatment to assess changes in patient smoking status against individual baseline data that were entered into a database at the time of TB registration. The patients were tracked by trained village doctors and validated by township health staff. Their smoking status was assessed and entered into the database and analysed.

RESULTS

Of the 800 TB patients registered at baseline, 650 (81.2%) were tracked. Ninety-one (11.4%) patients died and 59 (7.4%) were lost to follow-up. The rates of remaining non-smoking after 5 years were 82.0%, 63.0%, 49.6%, 43.5% and 30.0%, respectively for non-smokers, ex-smokers, current smokers who received cessation intervention, recent quitters, and current smokers not on a cessation intervention. The odds of smoking relapse were significantly higher for those aged ≥65 years (p=0.003) and registered in Xingguo County (p=0.025).

CONCLUSIONS

Findings from this study confirmed that non-smokers, ex-smokers and current smokers who received cessation intervention at baseline maintained higher non-smoking rates compared with those who did not receive the intervention. To prevent relapse, intensive cessation support should be given to TB patients aged ≥65 years. TB programme managers need to ensure integration and provision of smoking cessation advice and smoke-free policy in routine TB services.

Health worker and patient views on implementation of smoking cessation in routine tuberculosis care

Smoking worsens tuberculosis (TB) outcomes. Persons with TB who smoke can benefit from smoking cessation. We report findings of a multi-country qualitative process evaluation assessing barriers and facilitators to implementation of smoking cessation behaviour support in TB clinics in Bangladesh and Pakistan. We conducted semi-structured qualitative interviews at five case study clinics with 35 patients and 8 health workers over a period of 11 months (2017-2018) at different time points during the intervention implementation phase. Interviews were conducted by trained researchers in the native languages, audio-recorded, transcribed into English and analysed using a combined deductive-inductive approach guided by the Consolidated Framework for Implementation Research and Theoretical Domains Framework. All patients report willingness to quit smoking and recent quit attempts. Individuals' main motivations to quit are their health and the need to financially provide for a family. Behavioural regulation such as avoiding exposure to cigarettes and social influences from friends, family and colleagues are main themes of the interviews. Most male patients do not feel shy admitting to smoking, for the sole female patient interviewee stigma was an issue. Health workers report structural characteristics such as high workload and limited time per patient as primary barriers to offering behavioural support. Self-efficacy to discuss tobacco use with women varies by health worker. Systemic barriers to implementation such as staff workload and socio-cultural barriers to cessation like gender relations, stigma or social influences should be dealt with creatively to optimize the behaviour support for sustainability and scale-up.