Smoking cessation intervention in rural kerala, India: findings of a randomised controlled trial

A Comparative Evaluation of Hearing and Psychological Distress in Smokers and Non-smokers: A Cross-Sectional Study

Background Smoking is a major global health concern, linked to numerous medical conditions, including hearing loss and psychological distress. Research suggests that smokers have a significantly higher risk of hearing impairment than non-smokers, possibly due to oxidative stress and vascular damage. Smoking is also associated with psychological effects such as depression, anxiety, and stress, though the relationship is complex. This study aims to compare the prevalence and degree of hearing loss between smokers and non-smokers using pure tone audiometry, and to evaluate the levels of psychological distress (depression, anxiety, and stress) in both groups using the Depression, Anxiety, and Stress Scale-21 (DASS-21) score. It also aims to assess the relationship between smoking frequency and duration with hearing loss and psychological distress. Materials and methods A prospective cross-sectional study was conducted at the ENT Outpatient Department of AIIMS Bhopal over three months. A total of 100 male participants aged 18-55 years were divided into two groups: 50 smokers (current or past) and 50 age- and gender-matched non-smokers. Hearing was evaluated through pure tone audiometry, tuning fork tests, and otoscopy. Psychological distress was assessed using the DASS-21, while nicotine dependence was measured using the Fagerström Test for Nicotine Dependence. Data were analyzed using IBM SPSS Statistics for Windows, Version 21 (Released 2012; IBM Corp., Armonk, NY, USA), applying the Chi-square test, with a significance level of p < 0.05. Results Hearing loss was significantly more prevalent in smokers (18, or 36%) than in non-smokers (7, or 14%) (p = 0.017). However, no statistically significant correlation was found between the severity of hearing loss and the frequency or duration of smoking. Psychological distress was observed in both groups, with depression (10 (20%) vs. 6 (12%)), anxiety (18 (36%) vs. 23 (46%)), and stress (2 (4%) vs. 0%) being more common in smokers, though these differences were not statistically significant. Nicotine dependence varied, with 22 (44%) of smokers having very low dependence, while two (4%) had very high dependence. Higher cigarette consumption was significantly associated with greater nicotine dependence (p < 0.001). Conclusion Smoking is associated with a significantly higher risk of hearing loss, reinforcing the need for awareness and early screening among smokers. However, no strong link was found between smoking and psychological distress in this study. Given the limitations of sample size and study duration, further research is needed to explore the long-term effects of smoking on both hearing and mental health. Smoking cessation programs should incorporate regular hearing assessments and psychological support for better overall well-being.

Behavioral Interventions for Tobacco Cessation in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis

INTRODUCTION

An estimated 78% of the total deaths attributable to smoking tobacco use occurred in low- and middle-income countries (LMICs) in 2019. In addition, smokeless tobacco increases the risk of all-cause mortality, all cancers, including upper aero-digestive tract cancer, stomach cancer, ischemic heart disease and stroke, with 88% of the mortality burden being borne by the South-East Asian region. Evidence-based interventions from high-income countries (HICs) are not easily transferable to LMICs, as patterns of tobacco use, health beliefs associated with tobacco use, and awareness of specific health risks vary substantially.

METHODS

We synthesized the effectiveness of behavioral interventions for tobacco cessation in LMICs through a systematic review and meta-analysis. Interventional studies which delivered individual behavioral intervention and assessed abstinence from tobacco use were included. We examined the pooled intervention effect at 6 months postintervention follow-up.

RESULTS

For continuous abstinence at 6 months, the intervention was superior to the active comparator (RR 2.32; 95% CI 1.78 to 3.02) and usual care (RR 4.39; 95% CI 2.38 to 8.11). For point prevalence abstinence at six months, the intervention was superior to the active comparator (RR 1.76; 95% CI 1.28 to 2.44), and usual care (RR 2.37; 95% CI 1.47 to 3.81). The statistical heterogeneity was substantial to considerable for all comparisons. Only six studies had an overall low risk of bias. Publication bias was observed for all comparisons except for 6-month continuous outcomes.

CONCLUSIONS

Implementation research is needed to understand factors for programme sustainability and equity of the impact of behavioral interventions in reducing tobacco use in LMICs.

IMPLICATIONS

Our review is an important step towards understanding the effectiveness of behavior interventions for tobacco cessation suited for LMICs and which are responsive to the contextual needs of such countries.

Designing Gender-Responsive Health Promotion Programs for Men: A Scoping Review

Over the past decade, there has been an increased emphasis on tailoring men's health promotion programs. To optimize outcomes, participatory action research that involves and elicits feedback from end-users has been highlighted as important to creating gender-responsive interventions. In this scoping review, we examine (a) how participatory action research has been used to design health promotion interventions for men and (b) what constitutes a gender-responsive intervention design. Following a comprehensive search, 53 articles were included in the review, reporting on 35 men's health promotion programs. Our findings suggest that participatory action methods harness varying degrees of end-user involvement, with a large majority limited to post-intervention evaluations rather than co-design and consumer collaboration. In addition, there are inconsistencies for applying gender-responsive approaches within programs, particularly regarding how interventions are targeted, tailored, and promoted to men. We conclude that participatory action research methods translate to varying degrees of gender responsiveness in men's health promotion programs. That said, involving end-users at various stages of intervention design, implementation, and evaluation may increase the likelihood that programs are more attuned to masculinities and better engage participants in promoting healthy behavior change. Efforts to advance gender-responsive designs can benefit from inductively deriving and incorporating men's masculine values.

A systematic review of task-sharing interventions for substance use and substance use disorder in low- and middle-income countries

INTRODUCTION

Substance use (SU) and substance use disorders (SUDs) are associated with adverse health and socio-economic consequences. Due to the shortage of specialist healthcare providers, people with SUDs in low- and middle-income countries (LMICs) have limited access to adequate treatment. Task-sharing with non-specialist health workers (NSHWs) has the potential to improve treatment accessibility for these individuals. This review synthesizes the evidence on the effectiveness of task-sharing interventions for SU and SUDs outcomes in LMICs.

METHODS

PsycINFO, MEDLINE, EMBASE, Global Health and CENTRAL databases were searched to identify eligible studies. Quality assessment was conducted using the Cochrane risk of bias (RoB2) and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool. A narrative synthesis was undertaken to analyze the data.

RESULTS

Nineteen RCTs and two quasi-experimental studies met the eligibility criteria, and the majority had a low risk of bias rating. NSHW-delivered interventions significantly impact SU and SUDs outcomes, particularly in reducing alcohol and other substance use, cessation of smoking, and use of opioids. Multiple sessions delivered via face-to-face interactions was the most utilized method for intervention delivery. There were variations in terms of components of the intervention across studies; however, the most common intervention strategies used were a) personalized feedback, b) psychoeducation, c) motivational enhancement, d) problem-solving, and e) coping skills.

CONCLUSION

Our review highlights the growing interests in leveraging NSHWs to provide interventions to people with SU and SUDs in LMICs where access to treatment is limited. However, additional research is necessary to explore the effectiveness of these interventions and identify the specific active components linked to enhancing treatment outcomes on a broader scale.

Behavioural interventions for tobacco cessation in India: A systematic review and meta-analysis

Tobacco consumption is an area of public health concern in India. One of the unmet needs of many low-resource countries is to provide cost-effective tobacco cessation interventions for reducing tobacco-related mortality. This article reviews studies on non-pharmacological interventions for tobacco cessation in India. A systematic review by PICO (population, intervention, comparison, outcome) of behavioural intervention-based tobacco cessation studies that met the inclusion criteria, with a minimum 1-month follow-up, reporting outcomes in terms of frequencies or percentages published between 2010 and 2020 was performed. Following the review stages, 16 studies comprising 9,613 participants were included in the review. A pooled estimate was derived using both fixed-effects and random-effects models. The intervention showed good overall efficacy for any tobacco user (relative risk [RR] = 1.73 [95% confidence interval [CI]: 1.58-1.90) (fixed-effect model)] and (RR = 2.02 [95% CI: 1.64-2.48] [random-effects model]). Behavioural intervention studies targeted towards only smokers (RR of 1.81 [95% CI: 1.55-2.11] and 1.96 [95% CI: 1.52-2.53]) and combined smoking and smokeless tobacco users (RR of 1.69 [95% CI: 1.50-1.90] and 2.12 [95% CI: 1.49-3.01]) were equally efficacious. The review provides the effectiveness of behavioural interventions in quitting tobacco among users of both smoking and smokeless forms of tobacco. The review findings are of particular significance to inform health policy decisions on the integration of cost-effective brief behavioural intervention into existing health care services in resource-constrained countries.

Effectiveness of Medical Student Counseling for Hospitalized Patients Addicted to Tobacco (MS-CHAT): a Randomized Controlled Trial

BACKGROUND

Low-middle-income countries face an enormous burden of tobacco-related illnesses. Counseling for tobacco cessation increases the chance of achieving quit outcomes, yet it remains underutilized in healthcare settings.

OBJECTIVE

We tested the hypothesis that utilizing trained medical students to counsel hospitalized patients who use tobacco will lead to an increase in patient quit rates, while also improving medical student knowledge regarding smoking cessation counseling.

DESIGN

Investigator-initiated, two-armed, multicenter randomized controlled trial conducted in three medical schools in India.

PARTICIPANTS

Eligibility criteria included age 18-70 years, active admission to the hospital, and current smoking.

INTERVENTION

A medical student-guided smoking cessation program, initiated in hospitalized patients and continued for 2 months after discharge.

MAIN MEASURES

The primary outcome was self-reported 7-day point prevalence of smoking cessation at 6 months. Changes in medical student knowledge were assessed using a pre- and post-questionnaire delivered prior to and 12 months after training.

KEY RESULTS

Among 688 patients randomized across three medical schools, 343 were assigned to the intervention group and 345 to the control group. After 6 months of follow up, the primary outcome occurred in 188 patients (54.8%) in the intervention group, and 145 patients (42.0%) in the control group (absolute difference, 12.8%; relative risk, 1.67; 95% confidence interval, 1.24-2.26; p < 0.001). Among 70 medical students for whom data was available, knowledge increased from a mean score of 14.8 (± 0.8) (out of a maximum score of 25) at baseline to a score of 18.1 (± 0.8) at 12 months, an absolute mean difference of 3.3 (95% CI, 2.3-4.3; p < 0.001).

CONCLUSIONS

Medical students can be trained to effectively provide smoking cessation counseling to hospitalized patients. Incorporating this program into the medical curriculum can provide experiential training to medical students while improving patient quit rates.

TRIAL REGISTRATION

URL: http://www.

CLINICALTRIALS

gov . Unique identifier: NCT03521466.

Comparative evaluation of the efficacy of nicotine chewing gum and nicotine patches as nicotine replacement therapy using salivary cotinine levels as a biochemical validation measure

Background

Nicotine replacement therapy (NRT) and habit cessation counseling are considered the mainstay treatment for high nicotine dependence smokers. However, adherence to NRT is very poor. Among the NRTs, nicotine gums and nicotine patches are the most widely available. This study mainly evaluates the efficacy of nicotine gum and nicotine patches as NRT using salivary cotinine levels as a biochemical validation measure.

Materials and Methods

A cross-sectional study was conducted on 72 known smokers who were willing to receive nicotine replacement therapy for cessation of smoking habits. The sample was divided into two groups: Group 1 tobacco smokers were offered nicotine chewing gum, and group 2 tobacco smokers were offered nicotine patches. Both groups received treatment for 12 weeks. At baseline and at the end of the trial period, the saliva samples were analyzed for cotinine levels using an enzyme-linked immunosorbent assay (ELISA). The severity of smoking was assessed using the Fagerstrom Test for Nicotine Dependence (FTND).

Results

The quit rate was higher in the nicotine patch group compared with the nicotine gum group. On comparison of week one vs week twelve in the nicotine group nicotine gum group showed (CI: 18.10 to 13.83) and in the patch group (CI: 7.754 to 6.56) with P < 0.001. The pre- and post-cotinine estimation was significantly reduced for nicotine patches compared with nicotine gums, and patient compliance also yielded better results for nicotine patches.

Conclusion

This study depicts that nicotine patches were better adhered to in comparison with nicotine gums, and salivary cotinine level is an effective biochemical validation measure.

Self-efficacy in predicting smoking cessation: A prospective study in Italy

INTRODUCTION

Predicting the success of smoking cessation might be crucial to guide towards the treatment of smoking dependence in a clinical setting. We analyzed the potential determinants of successful smoking cessation with a specific focus on self-efficacy in predicting quitting smoking.

METHODS

All consecutive smokers (n=478; 224 men and 254 women) attending the Careggi University Hospital Smoking Cessation Service in Florence (Italy) in 2018-2019 provided information on self-efficacy in predicting smoking cessation, using a 1-10 rating scale during their first visit. Patients were followed up for success in quitting smoking at 3, 6 and 12 months, validated through CO exhaled measurement. To evaluate the association between self-efficacy and the probability of success, we estimated multivariable relative risks (RRs) and corresponding 95% confidence intervals (CIs) through log-binomial models for longitudinal data.

RESULTS

Overall, 47.9% of smokers succeeded in their attempt to quit at 3 months, 40.2% at 6 months, and 33.9% at 12 months. Compared to low self-efficacy (rating scale 1-5), the RR of success in quitting smoking was 1.40 (95% CI: 1.06-1.85) for intermediate self-efficacy (scale 6-7) and 1.64 (95% CI: 1.28-2.12) for high self-efficacy (scale 8-10).

CONCLUSIONS

Self-efficacy is an independent determinant of smoking cessation. We recommend to systematically collect self-efficacy, together with other relevant variables, to predict successful smoking cessation. Moreover, strategies to develop and maintain high levels of self-efficacy are essential to increase quit success and improve treatment.

The effectiveness of smoking cessation interventions in rural and remote populations: Systematic review and meta-analyses

BACKGROUND

Rural and remote residents are more likely to smoke tobacco than those in major cities. However, they may experience unique systemic, provider, and individual barriers to accessing smoking cessation treatments, including distance and limited resources. Understanding the effectiveness of smoking cessation interventions in this population is important due to higher smoking-related disease burden and death compared to those in major cities.

METHODS

Medline, EMBASE, Scopus, PsychINFO, and Cochrane Library were searched until 19-02/2021. Inclusion criteria were randomised controlled trials (RCTs), cluster RCTs, randomised trials, or cluster randomised trials investigating behavioural interventions and pharmacotherapies for smoking cessation in rural and remote populations compared with a control or another smoking cessation treatment; and published in English. Given there is no internationally-standardised rurality index, definitions of 'rural' and 'remote' used by authors of studies were applied to reflect their country. Exclusion criteria were studies of non-combustible smoking cessation; and studies with urban participants in the sample. Two reviewers independently screened records for eligibility, extracted data from studies utilising a modified Cochrane Effective Practice and Organisation of Care Group form, and rated methodological quality using the Quality Assessment Tool for Quantitative Studies.

RESULTS

Sixteen studies were included. Meta-analysis revealed a statistically significant treatment effect of individual face-to-face counselling on smoking cessation (RR 2.35, 95% CI 1.16-4.76, I²=0%) in rural and remote populations. There was no statistically significant treatment effect for nicotine replacement therapy (RR 2.97, 95% CI 0.84-10.53, I²=47%), telephone-counselling (RR 1.69, 95% CI 0.56-5.06, I²=62%), and community-based multiple-interventions (RR:1.57, 95% CI 0.89-2.78, I²=85%). Certainty of evidence was rated very low for each meta-analysis.

CONCLUSION

Despite limited resources in rural and remote settings, individual face-to-face counselling for smoking cessation appears promising. Given the limited number of studies, further research about the effectiveness of smoking cessation interventions in rural and remote populations is warranted.

A Prospective Study to Assess the Outcome of Motivational Interviewing Among Male Students of Haryana, India: A Strive Towards Smoking Cessation in the Youth

Background

The brown plague is a classic example of the modern-day epidemic.Motivational interviewing has been found to increase smokers' readiness to quit, attempts to quit, and reduce smoking levels.Thus, this study, attempts to find out the prevalence of smoking and assess the impact of motivational interviewing on male smoker students (18-30 years).

Methodology

The study was conducted among the male students of educational institutes in Maharishi Markandeshwar University in Haryana. A cross-sectional study to estimate the prevalence of smoking was carried out. With motivational interviewing of the smokers a prospective cohort study was conducted following the smokers for six months. The probability proportionate to size (PPS) sampling method was applied to recruit 830 participants in the study. A self-designed, semi-structured proforma was used to collect data on smoking behavior, level of dependence, and level of motivation to quit. A modified Fagerstrom questionnaire was used to assess the nicotine dependence level. The motivation to quit smoking was measured by the 10 point scale of Contemplation Ladder, Prochaska, and DiClemente transtheoretical model was used to categorize smokers into stages of readiness to change. Statistical analysis was done using SPSS version 16.0 (IBM Inc., Armonk, New York).

Results

The prevalence of smoking was 20.4%. Following motivational interview on the first contact, more than half of the current smokers (66.2%) had high motivation which further increased to 88.13% on the third visit at six months (p < 0.001). Likewise, at first contact, 47% had low nicotine dependence; this increased to 52.5 % at two weeks, and finally, at six months, 53.4% had low nicotine dependence. But this finding was statistically insignificant (p=0.23). It was noted that 21 (16.5%) smokers out of 127 quit smoking. A high degree of motivation, support from family and friends, and a low degree of nicotine dependence were identified as significant independent predictors for smoking cessation.

Conclusion

A satisfying proportion of smokers could attain a high level of motivation for quitting smoking, but less than one-fourth of the current smokers were able to abstain from smoking at the end of the study period. However, the impact of motivational interviewing was not very promising and calls for multi-pronged approach for discouraging smoking.

Community-Based Interventions for Cardiovascular Disease Prevention in Low-and Middle-Income Countries: A Systematic Review

Objectives: To synthesize evidence on the effectiveness of community-based interventions for cardiovascular disease (CVD) prevention in low- and middle-income countries (LMICs) to inform design of effective strategies for CVD prevention. Methods: We searched MEDLINE, EMBASE, CINAHL, Cochrane register of controlled studies and PSYCINFO databases for studies published between January 2000 and June 2019. Other studies were identified from gray literature sources and review of reference lists of included studies. The primary outcomes for the review were those aimed at primary prevention of CVD targeting physical activity, diet, smoking and alcohol consumption. Results: Database searches yielded 15,885 articles and 94 articles were identified through snowball searching. After screening, the articles from LMICs were 32 emanating from 27 studies: 9 cluster randomized trials, eight randomized controlled trials and 10 controlled before and after studies. Community-based interventions successfully improved population knowledge on CVD and risk factors and influenced physical activity and dietary practices. Evidence of interventions on smoking cessation and reduced alcohol consumption was inconsistent. Conclusion: This evidence should inform policy makers in decision-making and prioritizing evidence-based interventions.

New Biomarkers Based on Smoking-Related Phenotypes for Smoking Cessation Outcomes of Nicotine Replacement Therapy: A Prospective Study

INTRODUCTION

Identifying a potent biomarker for smoking cessation can play a key role in predicting prognosis and improving treatment outcomes. This study aimed to evaluate the contribution of new biomarkers based on the levels of Cotinine (Cot) and carbon monoxide (CO) to the short- and long-term quit rates of nicotine replacement therapies (Nicotine Patch [NP] and Nicotine Lozenge [NL]).

METHODS

In this prospective interventional study, 124 smokers under treatment with the 5A's method were selected from an outpatient smoking cessation center in district 18 of Tehran City, Iran. The study was conducted from April 2016 to December 2018. They were divided into NP (n=56) and NL (n=61) intervention groups. The levels of Cot and CO were measured using ELISA and breath analysis at the beginning of the study. Three markers were calculated: Cot/CO, Cot to cigarette per day ratio (Cot/CPD), and CO/CPD. Binary logistic regression models and generalized estimating equations models were analyzed by SPSS software, version 21 to determine the chances of quitting smoking.

RESULTS

Of the NP participants, 30.4% and 19.6% were abstinent after 2 and 6 months, respectively, while NL was found less effective with 19.7% for 2-month follow-up and 13.1% for 6-month follow-up. The 6-month success of quitting attempts was significantly different for the NP participants at the second half of Cot/CO (P=0.029). Of the NL participants, CO/CPD would be a superior predictor for smoking cessation success (P>0.05).

CONCLUSION

The findings of this study suggested two markers of Cot/CO and CO/CPD in this order for the optimum treatment outcomes of NP and NL.

Cost Analysis of Community-Based Smoking Cessation Services in Vietnam: A Cluster-Randomized Trial

The study aimed to estimate the cost for developing and implementing 2 smoking cessation service delivery models that were evaluated in a 2-arm cluster randomized trial in Commune Health Centers (CHCs) in Vietnam. In the first model (4As) CHC providers were trained to ask about tobacco use, advise smokers to quit, assess readiness to quit, and assist with brief counseling. The second model included the 4As plus a referral to Village Health Workers (VHWs) who were trained to provide multisession home-based counseling (4As + R). An activity-based ingredients (ABC-I) costing approach with a healthcare provider perspective was applied to collect the costs for each intervention model. Opportunity costs were excluded. Costs during preparation and implementation phase were estimated. Sensitivity analysis of the cost per smoker with the included intervention' activities were conducted. The cost per facility-based counseling session ranged from USD 9 to USD 11. Cost per home-based counseling session at 4As + R model was USD 4. The non-delivery cost attributed to supportive activities (eg, Monitoring, Logistic, Research, General training) was USD 107 per counseling session. Cost per smoker ranged from USD 6 to USD 451. The study analyzed and compared cost of implementing and scaling community-based smoking cessation service models in Vietnam.

Efficacy of group intervention on tobacco cessation among male employees in health-care setting: A randomized controlled trial

Background

The tobacco epidemic is one of the biggest public health threats the world has ever faced. World Health Organization has estimated that tobacco use (smoking and smokeless) is currently responsible for the death of about 7 million people across the world each year. The objective of the study was not only to find the effect of group intervention on tobacco cessation but also to describe certain epidemiological factors associated with tobacco cessation and make suitable recommendations to tackle this epidemic.

Methods

A randomized controlled trial was carried out among male employees who were tobacco users in health-care setting in Western Maharashtra. In the study, 60 subjects each in intervention and control arm were taken. Pretested validated questionnaires were used for the study. The intervention comprised of two sessions delivered 5 weeks apart. Control arm received self-help material (Booklet) immediately after baseline data collection. The outcomes were measured using structured interview schedule. The data were analyzed using SPSS, version 20.

Results

Overall, 13.3% of the study subjects had quit tobacco use post intervention. In the intervention group 21.7% of the participants had quit tobacco since past one month and 5% in the control group (relative risk (RR) = 4.33). Low to moderate nicotine dependence (p = 0.023, RR = 6.46) and stage of contemplation (p = 0.018) were found to be important predictors of abstinence.

Conclusion

Community-based group intervention for tobacco cessation is the way forward to tackle the tobacco epidemic.

Non-communicable diseases risk factors and their determinants: A cross-sectional state-wide STEPS survey, Haryana, North India

Background

Recent studies have documented high variation in epidemiologic transition levels among Indian states with noncommunicable disease epidemic rising swiftly. However, the estimates suffer from non-availability of reliable data for NCDs from sub populations. In order to fill the knowledge gap, the distribution and determinants of NCD risk factors were studied along with awareness, treatment and control of NCDs among the adult population in Haryana, India.

Methods

NCD risk factors survey was conducted among 5078 residents, aged 18–69 years during 2016–17. Behavioural risk factors were assessed using STEPS instrument, administered through an android software (mSTEPS). This was followed by physical measurements using standard protocols. Finally, biological risk factors were determined through the analysis of serum and urine samples.

Results

Males were found to be consuming tobacco and alcohol at higher rates of 38.9% (95% CI: 35.3–42.4) and 18.8% (95% CI: 15.8–21.8). One- tenth (11%) (95% CI: 8.6–13.4) of the respondents did not meet the specified WHO recommendations for physical activity for health. Around 35.2% (95%CI: 32.6–37.7) were overweight or obese. Hypertension and diabetes were prevalent at 26.2% (95% CI: 24.6–27.8) and 15.5% (95% CI: 11.0–20.0). 91.3% (95% CI: 89.3–93.3) of the population had higher salt intake than recommended 5gms per day.

Conclusion

The documentation of strikingly high and uniform distribution of different NCDs and their risk factors in state warrants urgent need for evidence based interventions and advocacy of policy measures.

Effectiveness of Village Health Worker-Delivered Smoking Cessation Counseling in Vietnam

INTRODUCTION

Smoking prevalence is high in Vietnam, yet tobacco dependence treatment (TDT) is not widely available.

METHODS

We conducted a quasiexperimental study that compared the effectiveness of health care provider advice and assistance (ARM 1) versus ARM 1 plus village health worker (VHW) counseling (ARM 2) on abstinence at 6-month follow-up. This study was embedded in a larger two-arm cluster randomized controlled trial conducted in 26 community health centers (CHCs) in Vietnam. Subjects (N = 1318) were adult patients who visited any participating CHC during the parent randomized controlled trial intervention period and were self-identified as current tobacco users (cigarettes and/or water pipe).

RESULTS

At 6-month follow-up, abstinences rates in ARM 2 were significantly higher than those in ARM 1 (25.7% vs. 10.5%; p < .001). In multivariate analyses, smokers in ARM 2 were almost three times more likely to quit compared with those in ARM 1 (adjusted odds ratio [AOR] = 2.96, 95% confidence interval [CI] = 1.78% to 4.92%). Compared to cigarette-only smokers, water pipe-only smokers (AOR = 0.4, 95% CI = 0.26% to 0.62%) and dual users (AOR = 0.62, 95% CI = 0.45% to 0.86%) were less likely to achieve abstinence; however, the addition of VHW counseling (ARM 2) was associated with higher quit rates compared with ARM 1 alone for all smoker types.

CONCLUSION

A team approach in TDT programs that offer a referral system for health care providers to refer smokers to VHW-led cessation counseling is a promising and potentially scalable model for increasing access to evidence-based TDT and increasing quit rates in low middle-income countries (LMICs). TDT programs may need to adapt interventions to improve outcomes for water pipe users.

IMPLICATIONS

The study fills literature gaps on effective models for TDT in LMICs. The addition of VHW-led cessation counseling, available through a referral from primary care providers in CHCs in Vietnam, to health care provider's brief cessation advice, increased 6-month biochemically validated abstinence rates compared to provider advice alone. The study also demonstrated the potential effectiveness of VHW counseling on reducing water pipe use. For LMICs, TDT programs in primary care settings with a referral system to VHW-led cessation counseling might be a promising and potentially scalable model for increasing access to evidence-based treatment.

Evaluation of research on interventions aligned to WHO 'Best Buys' for NCDs in low-income and lower-middle-income countries: a systematic review from 1990 to 2015

Background

Non-communicable diseases (NCDs) are the leading cause of death and disability worldwide, with low-income and middle-income countries experiencing a disproportionately high burden. Since 2010 WHO has promoted 24 highly cost-effective interventions for NCDs, dubbed ‘best buys’. It is unclear whether these interventions have been evaluated in low-income and lower-middle-income countries (LLMICs).

Aim

To systematically review research on interventions aligned to WHO ‘best buys’ for NCDs in LLMICs.

Methods

We searched 13 major databases and included papers conducted in the 83 World Bank-defined LLMICs, published between 1 January 1990 and 5 February 2015. Two reviewers independently screened papers and assessed risk of bias. We adopted a narrative approach to data synthesis. The primary outcomes were NCD-related mortality and morbidity, and risk factor prevalence.

Results

We identified 2672 records, of which 36 were included (608 940 participants). No studies on ‘best buys’ were found in 89% of LLMICs. Nineteen of the 36 studies reported on the effectiveness of tobacco-related ‘best buys’, presenting good evidence for group interventions in reducing tobacco use but weaker evidence for interventions targeting individuals. There were fewer studies on smoking bans, warning labels and mass media campaigns, and no studies on taxes or marketing restrictions. There was supportive evidence that cervical screening and hepatitis B immunisation prevent cancer in LLMICs. A single randomised controlled trial supported polypharmacy for cardiovascular disease. Fourteen of the ‘best buy’ interventions did not have any good evidence for effectiveness in LLMICs.

Conclusions

We found studies on only 11 of the 24 interventions aligned with the WHO ‘best buys’ from LLMIC settings. Most LLMICs have not conducted research on these interventions in their populations. LLMICs should take action to implement and evaluate ‘best buys’ in their national context, based on national priorities, and starting with interventions with the strongest evidence base.

Community health workers for non-communicable diseases prevention and control in developing countries: Evidence and implications

Background

National programs for non-communicable diseases (NCD) prevention and control in different low middle income countries have a strong community component. A community health worker (CHW) delivers NCD preventive services using informational as well as behavioural approaches. Community education and interpersonal communication on lifestyle modifications is imparted with focus on primordial prevention of NCDs and screening is conducted as part of early diagnosis and management. However, the effectiveness of health promotion and screening interventions delivered through community health workers needs to be established.

Objective

This review synthesised evidence on effectiveness of CHW delivered NCD primary prevention interventions in low and middle-income countries (LMICs).

Methods

A systematic review of trials that utilised community health workers for primary prevention/ early detection strategy in the management of NCDs (Diabetes, cardiovascular diseases (CVD), cancers, stroke, Chronic Obstructive Pulmonary Diseases (COPD)) in LMICs was conducted. Digital databases like PubMed, EMBASE, OVID, Cochrane library, dissertation abstracts, clinical trials registry web sites of different LMIC were searched for such publications between years 2000 and 2015. We focussed on community based randomised controlled trial and cluster randomised trials without any publication language limitation. The primary outcome of review was percentage change in population with different behavioural risk factors. Additionally, mean overall changes in levels of several physical or biochemical parameters were studied as secondary outcomes. Subgroup analyses was performed by the age and sex of participants, and sensitivity analyses was conducted to assess the robustness of the findings.

Results

Sixteen trials meeting the inclusion criteria were included in the review. Duration, study populations and content of interventions varied across trials. The duration of the studies ranged from mean follow up of 4 months for some risk factors to 19 months, and primary responsibilities of health workers included health promotion, treatment adherence and follow ups. Only a single trial reported all-cause mortality. The pooled effect computed indicated an increase in tobacco cessation (RR: 2.0, 95%CI: 1.11, 3.58, moderate-quality evidence) and a decrease in systolic blood pressure ((MD: -4.80, 95% CI: -8.12, -1.49, I² = 93%, very low-quality evidence), diastolic blood pressure ((MD: -2.88, 95% CI: -5.65, -0.10, I² = 96%, very low-quality evidence)) and blood sugar levels (glycated haemoglobin MD: -0.83%, 95%CI: -1.25,-0.41). None of the included trials reported on adverse events.

Conclusions

Evidence on the implementation of primary prevention strategies using community health workers is still developing. Existing evidence suggests that, compared with standard care, using CHWs in health programmes have the potential to be effective in LMICs, particularly for tobacco cessation, blood pressure and diabetes control.

A Randomized Pilot Study of Brief Intervention versus Simple Advice for Women Tobacco Users in an Urban Community in India

AIM

The study aimed to assess the efficacy of providing brief intervention (BI) for women tobacco users in a community-based setting.

METHODS

In this open-labeled randomized study, a representative sample of women (n = 100) from a community in East Delhi were screened using Alcohol, Smoking and Substance Involvement Screening Test. Eligible women were randomized to BI or simple advice (SA) arms. At baseline, they were assessed for tobacco use characteristics and severity of nicotine dependence using Fagerstrom's test for nicotine dependence. Intervention in the form of a single session of BI or SA to quit tobacco was provided at baseline. All participants were assessed at 1 week and 3 months following intervention. The principal outcome was self-reported abstinence from tobacco use at 3 months follow-up.

RESULTS

The mean age of the sample was 43 years (standard deviation = 13). Most women were married (80%), housewives (69%), illiterate (61%), socioeconomically disadvantaged and were smokeless tobacco users (94%). The subjects in the BI group were twice more likely to stop tobacco use as compared to individuals in the SA group (odds ratio = 2.2, 95% confidence interval: 0.962-5.197, P = 0.06).

CONCLUSION

The study results are suggestive of beneficial effect of BI. A larger study might provide more significant results.

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.

Smoking cessation interventions for adults aged 50 or older: A systematic review and meta-analysis

BACKGROUND

The older population size has increased substantially, and a considerable proportion of older adults are cigarette smokers. Quitting smoking is associated with reduced health risk. This review is among the first to quantitatively assess the relative efficacy of types of cessation interventions for smokers aged ≥50 years.

METHODS

We conducted searches of the Cochrane Library, Embase, MEDLINE, and PsycINFO to identify smoking cessation studies on adults aged ≥50 years. Twenty-nine randomized clinical trials met the inclusion criteria. Three main types of interventions were identified. We analyzed relative cessation rates or Risk Ratios (RRs) between the type of intervention groups and the control group by fixed- and random-effects meta-analyses at the study level. We conducted a weighted least squares meta-regression of cessation rates on trial and sample characteristics to determine sources of outcome heterogeneity.

RESULTS

Fixed-effects analysis showed significant treatment effects for pharmacological (RR=3.18, 95% CI: 1.89-5.36), non-pharmacological (RR=1.80, 95% CI: 1.67-1.94), and multimodal interventions (RR=1.61, 95% CI: 1.41-1.84) compared with control group. Estimations based on meta-regression suggested that pharmacological intervention (mean point prevalence abstinence rate (PPA)=26.10%, CI: 15.20-37.00) resembled non-pharmacological (27.97%, CI: 24.00-31.94), and multimodal interventions (36.64%, CI: 31.66-41.62); and non-pharmacological and multimodal interventions had higher PPAs than the control group (18.80%, CI: 14.48-23.12), after adjusting for a number of trial and sample characteristics.

CONCLUSIONS

A small number of smoking cessation studies examined smokers aged ≥50 years. Additional research is recommended to determine smoking cessation efficacy for diverse older population groups (e.g., ethnic minorities).

Role of tobacco warning labels in informing smokers about risks of smoking among bus drivers in Mangalore, India

BACKGROUND

Smoking tobacco is considered as a leading cause of preventable death, mostly in developing countries like India. One of the primary goals of international tobacco control is to educate smokers about the risks associated with tobacco consumption. Tobacco warning labels (TWLs) on cigarette packages are one of the most common statutory means to communicate health risks of smoking to smokers, with the hope that once educated, they will be more likely to quit the habit.

MATERIALS AND METHODS

The present survey was conducted to assess the effectiveness of TWLs in communicating health risks of tobacco usage among 263 adult smokers working as bus drivers in Karnataka State Road Transport Corporation (KSRTC), Mangalore, India. Information was collected on demographic details, exposure and response to health warnings on tobacco products, intention to quit and nicotine dependency.

RESULTS

The majority (79.5%) of the respondents revealed negative intentions towards quitting smoking. Nearly half of the participants had a 'low' nicotine dependency (47.5%) and 98.1% of the respondents had often noticed warning labels on tobacco packages. These health warnings made 71.5% of the respondents think about quitting smoking. Respondents who noticed advertisement or pictures about dangers of smoking had better knowledge, with respect to lung cancer and impotence as a consequence of tobacco. A higher exposure to warning labels was significantly associated with lower nicotine dependency levels of smokers among the present study population. A significantly higher number of respondents who noticed advertisement or pictures about the dangers of smoking thought about the risks of smoking and were more inclined to think about quitting smoking. As exposure increased, an increase in the knowledge and response of participants was also observed.

CONCLUSIONS

Exposure to tobacco warning labels helps to educate smokers about health risks of tobacco smoking. It may be possible to promote oral health among bus drivers by developing strategies to educate them about these risk factors.

Biomarkers of Response to Smoking Cessation Pharmacotherapies: Progress to Date

For the past 30 years, research examining predictors of successful smoking cessation treatment response has focused primarily on clinical variables, such as levels of tobacco dependence, craving, and self-efficacy. However, recent research has begun to determine biomarkers (such as genotype, nicotine and metabolite levels, and brain imaging findings) that may have utility in predicting smoking cessation. For genotype, genes associated with nicotinic acetylcholine receptors (nAChRs) and related proteins have been found to predict response to first-line medications (e.g. nicotine replacement therapy [NRT], bupropion, or varenicline) or quitting over time without a controlled treatment trial. For nicotine and metabolite levels, function of the cytochrome P450 2A6 liver enzyme, which can be assessed with the nicotine metabolite ratio or via genotype, has been found to predict response, with slow nicotine metabolizers having less severe nicotine dependence and a greater likelihood of quitting with NRT than normal metabolizers. For brain imaging, decreased activation of brain regions associated with emotion regulation and increased connectivity in emotion regulation networks, increased responsiveness to pleasant cues, and altered activation with the Stroop effect have been found in smokers who quit with the first-line medications listed above or counseling. In addition, our group recently demonstrated that lower pre-treatment brain nAChR density is associated with a greater chance of quitting smoking with NRT or placebo. Several of these studies found that specific biomarkers may provide additional information for predicting response beyond subjective symptom or rating scale measures, thereby giving an initial indication that biomarkers may, in the future, be useful for guiding smoking cessation treatment intensity, duration, and type.

Effect on smoking quit rate of telling smokers their health risk appraisal in terms of health age: a randomized control trial

BACKGROUND

We evaluated whether providing health risk appraisal for Koreans (KHRA) in terms of 'health age' during smoking cessation program would effectively help smokers quit smoking or not.

MATERIALS AND METHODS

A total of 332 male smokers aged between 30-65 years old, registered for a smoking cessation program in a public health center in a city, were recruited and underwent a baseline survey from January 2010 to February 2011. They were then prospectively randomized to a conventional counseling group (n=165) or a KHRA group (n=167), and received conventional counseling or KHRA-based counseling for six months. Abstinence rates were identified through carbon monoxide measurement (at the 4th and 24th weeks) or urinary cotinine level (at the 12th week).

RESULTS

The abstinence rate confirmed by exhaled carbon monoxide was significantly higher in the KHRA group (61.1%) than the control group (49.1%) at the 4th week (absolute difference 12.0%, 95% CI: 1.4%-22.6%). However, there was no difference in abstinence rates between the two groups at the 12th and 24th weeks. The predicting factors of 24 week's smoking cessation success were age, older than 50 years old (OR 2.02, 95% CI: 1.16-3.52), lower Fagerstrom Test for Nicotine Dependence score less than 4 (OR 1.84, 95% CI: 1.03-3.29), and higher Self Efficacy/Temptation score (OR 1.79, 95% CI: 1.05-3.06).

CONCLUSIONS

Smoking cessation counseling with KHRA could be effective compared to conventional counseling in the short period of smoking cessation. Further study is needed to evaluate the long-term efficacy of KHRA in tobacco dependence treatment and to establish the indication and target population of this tool.

Process evaluation of the first computer tailored program for smoking cessation among Romanian smokers

The objective of this paper is to present the implementation and process evaluation of the first computer tailored program for smoking cessation among Romanian smokers. The program targeted adult smokers who declared the intention to quit smoking in the next six months. The intervention consisted of a letter tailored to several respondent characteristics: gender, cognitive variables (attitude, social influence, and self-efficacy), intention to quit smoking, goal and relapse prevention strategies (action and coping plans), and smoking behaviour. The first 80 participants entered into the program filled in a process evaluation questionnaire one month after the intervention. The results of our study confirmed that the participants had read and remembered the letter. Moreover, new for Romania, this approach was positively appreciated by the participant and the score received for the tailored letter was high. The opinions of the participants confirmed that the tailored letter provided information that was useful, trustworthy and relevant for the individual. At the same time, the participants appreciated the polite, easy to understand content of the letter. These data underlined the premises for continuing the program and for using the information and communication technologies for healthy lifestyle promotion among Romanian population.