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 Table of Contents  
Year : 2020  |  Volume : 8  |  Issue : 1  |  Page : 1-3

Evaluation of tobacco cessation counseling program and the challenges identified

1 Professor and Head, Department of Public Health Dentistry, Mahatma Gandhi Post Graduate Institute of Dental Sciences, Puducherry, India
2 Assistant Professor, Department of Public Health Dentistry, Mahatma Gandhi Post Graduate Institute of Dental Sciences, Puducherry, India

Date of Submission25-Jul-2020
Date of Acceptance30-Aug-2020
Date of Web Publication07-Apr-2021

Correspondence Address:
Dr. S Saravanan
Department of Public Health Dentistry, Mahatma Gandhi Post Graduate Institute of Dental Sciences, Puducherry - 605 006
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijcd.ijcd_8_20

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Background: The prevalence of tobacco use is high in India, with nearly half of males and one-fifth of females using tobacco in some form. An effort has been made to offer help to quit tobacco use among patients by initiating tobacco cessation counseling (TCC) services in our Institution. The aim was to assess the effectiveness of TCC program among tobacco users. Methods: The evaluation of the TCC program was carried out by reviewing of records enrolled from January 2014 to March 2016. The baseline information of the enrolled subjects was assessed for tobacco use status. The post-intervention follow-up details of the current tobacco users were analyzed for quit status, and the tobacco quit rate was determined. Chi-square test was applied for statistical analysis. Results: Of the 1472 current tobacco users, 95.9% were males and 4.1% were females. An overall quit rate of 5.2% was recorded with women having 2.73 times higher quit rate than men (P = 0.004). Losses to follow-up were very high. Conclusion: A lower tobacco quit rate was recorded due to high losses to follow-up. Integration of proactive follow-up measures while designing the public health program is required, to overcome the challenge “high losses to follow-up” and to achieve a better response and outcome.

Keywords: Behavioral counseling, challenges in tobacco cessation counseling, evaluation of tobacco cessation counseling, tobacco cessation counseling, tobacco quit rate

How to cite this article:
Saravanan S, Lenin K R. Evaluation of tobacco cessation counseling program and the challenges identified. Int J Community Dent 2020;8:1-3

How to cite this URL:
Saravanan S, Lenin K R. Evaluation of tobacco cessation counseling program and the challenges identified. Int J Community Dent [serial online] 2020 [cited 2023 Jan 29];8:1-3. Available from: https://www.ijcommdent.com/text.asp?2020/8/1/1/313147

  Background and Purpose Top

India is the third largest producer and second largest consumer of tobacco products in the world. As per the Global Adult Tobacco Survey, the prevalence of tobacco use in India is 34.6% with 47.9% of males and 20.3% of females using tobacco in some form.[1] Men smoke and chew tobacco, whereas women mainly chew tobacco, except in a few places where the prevalence of smoking among females is higher.[2]

According to the WHO, tobacco kills around 6 million people every year. More than 5 million deaths are due to direct tobacco use, while 6 lakh deaths are non-smokers being exposed to secondhand smoke.[3] In India, nearly 8-“9 lakh people die every year due to diseases related to tobacco use.[4]

Hence, an effort has been made to offer help to quit tobacco by initiating tobacco cessation counseling (TCC) services in the department of public health dentistry in our Institution. The program was conducted as a routine oral healthcare service in our Institution, and it was evaluated with the following objectives to assess:

  1. The proportion of subjects who successfully quit tobacco
  2. The proportion of subjects with reduced tobacco intake up to 50% or more
  3. The proportion of subjects with “no change”
  4. The existing structure and process.

  Methods Top

A retrospective cohort design was used to evaluate the TCC program conducted in the Department of Public Health Dentistry, Mahatma Gandhi Post Graduate Institute of Dental Sciences. The TCC was based on the “5A's” approach described in the training manual for tobacco cessation developed by the Ministry of Health and Family Welfare, Government of India,[5] and WHO-SEARO.[6] The data for the present evaluation were collected from the existing records enrolled from January 31, 2014, to March 31, 2016. Records of subjects who currently use tobacco in any form and participated in cessation counseling were included in the evaluation. Ex-tobacco users who participated in the counseling were excluded from the evaluation process. The pre- and post-intervention data of the current tobacco users were evaluated, and the tobacco quit status was analyzed and the quit rate was determined. A subject was considered “quitted tobacco” when the user was abstained from tobacco continuously for a duration of 2 weeks. The proportion of subjects with “reduced tobacco intake up to 50% or more” and subjects with “no change” compared to baseline were estimated. A subject was considered “lost to follow-up” when there was no follow-up report after the initial/baseline visit.

Frequency tables and proportions were used to present the data. The Chi-square test was applied to test the significance of difference in quit rates between genders. A P < 0.05 was considered statistically significant. The analysis was done using SPSS version 17 (SPSS statistics for Windows, Chicago: SPSS Inc) software.

  Results Top

All the subjects who gave verbal consent were given TCC intervention and registered. Four individuals were not willing to participate in the TCC and hence not registered. Of the 1519 subjects counseled, 95.7% were males and 4.3% were females. 97% were current tobacco users and 3% were ex-tobacco users [Table 1].
Table 1: Distribution of subjects reported for tobacco cessation counseling by tobacco use status

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The ex-tobacco users were not included in the final analysis. Thus, the total participants became 1472 current tobacco users wherein 145 reported for the first follow-up and 18 reported for the second follow-up.

Among the current tobacco users who were counseled, 5.2% of the participants self-reported to have quit tobacco. In men, the quit rate was 4.8% whereas a higher cessation rate of 13.1% was recorded in women. This difference in observation was statistically highly significant (P = 0.004) [Table 2]. Fifty-two (3.5%) of the current tobacco users (male) reported to have reduced tobacco intake by 50% or more and 17 (1.2%) males reported with “no change” in their tobacco use status.
Table 2: Distribution of tobacco quit rate according to gender

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Two participants who required psychiatric support were referred to specialized hospital for further management. 1327 (90.1%) participants were lost to follow-up.

  Discussion Top

In the current evaluation, the overall tobacco quit rate recorded was 5.2%. Studies in Western countries,[7],[8],[9] as well as in India,[10],[11] indicate improved quit rates with the addition of pharmacotherapy to behavioral counseling. In the present program, the only mode of cessation service given is face-to-face counseling, irrespective of the level of nicotine dependence. The medium and high nicotine dependents must be identified, and appropriate pharmacotherapy may be provided. This requires training of the service providers in delivering pharmacotherapy. In our evaluation, women recorded 2.73 times higher quit rate than men. The factors associated with improved outcomes in women are the use of smokeless form of tobacco,[12] which may be combined with the realization of social responsibility toward their family health and welfare and the effect of counseling. The observed low quit rate among men may be partly due to peer pressure, work pressure,[13] illiteracy or low educational level,[14],[15] nicotine dependence,[16] and alcoholism.[17]

It is evident that follow-up[18],[19] is a very important component of care to ensure better outcome. Unfortunately, in the present program, a low response rate of 9.9% was recorded although the recommended target goal for follow-up response rate for behavioral changes is 50%. Factors that attribute to the high losses to follow-up may be the lack of intention to quit or the deeply ingrained cultural attitudes to maintain tobacco use[4],[20] or the distant places of residence or the lack of recall system. However, these high losses to follow-up pose a major challenge not only to the outcome of the program but also for the cause and effect relation of the TCC program, despite an accurate planning and implementation of the program.

It is also evident from the present program that high losses to follow-up are inevitable in public health programs due to various factors. Hence, designing a public health program with proactive follow-up measures such as telephone recall system[21] or sending reminder letter/postcard[22] or providing telephone counseling following initial face-to-face counseling would improve the response rate (follow-up rate) as well as quit rate. The importance of telephonic recall system is substantiated by the study of Mony et al.[23] from the outpatient tobacco cessation clinic in Chest Medicine Department, Bengaluru, Southern India, wherein 56% of the patients enrolled were successfully contacted telephonically and were followed up though the loss to follow-up was 44%.

  Conclusion and Recommendations Top

The TCC program recorded a low quit rate due to high losses to follow-up. Evaluation of the cessation program resulted in identification of the challenges in the existing setup, which in turn affect the response of the participants to counseling and the outcome of the program. Implementation of certain proactive measures in the present program can successfully improve the response rate as well as the quit rate. The following are the recommendations that could be made in this context.

  1. An active reminder system such as telephone and letter/postcard may be introduced to provide a reminder notification for follow-up. One or two phone calls after an initial face-to-face counseling may increase the response rate
  2. A proactive telephonic counseling may be tried for patients who fail to turn up in spite of reminder calls which may increase their chance of quitting
  3. The carbon monoxide breath analyzer or biochemical validation may be used as a health education tool to increase the interest and confidence level of the participants and improve the outcome apart from confirming the abstinence from tobacco
  4. Further training and expansion in tobacco cessation services such as pharmacotherapy to treat medium and high nicotine dependents are required
  5. To identify the predictors of quitting tobacco use.

The prime intention of presenting this program is to highlight the actual difficulties encountered in the present setup during its implementation in developing countries like India.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Global Adult Tobacco Survey. GATS India Report 2009-2010. Mumbai, New Delhi: International Institute for Population Sciences, Ministry of Health and Family Welfare; 2010.  Back to cited text no. 1
International Institute for Population Sciences and Macro International. National Family Health Survey (NFHS-3), 2005-06. India. Vol. 1. Mumbai: International Institute for Population Sciences; 2007.  Back to cited text no. 2
WHO. Tobacco. Available from: http://www.who.int/mediacentre/factsheets/fs339/en/. [Last accessed on 2016 Aug 08].  Back to cited text no. 3
Reddy KS, Gupta PC. Report on Tobacco Control in India. New Delhi: Ministry of Health and Family Welfare, Government of India; 2004.  Back to cited text no. 4
Directorate General of Health Services. Manuals for Training in Cancer Control. Manual for Tobacco Cessation. New Delhi: Ministry of Health and Family Welfare, Government of India; 2005.  Back to cited text no. 5
World Health Organization Regional Office for South-East Asia. Helping People Quit Tobacco -“ A Manual for Doctors and Dentists. New Delhi: WHO-SEARO; 2010.  Back to cited text no. 6
Jorenby DE, Leischow SJ, Nides MA, Rennard SI, Johnston JA, Hughes AR, et al. A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med 1999;340:685-91.  Back to cited text no. 7
Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev 2007;1:CD000031.  Back to cited text no. 8
Aveyard P, West R. Managing smoking cessation. BMJ 2007;335:37-41.  Back to cited text no. 9
Varghese C, Kaur J, Desai NG, Murthy P, Malhotra S, Subbakrishna DK, et al. Initiating tobacco cessation services in India: Challenges and opportunities. WHO South East Asia J Public Health 2012;1:159-68.  Back to cited text no. 10
Kumar R, Kushwah AS, Gopal C, Mahakund SP, Vijayan VK. Smoking cessation interventions and continuous abstinence rate at one year. Indian J Chest Dis Allied Sci 2007;49:201-8.  Back to cited text no. 11
Mishra GA, Majmudar PV, Gupta SD, Rane PS, Uplap PA, Shastri SS. Workplace tobacco cessation program in India: A success story. Indian J Occup Environ Med 2009;13:146-53.  Back to cited text no. 12
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Hussain JS, Ram SM. Prevalence of tobacco habits and attitude toward its cessation among outpatients of Mahatma Gandhi Mission's Dental College and Hospital, Navi Mumbai, Maharashtra. J Contemp Dent 2013;3:57-60.  Back to cited text no. 13
Droomers M, Schrijvers CT, Mackenbach JP. Why do lower educated people continue smoking? Explanations from the longitudinal GLOBE study. Health Psychol 2002;21:263-72.  Back to cited text no. 14
Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L. Tobacco use in India: Prevalence and predictors of smoking and chewing in a national cross sectional household survey. Tob Control 2003;12:1-8.  Back to cited text no. 15
Hyland A, Li Q, Bauer JE, Giovino GA, Steger C, Cummings KM. Predictors of cessation in a cohort of current and former smokers followed over 13 years. Nicotine Tob Res 2004;6 Suppl 3:S363-9.  Back to cited text no. 16
Hymowitz N, Cummings KM, Hyland A, Lynn WR, Pechacek TF, Hartwell TD. Predictors of smoking cessation in a cohort of adult smokers followed for five years. Tob Control 1997;6 Suppl 2:S57-62.  Back to cited text no. 17
Cruse SM, Forster NJ, Thurgood G, Sys L. Smoking cessation in the workplace: Results of an intervention programme using nicotine patches. Occup Med (Lond) 2001;51:501-6.  Back to cited text no. 18
Mishra GA, Pimple SA, Shastri SS. An overview of the tobacco problem in India. Indian J Med Paediatr Oncol 2012;33:139-45.  Back to cited text no. 19
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Murthy P, Saddichha S. Tobacco cessation services in India: Recent developments and the need for expansion. Indian J Cancer 2010;47 Suppl 1:69-74.  Back to cited text no. 20
Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Atun R, Car J. Mobile phone messaging reminders for attendance at healthcare appointments. Cochrane Database Syst Rev 2013;12:CD007458.  Back to cited text no. 21
Can S, Macfarlane T, O'Brien KD. The use of postal reminders to reduce non-attendance at an orthodontic clinic: A randomised controlled trial. Br Dent J 2003;195:199-201.  Back to cited text no. 22
Mony PK, Rose DP, Sreedaran P, D'Souza G, Srinivasan K. Tobacco cessation outcomes in a cohort of patients attending a chest medicine outpatient clinic in Bangalore city, Southern India. Indian J Med Res 2014;139:523-30.  Back to cited text no. 23
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  [Table 1], [Table 2]


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