Health systems challenges for tobacco dependence treatment in LMICs: Smokeless tobacco and Bidi

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2 Health systems challenges for tobacco dependence treatment in LMICs: Smokeless tobacco and Bidi Dr. Rajmohan Panda Senior Public Health Specialist, Public Health Foundation of India

3 Overview 1 Bidi and Smokeless Tobacco Burden 2 Resources Available 3 Present Challenges 4 Supply and Demand Side Barriers to Tobacco Dependence Treatment 5 Strengthening Health System 6 Way Forward 1

4 In millions Tobacco Burden CHN IND IDN RUS BGD USA PAK VNM PHL TUR EGY Number of smokers 60% of the world's current smokers live in three Asian countries: China, India, and Indonesia Middle-income countries have seen the greatest increase in number of smokers Lowlight: In India 111 million adults smoke in some form 73 million Bidi Smokers: (23%of population of US) 2

5 Tobacco Burden (Smokeless Tobacco) India 206 million adults use smokeless forms of tobacco 268 million people uses smokeless tobacco in South East Asia Region SEAR- 89% of ST users Source: Global Adult Tobacco Survey, India Data National Cancer Institute and Centers for Disease Control and Prevention. Smokeless Tobacco and Public Health: A Global Perspective. Bethesda, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Institutes of Health, National Cancer Institute;

6 Socio-economic gradients in Bidi smoking and smokeless tobacco Bidi smoking and smokeless tobacco use is concentrated among the socio-economically disadvantaged Average expenditure incurred by bidi smokers and smokeless tobacco users is higher in rural areas 1 Low household income is associated with a higher likelihood of bidi and smokeless tobacco use in most states of India 2 Bidi and Smokeless tobacco users who have less than primary level of education incur more expenditure on bidi and smokeless tobacco 1 1. Ministry of Health and Family Welfare, Government of India. Global Adult Tobacco Survey (GATS), India, Report, Thakur J.S. Widespread inequalities in smoking & smokeless tobacco consumption across wealth quintiles in States of India: Need for targeted interventions. Indian J Med Res Jun; 141(6):

7 Real Picture Available Resources Challenges Knowledge Preventing tobacco use Promoting cessation Protecting non-smokers from SHS Government of India released National Guidelines on Tobacco Dependence Treatment (2011) Cessation facilities at district level under NTCP (42 out of 642 districts) Tool Accelerating FCTC implementation MPOWER Tobacco Dependence Guidelines Application of guidelines in routine care? Network of TCC Pilot phase Tertiary centers Urban based Behavior counseling Lack of follow-up Lack of monitoring & Evaluation General hospitals, TB hospitals, and clinics Private Hospitals?? Evidence-base cessation practice not followed 5

8 Supply and Demand Side Barriers to Tobacco Dependence Treatment Service Utilization Barriers related to tobacco cessation service utilization Health System Barriers Service Providers Barriers Availability, Affordability& Acceptability Tobacco Dependence Treatment services, cost, access, and availability 6

9 1. Tobacco cessation service utilization 50% 40% 30% 20% 26% 22% Smokers Smokeless tobacco users 10% 9% 8% 4% 0% Counseling Pharmacotherapy Others Source: 1.Global Adult Tobacco Survey, India, Data 7

10 2. Providers Barriers Opportunities for screening and providing tobacco cessation advice are largely missed in primary care settings 3 Lack of knowledge and trained health professionals, paucity of funds, and low priority given to tobacco control interventions 3... SLT as harm reduction measure: 21% of physicians advise patients to switch to smokeless tobacco 4 3.Panda R, Persai D, Venkatesan S. Missed opportunities for brief intervention in tobacco control in primary care: Patients perspectives from primary health care settings in India. BMC Health Services Research. 2015;15(1):50. 4Panda R, Persai D, Mathur M, Sarkar BK. Perception and practices of physicians in addressing the smokeless tobacco epidemic: findings from two States in India. Asian Pac J Cancer Prev. 2013;14(12):

11 3.Tobacco Dependence Treatment Services: Access, Availability & Acceptability Amount spent on Bidi smoking is more than the cost of treatment Expenditure on Bidi in an year (GATS, India-2010) Expenditure on SLT in an year (GATS-2010 Expenditure on NRT for high dependence (12 weeks) 16.5 USD 8 USD 68 USD ISSUES NRT gums and patch, Bupropion and Varenicline available as over the counter drugs and on prescription Bupropion used mainly by psychiatrists and not general practitioners Varenicline is used mainly by private hospitals as cost is a factor Expenditure on Bupropion for high dependence (8 weeks) 16 USD Expenditure on Vareniciline for high dependence (8 weeks) 83 USD 9

12 3.Tobacco Dependence Treatment Services: Access, Availability & Acceptability FTND Score ISSUES Smokeless tobacco users: Dual Use& Myriad forms Culturally ingrained SLT products: Low cost & High Nicotine Dependence % Bidi Smokers Smokeless Tobacco Users Low receipt of Advise, Assess and Assist, Arrange component of 5As among tobacco users 5 Low Agreement between physicians and patients on 5As. Agreement was higher among patients who were smokeless tobacco users 5 80% 60% 40% 20% 0% 77% 79% 53% 51% 44% 42% 29% 20% 35% 25% Bidi Smokers Smokeless Tobacco Users 5 Panda R et.al.. Physician and patient concordance of report of tobacco cessation intervention in primary care in India. BMC Public Health201515:456 Source: Strengthening of Tobacco Control Efforts through Innovative Partnerships and Strategies (2013). Exit Interviews Unpublished Data 10

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14 Intervention Works!! The "5 As" model helping tobacco users in quitting Project STEPS ( ) Integrated tobacco cessation practices in routine practices of Health Patients who reported that they were advised to quit, assessed for readiness to quit and offered cessation assistance were more satisfied with the counseling services 6 Patients satisfied with the counseling services were five times more likely to have an intention to quit tobacco and four times as likely to recommend counseling to other tobacco users 6 Project Quit International Designed a tobacco curriculum for medical colleges Developed culturally appropriate approaches to clinic and community-based tobacco cessation 6.Persai D, Panda R et.al.. Does receipt of 5As services have implications for patients satisfaction in India? BMC Family Practice :209 12

15 Strengthening Health Systems Change Lessons learned from Project SCCOPE Hub and spoke model: Hub (set up center of excellence in tobacco cessation), develop spokes around them (empowered facilities for tobacco cessation regionally in premier institutes) Building Capacity and Establishing Models (online &face to face training)of NTCP state officials & physicians in primary and secondary health care to deliver an evidence-based brief tobacco cessation intervention Creating a network and training model for tobacco cessation Initiated formation of a research and practice network in tobacco control Technical support to Government for establishing TCC 13

16 Way Forward Development of standard measures for measurement of nicotine dependence among Bidi & SLT users Developing interventions tailored to regionally driven patterns of Bidi and SLT use Incorporation of Tobacco Cessation in Medical Curriculum & Integration of TC program in TB program, Cancer Control, CVDs and Respiratory Diseases Online network of cessation experts, certification in cessation Expansion of Tobacco Cessation Centers across the country 14

17 Thank You Contributions: Dr. Rajmohan Panda Dr.Divya Persai Public Health Foundation of India 14