A Tobacco Cessation Initiative by:

A Tobacco Cessation Initiative by:

Health is a major area of focus for the Narotam Sekhsaria Foundation and it supports health interventions across various healthcare settings. The Foundation has also supported several projects in cancer prevention and care, right from its inception. As an extension of this support, a tobacco treatment service called LifeFirst was initiated in 2013, with the objective of helping people overcome their dependence on tobacco.

The Burden of Tobacco in India According to the Global Adult Tobacco Survey, India is home to 275 million current tobacco users. This equates to 48% of Indian men over age 15 being current tobacco users, of which 24% of men are smokers and 33% are smokeless tobacco users. Among Indian women over age 15 years, 18% are smokeless tobacco users and 3% are smokers Source: Giovino GA, Mirza SA, Samet JM, et al. Tobacco use in 3 billion individuals from 16 countries: an analysis of nationally representative cross sectional household surveys. Lancet. Aug 2012; 380(9842):668-679.

Need for Cessation Services Nearly half of the current smokers (47%) and smokeless tobacco users (46%) want to quit their tobacco use (GATS 09-10) Nearly 2 out of every 5 smokers have attempted to quit (GATS 09-10) Among those who visited a health facility, less than half (46%) of smokers and less than one-third (27%) of smokeless tobacco users were advised by health care professionals to quit tobacco. (GATS 09-10)

Challenges and Opportunities High prevalence of smokeless tobacco use Need to adapt the evidence on tobacco cessation to the specific conditions of tobacco use in India Tobacco cessation medication is not affordable for most, but counseling may have a bigger effect than in the West Importance of family and social role

LifeFirst is a Tobacco Treatment Service that has been created to catalyse, build capacity and establish a high quality, proven tobacco cessation service. It is built upon international evidence base, standards and protocols (from Massachusetts General Hospital s Tobacco Treatment Service, Ottawa Model, Canada and National Health Service, UK) and adapted to the Indian context. The service aims to deliver a comprehensive, evidence based tobacco treatment for patients from all social strata. Components: 1. Service delivery 2. Training Service providers, tobacco free sites 3. Research Monitoring and evaluation, allied research

Ottawa Model for Smoking Cessation- Concepts referred OMSC in primary care Ottawa Model s components Ottawa Model Implementation Plan Ottawa Model for Smoking Cessation Program Management Database

Ottawa Model for Smoking Cessation- Concepts referred ASK AND DOCUMENT - Include tobacco use question as one of the patient s vital signs. ADVISE AND REFER - Provide strong, personalized, nonjudgmental advice to quit ACT For Patient who is READY TO QUIT: QUIT PLAN VISIT Strategic counseling Pharmacotherapy, Followup/Smokers Helpline For Patient who is NOT READY TO QUIT: Followup/Smokers Helpline ASK AND DOCUMENT Screening of OPD patients by counselor ADVISE AND REFER - Provide strong, personalized, nonjudgmental advice to quit by counselor ACT Intensive counseling and follow-up support(face-toface/phone) for 6 months For Patient who is NOT READY TO QUIT: Motivational interviewing and 5R s

Constraints in adaptation Pharmacotherapy Limited evidence in smokeless use Availability and affordability No dedicated Quitline for tobacco cessation

Ottawa Model Implementation Plan Phase 1 - Program Introduction Phase 2 - Baseline Assessment Phase 3 - Planning Clinic Tobacco Control Protocol Phase 4 - Training Phase 5 - Program Implementation ( Go Live Date) Phase 6 - Post-Assessment and Ongoing Quality Improvement Phase 7 - Sustaining the Program

Phase 1 - Program Introduction Meetings with the Municipal Commissioner and Medical Officer Health Meetings with Family Welfare Officer Joint meetings with Family Welfare Officer, Medical officers and staff at the two Urban Health Posts

Phase 2 - Baseline Assessment Baseline study to know- prevalence of tobacco use among OPD patients knowledge of health effects related to tobacco among patients Intention to make quit attempts Past quit attempts Willingness to enroll in a cessation service provided through the urban health post

Phase 3 - Planning Clinic Tobacco Control Protocol

Phase 4 - Training Training of counselor by Mayo Trained TTS Trained tobacco cessation counselor to provide intensive cessation counseling to OPD patients 1 day training for doctors, nurses and other health post and outreach staff in providing brief advice and referral to the counselor

Phase 5 - Program Implementation ( Go Live Date) LifeFirst cessation service launched in the presence of officials form the Municipal Corporation

Phase 6 - Post-Assessment and Ongoing Quality Improvement Monitoring visits by the core team Monthly reporting on set indicators Ongoing training to counselor

Phase 7 - Sustaining the Program Yearly reporting to the Navi Mumbai Municipal Corporation Meetings with the Medical Officers to share performance and program outcomes on a periodic basis

Results: 2 years report Patients enrolled so far- 458 Patients completed 6 follow-ups- 266 Self-reported 7-day PPA among patients completed 6 months (including loss to follow-up)- 26%

LifeFirst E-App LifeFirst team developed an Android based E-app to manage patient data and provide counseling effectively. Based on the 5A s approach. Based on Ottawa Model for Smoking Cessation Program Management Database

Ask- Screening patients TTS asks all admitted patients about their tobacco use (showing images of locally used tobacco products). Real-time data on patients tobacco use is entered into the E-App, and later used for counseling and followups.

Advice- Provide Brief Advice Videos and images on health effects of tobacco, benefits of quitting and association of tobacco use with current diagnosis is shown.

Assessing willingness to quit For patients willing to quit TTS contacts patients for a detailed 1st session based on the patient s stage of readiness to quit i.e. 1 month (preparation stage) or 6 months (contemplation stage) For patients not willing to quit- Using 5R s techniques with the help of multimedia(videos and images)

Assist in providing counseling For patients willing to quit, an electronic referral is made and an appointment is allotted. An SMS reminder is sent to the patient a day prior to the appointment and creates a list of appointments for the TTS.

Arrange System gives prompts on patients due follow-ups at set intervals(7 day, 15 day, 1 month etc.). Counselor can access data collected during the detailed session and use information during follow-ups.

Use for monitoring -Sample report received

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