Smoking Cessation Intervention in a Rural Healthcare Setting in South-India. A Pilot Feasibility Study.

Abstract

Introduction Tobacco kills about eight million people every year with seven million deaths caused due to direct tobacco use and 1.2 million deaths due to second-hand smoke exposure. Eighty per cent of the world’s 1.1 billion smokers live in low- and middle-income countries (LMICs). Yet, support for smokers to quit is limited, especially in low and middle-income countries. Many live in remote rural settings, as in India. Smoking cessation is vital to reducing tobacco-related morbidity and mortality. Most smoking cessation research occurs in high-income countries and its applicability to LMICs is unclear. There is convincing evidence about the role of healthcare providers in providing smoking cessation. However, nicotine is highly addictive and there is a need to build a system of a continuum of care for continued support for smokers who are likely to relapse several times during their quit attempts. I aimed to undertake a theory-based, contextually adapted smoking cessation intervention and evaluate its feasibility and effectiveness in a rural healthcare setting in South India. The key feature of the intervention was an integrated health-facility and community-based system to deliver smoking cessation. Methods Cognisant of the multidimensional drivers of smoking behaviour, we used Michie’s Behaviour Change Wheel (BCW) framework to design a smoking cessation intervention in a rural healthcare setting in India. A systematic review of smoking cessation interventions in low- and middle-income countries was undertaken to draw on the findings and incorporate them into the intervention design. The focus of the systematic review was the identification of key intervention strategies and abstinence outcomes through a narrative synthesis. Following the BCW framework, the target problem was identified and specified in behavioural terms through a process of iterative consultations with the core supervisory team. A workshop involving the public health experts at the University of Auckland aided in mapping the evidence-based behaviour change techniques (BCT) to the theoretical determinants of capability, opportunity and motivation for behaviour change (COM-B) that forms the crux of the BCW framework. This was followed by a contextual adaptation of the smoking cessation intervention through qualitative interviews and focus group discussions involving key implementers and target population in the study setting. The co-designed intervention was evaluated through a parallel, two-arm, pragmatic randomised controlled trial. Male adult out-patients aged 18 years or above, smoking at least one cigarette per week, were included in the trial. The ABC (ask - brief advice - cessation support) arm involved physician-led ABC and trained lay-counsellor-led cessation support in the first face to face session followed by two telephonic follow-up counselling by counsellors in the first and fourth weeks. The ABC-Plus arm, in addition also included community health-worker-led face to face home-based follow-up support in the second and third weeks. Smoking abstinence outcomes was evaluated using urine-cotinine validated fourteen-day point prevalence of abstinence measured six months after randomisation. The feasibility was quantitatively evaluated using the recruitment rate and adherence to ABC tasks at the hospital level and follow-up rate at the community level. This was followed by a post-intervention qualitative study involving the key implementers and the target population to evaluate the acceptability and feasibility. Results Through the systematic review, a total of 6398 studies were retrieved from the electronic databases and expert reference and cross-references. Abstract screening followed by a full-text review resulted in the inclusion of 33 studies. The most notable interventions shown to be effective were intensive behavioural support undertaken at healthcare facilities especially TB clinics and diabetes clinics; a combination of intensive face to face behavioural support and telephonic follow-up and pharmacotherapy especially nicotine replacement therapy as an adjuvant to behavioural support. The hospital-based opportunistic screening was the most frequent approach to identify potential smokers. There is a paucity of studies available on the other pharmacological therapy options such as bupropion and varenicline. The key findings of the intervention development were as follows; The target behaviour was ‘smokers quit smoking at all places and at all times’. The key barriers to smoking cessation were lack of knowledge, easy availability of cigarettes, poor family support system due to lack of woman empowerment, frequent interaction with peer smokers and lack of availability of smoking cessation services with untrained personnel at the healthcare facilities. The key enablers were a high sense of self-efficacy especially among those with a history of past quit attempts, strong sacrificial attitude for the welfare of the family members, a strong sense of interconnectedness and wanting to conform to societal norms and the implementing team’s experience in providing community-centred healthcare were the key enablers to implementing the smoking cessation intervention. A contextually adapted intervention including 26 BCTs was developed to address capability, opportunity and motivation for smoking cessation. The key findings of the intervention trial were as follows; One hundred and forty-six individuals were randomised between January and March 2018. Over this period, the hospital attended to an average of 16 male adults daily, of whom a sixth were identified as smokers. Being asked about smoking increased from 29.3% in the first week to 91.9% in the last week of recruitment. Brief advice from physicians increased from 33.6% in the first week to 82.6% in the last week of recruitment. ABC documentation among physicians increased from 9.5% in the first week to 82.6% in the last week. The cessation support from counsellors increased from 70% in the first week to 93.3% in the last week. The biochemically verified fourteen-day point prevalence in the ABC-Plus arm and the ABC arm were 25% and 10.8% respectively. The difference was statistically significant (p=0.025). The other two outcomes that were significantly greater in the ABC Plus arm than the ABC arm were smoking reduction and smoke-free homes. The key findings of the post-intervention consultations revealed that the intervention was highly acceptable to participants and implementers. The anticipated benefits of quitting on their family members especially to their children and the strong sense of family-interconnectedness strongly motivated them to quit smoking. Conclusions In this rural Indian setting, implementing the ABC approach was feasible. Combining ABC with community-based cessation support was also feasible and more effective than hospitalbased intervention alone. Contextual adaptation of the BCW framework provides an acceptable and practical approach to developing a smoking cessation intervention in a rural Indian context.