|BRIEF RESEARCH ARTICLE
|Year : 2021 | Volume
| Issue : 3 | Page : 287-290
Outcomes of integrating quitline methodology in tobacco cessation delivered through a model tobacco treatment clinic of a private sector hospital at Rajasthan, India
Rakesh Gupta1, Garima Bhatt2, Sameer Narake3, Harsh Udawat4, Sonu Goel5
1 President, Rajasthan Cancer Foundation & Honorary Consultant, Tobacco Cessation; Department of Deaddiction, Santokba Durlabhji Memorial Hospital and Medical Research Institute, Jaipur, Rajasthan, India
2 Research Scholar, PGIMER, Chandigarh, India
3 Senior Statistician, Healis Sekhsaria Institute for Public Health, Navi Mumbai, Maharashtra, India
4 Senior Consultant, Departments of Gastroenterology and Deaddiction, Santokba Durlabhji Memorial Hospital, Jaipur, Rajasthan, India
5 Professor of Health Management, Department of Community Medicine, School of Public Health, PGIMER, Chandigarh, India
|Date of Submission||16-Feb-2021|
|Date of Decision||19-Apr-2021|
|Date of Acceptance||23-Jul-2021|
|Date of Web Publication||22-Sep-2021|
B-113, 10 B Scheme, Gopalpura Bypass, Jaipur, Rajasthan, Pin 302 018
Source of Support: None, Conflict of Interest: None
| Abstract|| |
India despite progress in tobacco cessation delivery in government sector has lagged in private health sector. Adopting a two-fold approach of intensive intervention-based counseling with (or without) pharmacotherapy; and prescheduled proactive follow-ups over the subsequent year, this study reports 337 tobacco patients, each followed for a period of 1 year. It observed a quit rate (QR) of 40.9% for total abstinence at 1 year but with a drop of 15.9% when patients were followed up, up to 6 months (49.6%) versus 6–12 months (34.7%). The pharmacotherapy did not benefit to whom it was prescribed (196 [58.2%] patients; QR: 34.7%) versus the rest to who it was either not prescribed or was declined (141 [41.8%] patients; QR 49.6%). Countrywide tobacco cessation clinics (TCCs) may be established in private sector hospitals, and the component of quitline methodology of making proactive calls may be integrated to improve QR in India.
Keywords: Follow-up, India, quitline, telephonic calls, tobacco, tobacco cessation clinic
|How to cite this article:|
Gupta R, Bhatt G, Narake S, Udawat H, Goel S. Outcomes of integrating quitline methodology in tobacco cessation delivered through a model tobacco treatment clinic of a private sector hospital at Rajasthan, India. Indian J Public Health 2021;65:287-90
|How to cite this URL:|
Gupta R, Bhatt G, Narake S, Udawat H, Goel S. Outcomes of integrating quitline methodology in tobacco cessation delivered through a model tobacco treatment clinic of a private sector hospital at Rajasthan, India. Indian J Public Health [serial online] 2021 [cited 2021 Dec 2];65:287-90. Available from: https://www.ijph.in/text.asp?2021/65/3/287/326386
Tobacco cessation has significant potential to maximize the benefits of tobacco control, not only physically but also socially and financially too. Toward this realization, the Ministry of Health and Family Welfare of the Government of India (GoI) has established around 500 tobacco cessation clinics (TCCs) through the National Tobacco Control Program (NTCP) at the primary and secondary levels of health-care delivery. In addition, it established a national tobacco quitline service (NTQLS) and its 3 regional subsidiaries and the mCessation program.
While the TCCs under NTCP are yet to report on quit rates (QRs), the NTQLS and mCessation have reported these as 38.81% and 19% over 1–3 weeks and 30 days, respectively., Furthermore, Indian studies published on tobacco cessation over the past 12 years by specific services, e.g. diabetes, chest diseases, etc., have reported QRs varying from 5% to 45% over 0–12 months.
On the contrary, the private health sector that accounts for over 70% of the total health system in India has failed to sufficiently equip itself with such TCCs. Hence, this study was undertaken with a specific objective to determine whether adopting the quitline methodology of a series of prescheduled follow-ups over the subsequent year (minimum of 6 months and a maximum of up to 12 months) can improve QRs of tobacco users treated in a private hospital TCC through intensive intervention (II) with/without pharmacotherapy.
This descriptive study with a longitudinal design was conducted in a TCC established in a tertiary care hospital in the private health sector with effect from September 05, 2017–September 04, 2019, among 350 patients. The hospital-registered patients were treated by the II (delivered over 30 min on average), with/without pharmacotherapy – a combination of nicotine replacement therapy (NRT) given with or without bupropion (BPR), prescribed only to those who were assessed the treating physician as addicted to tobacco on the basis of (1) the physical and mental needs/states of the patients and/or (2) his/her overall capability to quit tobacco.
All patients, registered from September 05, 2017, to September 04, 2018, were followed up proactively through at least 6 telephonic calls carried out in the subsequent 1 year (till 4th September 2019). The follow-ups were scheduled telephonic calls on the 3rd and 7th days as well as at the end of the 1st, 3rd, 6th, and 12th months. Each follow-up with the patients typically lasted for about 1–3 min with the aim to determine their quit status and to resolve the issues they faced during and after quitting. The patients self-reported the outcomes, which were then recorded by the first author for every call made. Those who stayed quit (i.e., total abstinence from all forms of tobacco), for 1 month or more from the “set quit date” were categorized as successful quit (SQ) whereas those who stayed quit for <1 month were categorized as staying quit. Those who failed to quit altogether from the “set quit date,” after a follow-up call after 1 week, were categorized as failed to quit. In addition, patients were categorized as nonresponders (NR) when they failed to respond to one of the 6 scheduled calls (above) and failed to connect in 2 more attempts in the subsequent week – on the 2nd and 7th days. Finally, those who had died were categorized as Dead (Dead). Those who have had started tobacco use after successful quitting were categorized as relapsed.
The sole inclusion criteria of this study (for a patient) were “to be a current tobacco user who was treated duly and completely and could be followed for 1 year from the date he was registered in the study.” The rest, i.e., those who were former users, dead, those unwilling to quit, or did not follow-up at all, were excluded. The study had the approval of the in-house ethics committee of the hospital. The data were analyzed using IBM SPSS Statistics for Windows, Version 25.0. IBM Corp. Released 2017. Armonk, NY, USA.
Out of the enrolled 350 patients registered, 337 patients (96.2%) were eligible for the study and the remaining 13 patients (3.72%) were excluded as per the criteria mentioned above. The majority (76.6%) were males who smoked and were between 30 and 59 years of age. Independently, males and smokers constituted 92.6% and 48.7%, respectively, in the total study sample. After setting the quit date, 71.5% stayed with it whereas the rest (28.4%) changed it more than once. Pharmacotherapy was prescribed to 196 (58.2%) patients out of which compliance of its use could be confirmed only in one-fourth (24.9%).
[Table 1] presents the outcomes of the study after 1-year follow-up. The NR rate was 9.5% (n = 32). Among the responders (n = 305, 90.5%), 138 patients (40.9%) had quit successfully (SQ), 82 patients (24.3%) failed to quit, 67 patients (19.9%) relapsed, and 18 patients (5.3%) died of their primary disease. The QR was higher in the follow-up up to 6 months (49.6%) as compared to those over 6 months (34.7%). However, it did not vary either for the age or the type of tobacco used. The QR was the highest (48.1%) for those who stayed with the quit date set at the initial interaction. However, among those who altered it 2nd, 3rd, or 4th time, it was observed to be 21.9%, 26.1%, and 14.3%, respectively.
Furthermore, in 141 patients (41.8%) who did not avail pharmacotherapy, the quit rate was 49.6% vs. the rest 196 (58.2%) in whom it was 34.7%. Among those who were prescribed pharmacotherapy, 84 patients (24.9%) were given a combination of NRT with BPR vs. 33 patients (9.8%) and 49 patients (14.5%), respectively, who were prescribed either NRT or BPR alone. The former had a quit rate of 29.8% whereas the latter had a QR of 39.4% and 44.9%, respectively. Thus, a better outcome was achieved by those who did use pharmacotherapy. Overall, the cumulative influences of (1) their consultant's referral to the TCC and thus the patients' readiness to quit; (2) the skills empowered through the counseling to stay quit; and (3) the regularity of the prescheduled follow-ups by the treating physician “at no cost” appear as the contributory factors of higher QR observed among the nonusers of pharmacotherapy.
It is important to note that the higher QRs in the current study are in contrast to the other studies that have been conducted in India and globally.,, A plausible reason for this outcome could be the presence of specific settings with repetition of the reminder to “stay quit” through proactive follow-up calls. Furthermore, customizing the methodology of calls in each patient (as per his/her profile as well as the respective stage of behavioral changes) is an important factor due to the complex behavior of tobacco users, where both psychological and environmental factors play a critical role. We consider that this customization has led to better outcome due to an increase in the efficacy of the follow-up. Few studies have also observed similar QRs.
The strengths of the current study are (a) an ability to integrate quitline methodology to ensure a maximum possible follow-up proactively and (b) the general acceptance of the patients toward such a methodology through their phones versus a follow-up visit to the TCC each time. Its limitations are (a) an inability to verify the outcomes biochemically and to further investigate into the decision taken by the patient about the use of pharmacotherapy and (b) an under-representation of the results for a large population as compared to a specific private tertiary care setup.
To conclude, this study fulfilling its objectives of successfully establishing a TCC in a private sector hospital and achieving a QR of 40.9% over 1-year follow-up paves the way forward for the GoI to consider formulating a comprehensive policy to establish TCCs in the private health sector countrywide and add-on component of prescheduling proactive follow-ups (as in quitlines) to behavioral counseling with/without pharmacotherapy to achieve higher QR in future.
Toward their anticipated higher success, it should incentivize these by supplementing resources matching with TCCs operational under NTCP and monitor these for a robust implementation toward their effectively sustained operation.
The authors are grateful to the hospital administration of Santokba Durlabhji Memorial Hospital and Medical Research Institute, Jaipur, for facilitating the study, Dr. PC Gupta, Director, Healis-Sekhsaria Institute of Public Health, Mumbai, for facilitating the statistical analysis and Dr. Abhijeet Gupta, Post-Doctoral researcher, Heinrich Heine University, Dusseldorf, Germany, to revise the text for English language.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
United States Public Health Service Office of the Surgeon General; National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. Smoking Cessation: A Report of the Surgeon General [Internet]. Washington (DC): US Department of Health and Human Services; 2020. PMID: 32255575.
Kumar R, Jha A, Munish V, Pusp A, Sinha P, Gupta P, et al
. National tobacco quitline: The preliminary Indian experience. Indian J Chest Dis Allied 2018;60:712.
Gopinathan P, Kaur J, Joshi S, Prasad VM, Pujari S, Panda P, et al
. Self-reported quit rates and quit attempts among subscribers of a mobile text messaging-based tobacco cessation programme in India. BMJ Innov 2018;4:147-54.
Rakesh Gupta, Sameer Gupta R, Narake S, Udawat H, Gupta PC, Gupta GN. Proactive Telephonic Follow-up Calls by a Tobacco Cessation Clinic (TCC): Optimization for the Number of Calls. JIDA: Journal of Indian Dental Association 2020;14:12-8.
Rovina N, Nikoloutsou I, Katsani G, Dima E, Fransis K, Roussos C, et al
. Effectiveness of pharmacotherapy and behavioral interventions for smoking cessation in actual clinical practice. Ther Adv Respir Dis 2009;3:279-87.
Wadgave U, Nagesh L. Nicotine replacement therapy: An overview. Int J Heal Sci 2016;10:425-35.
Wu L, He Y, Jiang B, Zuo F, Liu Q, Zhang L, et al
. Effectiveness of additional follow-up telephone counseling in a smoking cessation clinic in Beijing and predictors of quitting among Chinese male smokers. BMC Public Health 2015;16:63.