smokeless tobacco SLT use Pratima Murthy Professor of Psychiatry Head Centre for Addiction Medicine National Institute of Mental Health and Neuro Sciences Bengaluru India Format of presentation ID: 1014692
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1. Challenges in cessation of smokeless tobacco (SLT) usePratima MurthyProfessor of PsychiatryHead, Centre for Addiction MedicineNational Institute of Mental Health and Neuro SciencesBengaluru, India
2. Format of presentationEnumerate and discuss the challenges from smokeless tobacco useExperiences with smokeless tobacco cessationChanges in prevalence of smokeless tobacco between GATS India 1 and GATS India 2Stepping up smokeless tobacco cessation
3. Challenge 1A large population that uses smokeless tobacco (SLT)SEAR has double burden of high prevalence of smoking (1 in 5) and SLT use (1 in 5). SLT use is higher in rural areas (1.25-3 times) and in the poorest communities (3-17 times) in SEAR and African Region. Among women tobacco users globally, SLT is the predominant form of tobacco used. SLT use among adolescents in SEAR is higher than smoking.NICPR 2017
4. Challenge 2More than 40 types of SMT products in the South Asian Region, particularly India (including gutka, khaini, mawa, mishri, kaddipudi, tambaku, snuff, lal dant manjan etc)WHO 2012
5. Marked variability in nicotine content of SLT productsSharma et al 2015Type of SLTAverage tobacco weight/unit (g)Average nicotine content mg/g tobaccoMishri 50.5±0.705.03±0.07Khaini5.9±0.896.6±2.64Kaddipudi49.0±1.45.3±0.565Tambaaku5.7±3.913.7±7.6Gutka2.0±0.923.2 5±0.7 0
6. Challenge 3- Positive expectancies from SLT useEnjoymentTime passBoredomRelief of tirednessMood reliefHabitEase of bowel movementMurthy et al 2018Good alternative to smoking Can “Chew and Work”Financial perspectivePoint of sale advertising
7. Verbatim response of SLT users‘Only a few get cancer; I know I spend money on this, but why should I spend all the money on my family and not on me. I don’t spend on clothes or bangles…’‘No health problems- in fact, it helps digestion and bowel movement; I stopped once and felt the world was coming to an end’‘I use without their knowledge; I don’t chew at the workplace because of fear of losing my job; I would rather quit my job than quit tobacco. Only the rich object, though some of them also use tobacco of higher quality which smells better’‘I have been using it for many years. nothing has happened. Why should I stop? I am not sure if the problems I have are due to my work or because of tobacco; If anyone wants to leave tobacco they can leave…but it’s not easy to leave; I think drinking (alcohol) is more problematic and lot of money gets spent. I only spend five rupees daily. Please help us to get treatment for drinking (for husbands’)“I took my wife for TB treatment, the doctor asked me is she smokes bidis. I did not tell him about my tobacco use, I felt it was not important; Who can help us? doctors themselves chew!”Murthy et al 2018
8. Challenge 4- Normalisation of SLT useOften used in panRole models within the family (Modeling)Peer approvalEasy availabilityPerceived psychological benefitsSocial and religious sanction
9. Factors influencing SLT use and maintenanceMurthy et al 2018
10. Challenge 5: Vulnerable populations - womenRisks associated with SLT use for mother Studies from LMIC Maternal anemia Underweight mothers Pregnancy induced hypertension Ante-partum haemorrhage Oligohydramnios Polyhydramnios Post-partum haemorrhage Adverse fetal outcomes associated with maternal SLT use during pregnancy Still birth (HR adj)= 2.6 Fetal distress (RR=1.8 (1.06-3.06) Low birth weight Pre-term births Small for gestational age (SGA) Murthy and Mishra 2017Adverse maternal and fetal consequences of maternal smokeless tobacco use
11. Challenge 6- Vulnerable populations -AdolescentsSLT use is prevalent in adolescents in 106 countries Prevalence even more prominent in boys in LICs and LMICsSLT products are easily available and accessible Taxation on SLT products is lower than cigarettes in most LICs & LMICs, thus affordability is highThere is evidence that oral cancer is increasing at a younger age group in some LIC and LMICsSinha et al 2017
12. Experiences with SLT cessation Pioneering community awareness programmes were from India in the 1980’s and 1990sQuit rates of tobacco following health awareness consistently higher among chewing tobacco users compared to smokers in community studiesSimilar experience in tobacco cessation clinics in India
13. Tobacco cessation clinics- one year self-reported quit/>50% reduction in tobacco useTCCs India
14. M-CessationGOI has initiated mobile based tobacco cessationRegistration through a missed call (011-22901701) or onlineReceive text message about the need and ways to quitInformation materials are present on the national health portal website.http://www.nhp.gov.in/quit-tobacco14
15. Preliminary experience with MCessationThrough National Health Portal in India since December 20151.8 million call-ins in one year150 behavioural change SMS messages, including health information, tips on quitting, and encouragement for those who want to quit. Programme evaluation of 3362 ever users (among 10340 Mcessation callers):15% were current smokers29% current users of smokeless tobacco14% used both smoking and smokeless forms.
16. M-Cessation experience in India66% of registered users had made a quit attempt in the last monthOverall past 30-day quit rate at 4–6 months of follow-up 19.06%Gopinathan et al 2018
17. Low access to tools/aids to quit tobaccoApart from Text messaging only 15% [97/643] reported access to any other tools/aids for tobacco cessation Of those who had received additional aids, One- third reported Counseling/NRT; One- fifth medications like Bupropion, traditional medicines, access to a Quit Line or specific support for SMT Cessation (IIHMR 2017)
18. Tobacco Quitlines- preliminary Indian experienceStarted at the VP Chest Institute, New Delhi in 2016Expanded to three more centres in the country in 2018 (NIMHANS, Tata Memorial, RCC Assam)Encouraging preliminary results from VPCI with 38.8% or registered callers reportedly quitting on the quit date
19. Policy – Impact of the Gutka Ban in IndiaWith the ban on Gutka in India, there has been an overall reduction in Gutka use. A 2014 study of retail environments and gutka users in 7 states (Ex and current):Less consumption of gutka after the banMost users bought pan masala and tobacco separately15% still continued to use gutkaA substantial proportion of users (from 41- 88%) reported that they “quit using gutka because of the ban” www.globaltobaccocontrol.org
20. Overall impact of tobacco control measures- an illustrative example from IndiaGATS 1GATS 2Current SLT users25.9%21.4%Current SLT users [male]32.9%29.6%Current SLT users [female]18.4%12.8%
21. Steps for up-scaling tobacco cessation servicesHealth provider focus on SLT in addition to smokingIntegrating tobacco cessation with alcohol cessation in primary care (Sabari et al 2017)Packaging and display of ingredientsCommunity engagementOral examinationLinkages with NCD programmesTowards an Ecological Model
22. Smokeless Tobacco Cessation- miles to goDe-normalisation of SLT useWide menu of resources to quitExpanding services in group and community settingsTraining a range of health professionals in brief counsellingIncreasing accessibility to cessation treatmentsGreater research in SLT cessationExtend reach to completely unserviced areas- like prisonMonitoring the trends