A Community Intervention Trial for Smoking Cessation in Rural Kerala, India

Abstract

Yhteisöinterventio auttaa miesten tupakoinnin lopettamista Keralan maaseudulla

Tupakointi on maailmanlaajuinen terveysongelma – niin myös Intiassa, jossa 48% miehistä ja 20% naisista käyttää tupakkaa joko polttamalla tai muussa muodossa. Tupakkakuolemien vähentämiseksi Intia laati vuosina 2007-08 tupakanvastaisen lainsäädännön, jonka yksi päätavoite oli lopettamisen helpottaminen.

Väitöskirjaprojektin aineisto perustui tupakoinnin lopettamiseen tähtäävään interventiotutkimuksen, joka tehtiin Intian lounaisosassa sijaitsevan Keralan osavaltion maaseudulla, missä miesten tupakanpoltto on yleisempää (28%) kuin muualla Intiassa (24%). Mukaan valittiin yli 3000 miestä jotka olivat iältään 18-60 vuotta (viideltä interventio- ja kuudelta vertailualueelta). Heidän tupakointitottu-muksensa ja nikotiiniriippuvuutensaarvioitiintutkimuksen alussa. Interventioalueella asuville tehtiin lääketieteellinen tutkimus ja annettiin ryhmäneuvonta tupakoinnin lopettamiseksi. Lisäksi heille järjestettiin neljä käynti- tai puhelinneuvontakertaa 26 viikon aikana. Neuvonnan suorittivat koulutetut sosiaalityöntekijät.

Tupakointitavat selvitettiin uudelleen vuoden kuluttua. Sekä interventio- että vertailualueella tupakointi oli vähentynyt, mutta interventioalueella (15%) lopettaneita oli kaksi kertaa enemmän kuin vertailualueella (7%). Vielä selvemmin väheni tupakoijien polttamien savukkeiden määrä.

Tulokset osoittavat että ryhmäneuvonta on toimiva tapa vähentää tupakointia myös maaseudun vähän koulutetun väestön joukossa. Tupakoinnin lopettamismenetelmä voitaisiin integroida hallituksen käynnissä oleviin terveysohjelmiin ilman lisäresurssitarpeita.

A Community Intervention Trial for Smoking Cessation in Rural Kerala, India

Tobacco related mortality has emerged as a major public health problem in the world. The magnitude of the problem is massive and catastrophic for India, where nearly a million deaths annually are attributed to tobacco consumption. Currently 48% of males and 20% of females in India are tobacco users. In view of the rising tobacco consumption and the mortality associated with it, the Government of India has enacted the National Tobacco Control Programme in the year 2007-08, where apart from strengthening legislation, one of the core areas envisaged was tobacco cessation. In a country where majority of the tobacco users live in rural areas, there is an urgent need to develop intervention programmes for tobacco cessation in the rural community.

The state of Kerala located in the south west corner of India, represents 3% of India’s population. Kerala ranks top in human development indicators and is a model for other states in the country. However, rise in tobacco consumption has emerged as a major public health problem in the state. It was estimated that 35.5% males and 8% females in Kerala use tobacco in some form or the other. The smoking prevalence (27.9%) among males was reported to be higher than the national average (24.3%). This dissertation explored the effectiveness of a proactive community-based smoking cessation programme in the southern state of Kerala in India. The dissertation also attempts to illustrate the tobacco prevalence, nicotine dependence and the multiple approaches that have been adopted for intervention programmes in the community.

The study was conducted in 4 selected rural Community Development Blocks (An administrative system prevailing in rural areas of the country) of relatively uniform socio-demographic characteristics in a southern district of Kerala using a multistage sampling method. 11 wards/clusters (the lowest level of administrative system) was identified from the blocks, which include 5 intervention and 6 control clusters. Men aged 18–60 years were interviewed by trained health workers through a house to house survey. ‘Current daily smokers’ were thus identified for the study. Nicotine dependence was assessed using the Fagerstrom Test for Nicotine Dependence scale on a scale of 1 to 10, where the maximum score denotes very high dependence to nicotine.

In the intervention area, four rounds of counselling (2-4 weeks, 4-6 weeks, 3 months and 6 months) were conducted after conducting the baseline survey in a span of one year by trained medical social workers. Initially a medical camp and group counselling was conducted in all the intervention clusters after completion of the baseline survey. The common modes of counselling were face to face counselling and telephone counselling. Self-reported smoking status was assessed at 12 months after completion of the baseline survey.

3304 subjects were interviewed about the tobacco use status. Among them, 928 respondents (28%) were ‘current daily smokers’ of cigarette/bidi (Bidi is locally made by casing coarse tobacco in dried temburni leaf). Of the current smokers, intervention groups consisted of 474 subjects (average age 44.5 years) while the control group had 454 subjects (average age 44.6 years). In general, the intervention and control groups were comparable in terms of age, socio-economic status and nicotine dependence score. The overall nicotine dependence score was 5.06, which represents moderate nicotine dependence. The scores in the control and intervention groups were 4.75 and 5.33 respectively.

The self reported 7 day point prevalence rates of smoking abstinence was 14.7% in the intervention and 6.8% in the control group with a twofold quit rate in the intervention group. Lower number of cigarettes/bidis, low nicotine dependence score and doctor consultation were the significant predictors for smoking cessation in the study. At the end of 12 months, 41.3% subjects in the intervention area and 13.6% in the control area had reduced smoking by 50% or more. The study demonstrated that proactive smoking cessation intervention utilizing multiple methods could enhance quit rates in smoking in rural areas of India.