Does a smoker have to remain a smoker always-evidence based tobacco cessation interventions: challenges and way forward in the Indian context.

Dear Editor-in-Chief

Quitting smoking is the single most important step a smoker can take to improve the length and quality of his or her life (www.lung.org). However, stopping smoking can be tough due to the addictive nature of nicotine. Thus, governments need to encourage smokers to quit and provide assistance to those who need help by formulating smoker-friendly policies. However, tobacco control efforts in developing countries such as India have mostly concentrated on advertising bans, package labeling, prohibition of smoking at public places and raising taxes. Such policies encourage the social norm of non-smoking and increase the demand for cessation services. However, poor cessation services will lead to more relapses and failed quit attempts. Several evidence based strategies like behavioral therapies, group and individual counseling, quitlines, pharmacotherapy (all forms of NRT, Bupropion, Varenicline), quit and win, text messaging have been repeatedly shown to increase quit rates significantly. Despite strong evidence based strategies, smoking cessation is not necessarily approached as a key tobacco-control strategy.

Challenges in the Indian context

High prevalence of smoking by health professionals, inadequate training of health care providers to deliver effective cessation interventions, lack of resources and government support, lack of infrastructure like cessation clinics and quitlines are the major hindrances. Smoking history taking is not a consistent feature of history taking. There is a gross lack of counseling during patient-physician interactions (1). According to GATS, less than half of smokers were advised to quit by their healthcare provider which is even lower (27%) for users of smokeless tobacco (2).

Way forward

Medical, dental and nursing curricula should address counseling techniques, cessation pharmacotherapy and be reinforced with practical training during patient interactions. The role of trained community health workers in implementing tobacco control policies in resource poor settings India can be very crucial in curbing the tobacco epidemic (3). Eliciting smoking history must be a routine component of history taking. Decreasing the out-of-pocket costs for cessation treatment increases quit attempts and the number of successful quitters (4). Thus, we should be thinking along the lines of Sri Lanka and Thailand where health insurance or the National Health Service supports the cost of cessation. Mass media should be promoted vigorously to advertise benefits of smoking cessation and availability of cessation services nearby. A quitline should be initiated to provide free counseling and other resources to quit and to prevent relapse for those who had already quitted. Tobacco cessation services should be integrated with the primary health care. It requires training of health professionals on cessation counseling and pharmacotherapy, access to low-cost pharmacological therapy by including in essential drug list of health facilities at various levels and raising community awareness about cessation services available.