What is Stop-smoking services: Purpose, Procedure, Results & Costs in India

Tobacco use stands as one of India's most pressing public health crises, casting a long shadow over the nation's health and economy. With an estimated 275 million adults engaging in tobacco consumption – whether smoking or smokeless forms – the statistics are alarming. This pervasive habit tragically claims approximately one million lives annually, contributing significantly to a myriad of preventable diseases including various cancers, cardiovascular conditions, chronic respiratory illnesses, and strokes. The human cost is immeasurable, impacting families, communities, and the nation's developmental progress.

In the face of such a formidable challenge, Stop-smoking services emerge as a beacon of hope and a critical intervention. These services are not merely about urging individuals to quit; they represent a comprehensive, evidence-based approach designed to empower tobacco users with the tools, support, and medical assistance needed to break free from addiction. They are a crucial component of India's broader public health strategy, aiming to curb tobacco-related morbidity and mortality, thereby fostering a healthier, more productive populace. This blog delves into the intricate world of stop-smoking services in India, exploring their purpose, the procedures involved, the preparation required, the encouraging results achieved, and the financial considerations, ultimately highlighting their indispensable role in shaping a tobacco-free future.

What is Stop-smoking services?

Stop-smoking services, often referred to as Tobacco Cessation Services, are structured, evidence-based programs and interventions designed to help individuals quit tobacco use. In India, these services are tailored to address the diverse forms of tobacco consumption, including cigarettes, bidis, hookahs, and various smokeless tobacco products like gutkha, khaini, and zarda. They acknowledge that nicotine addiction is a complex, chronic, and relapsing brain disorder, requiring a multi-faceted approach rather than simple willpower alone.

At their core, stop-smoking services provide a combination of behavioral support, pharmacological treatments, and ongoing guidance. They are built on the understanding that quitting tobacco is a journey, not a single event, and often involves multiple attempts. These services aim to:

• Identify Tobacco Users: Systematically screen and document tobacco use status for every patient encountered in healthcare settings.
• Offer Tailored Advice: Provide strong, personalized advice to quit, emphasizing the health benefits and addressing individual concerns.
• Assess Readiness to Quit: Understand the individual's motivation and stage of change, customizing interventions accordingly.
• Provide Active Support: Offer practical strategies, coping mechanisms, and medical interventions to manage withdrawal symptoms and cravings.
• Arrange Follow-up: Ensure sustained abstinence through regular check-ins and relapse prevention strategies.

In India, these services are being integrated into various levels of healthcare, from primary health centers to district hospitals, and are also extended through national helplines and community-based programs. Their comprehensive nature is crucial for tackling the widespread and deeply entrenched habit of tobacco use across the country. By offering accessible and effective cessation strategies, stop-smoking services become a vital lifeline for millions striving to reclaim their health and lives from the grip of tobacco addiction.

Why is Stop-smoking services Performed?

The performance of stop-smoking services in India is driven by an urgent and profound public health imperative. The devastating impact of tobacco on individual health and national well-being necessitates robust interventions. The primary reasons these services are performed include:

• Reducing the Burden of Tobacco-Related Diseases: Tobacco is a leading cause of non-communicable diseases (NCDs) in India. Performing stop-smoking services directly aims to:

  • Prevent Cancers: Significantly lower the risk of oral, lung, throat, esophageal, bladder, and many other forms of cancer.
  • Combat Lung Diseases: Reduce the incidence and severity of chronic obstructive pulmonary disease (COPD), asthma, and other respiratory ailments.
  • Mitigate Cardiovascular Risks: Decrease the likelihood of heart attacks, strokes, high blood pressure, and other heart-related conditions.
  • Manage Diabetes: Improve blood sugar control and reduce complications in individuals with diabetes.
  • Improve Overall Health: Enhance general well-being, life expectancy, and quality of life.

• Encouraging Current Tobacco Users to Quit: The most direct purpose is to motivate and support the vast existing population of tobacco users in India to make a successful quit attempt. This involves moving individuals from contemplation to action, providing them with the necessary tools and encouragement.

• Preventing Initiation Among Non-Users: While primarily focused on cessation, these services indirectly contribute to prevention by fostering a societal environment that de-normalizes tobacco use and highlights its severe consequences. Successful quit stories can inspire others and reinforce anti-tobacco messages.

• Making Cessation Therapy Accessible: A significant challenge in India is the accessibility of healthcare, especially in rural and underserved areas. Stop-smoking services strive to democratize access to evidence-based cessation support, ensuring that geographical location or socio-economic status does not become a barrier to quitting. This includes leveraging tele-counseling and community outreach programs.

• Integrating Tobacco Cessation into Routine Healthcare Practices: Historically, tobacco cessation might have been an afterthought in clinical consultations. A key purpose of these services is to embed tobacco cessation into every patient interaction, making it a routine part of primary healthcare. This means doctors, nurses, and other healthcare professionals are trained and empowered to address tobacco use as a vital sign, offering brief interventions and referrals.

• Addressing the "Risks" of Continued Use and Relapse: The "risk" of not quitting is severe – continued exposure to deadly toxins, leading to premature death and debilitating illness. Furthermore, nicotine addiction is a chronic, relapsing brain disorder, meaning many individuals might attempt to quit multiple times before succeeding. Stop-smoking services are performed precisely to mitigate these risks by:

  • Minimizing Health Consequences: Directly reducing the immediate and long-term health detriments of tobacco.
  • Preventing Relapse: Providing ongoing support and strategies to help individuals maintain abstinence and navigate triggers.
  • Countering Shifting Habits: Addressing the potential for users to switch from one form of tobacco to another (e.g., smoking to smokeless), ensuring complete cessation from all tobacco products.

By performing these services, India aims to build a healthier nation, reduce healthcare expenditures associated with tobacco-related diseases, and empower individuals to live longer, healthier lives free from the grip of addiction.

Preparation for Stop-smoking services

The effectiveness of stop-smoking services hinges critically on the preparedness and competence of healthcare professionals. In India, while the need for these services is immense, the preparation of the workforce to deliver them has been a recognized challenge.

Current Gaps in Preparation:

• Inadequate Training in Medical Education: Studies reveal a significant lacuna in formal medical education regarding tobacco cessation. A mere 21.3% of medical professionals report having received adequate tobacco cessation training during their undergraduate or postgraduate studies. This means many doctors enter practice without a solid foundation in how to effectively counsel and assist patients who want to quit.
• Minimal On-the-Job Training: Beyond formal education, on-the-job training in tobacco cessation is also notably scarce, with only 18.9% of physicians in primary care public health facilities receiving such training. This further exacerbates the knowledge and skill deficit, leaving many practitioners ill-equipped to address a prevalent health issue.
• Lack of Confidence and Skills: As a consequence of insufficient training, many healthcare professionals may lack the confidence, skills, and practical tools to initiate conversations about tobacco use, provide effective counseling, or prescribe appropriate pharmacotherapy. This can lead to missed opportunities for intervention during routine patient visits.
• Systemic Barriers: Beyond individual training, systemic issues like time constraints during consultations, lack of resources (e.g., counseling materials, NRT availability), and insufficient institutional support can also impede the delivery of cessation services.

Addressing the Need for Better Preparation:

Recognizing these gaps, there is a strong and recognized need for concerted efforts to enhance the preparedness of healthcare providers:

• Integration into Medical School Curricula: The government and medical education bodies are increasingly emphasizing the urgent need to integrate comprehensive tobacco cessation training into the core medical school curricula. This would ensure that future doctors are equipped with the foundational knowledge and practical skills from the outset of their careers.
• Structured On-the-Job Training Programs: Implementing well-designed, standardized, and accessible on-the-job training programs for practicing physicians, nurses, and other healthcare professionals is crucial. These programs should focus on:
  • The "5 A's" Framework: Providing practical training on how to Ask, Advise, Assess, Assist, and Arrange cessation interventions.
  • Behavioral Counseling Techniques: Equipping professionals with effective communication strategies, motivational interviewing skills, and relapse prevention techniques.
  • Pharmacotherapy Management: Training on the appropriate use, dosage, and side effects of Nicotine Replacement Therapy (NRT), bupropion, and varenicline.
  • Referral Pathways: Educating staff on how to effectively refer patients to specialized tobacco cessation clinics or quitline services when needed.
• Empowering Dental Professionals: Dental professionals, given their frequent interaction with patients for oral health issues, are uniquely positioned to identify and intervene with tobacco users, especially those using smokeless tobacco. Efforts are underway to train dental professionals to deliver structured tobacco cessation services, leveraging their expertise in oral health to highlight the direct impacts of tobacco.
• Developing Training Modules and Resources: Creating easily accessible, culturally appropriate training modules, educational materials, and clinical guidelines can standardize the approach to tobacco cessation across various healthcare settings.
• Building a Supportive Environment: Fostering an institutional culture that prioritizes tobacco cessation, provides necessary resources, and supports healthcare providers in delivering these services is essential for long-term success.

By systematically addressing the preparedness of healthcare professionals, India can significantly bolster the reach and efficacy of its stop-smoking services, transforming healthcare settings into crucial points of intervention against tobacco addiction.

The Stop-smoking services Procedure

The procedure for delivering stop-smoking services in India is typically structured around evidence-based interventions designed to offer comprehensive support. These procedures integrate counseling, pharmacotherapy, and follow-up to address the multifaceted nature of nicotine addiction.

The "5 A's" Framework: A Core Counseling Tool

The "5 A's" framework is a widely adopted, systematic approach for healthcare professionals to intervene with tobacco users during routine clinical encounters. Each 'A' represents a critical step:

1. Ask: This is the foundational step. Healthcare providers are trained to ask every patient, regardless of their presenting complaint, about their tobacco use status. This includes identifying if they use smoking tobacco (cigarettes, bidis, hookahs) or smokeless tobacco (gutkha, khaini, zarda), the frequency, and duration. Documenting this information as a "vital sign" ensures no opportunity for intervention is missed.

   • Example: "Do you currently use any tobacco products, such as cigarettes, bidis, or smokeless tobacco like gutkha?"

2. Advise: Once tobacco use is identified, the healthcare provider must advise the patient strongly and clearly to quit. This advice should be personalized, empathetic, and delivered in a non-judgmental manner, highlighting the specific health risks relevant to the patient (e.g., impact on existing medical conditions like diabetes or heart disease) and the benefits of quitting.

   • Example: "Quitting tobacco is the single most important thing you can do for your health right now. It can significantly reduce your risk of [mention specific health issue]."

3. Assess: The next step is to assess the patient's readiness to make a quit attempt. This involves understanding their motivation, perceived barriers, and confidence levels. Patients can be categorized as ready to quit, contemplating quitting, or not ready to quit. This assessment guides the subsequent intervention strategy.

   • Example: "Are you interested in quitting tobacco in the next 30 days?" or "What are your thoughts on quitting?"

4. Assist: For patients who are ready or contemplating quitting, the provider must assist them in their quit attempt. This is the most comprehensive step and often involves a combination of strategies:

   • Behavioral Interventions: This is a cornerstone, delivered through individual or group counseling. It includes:
     • Problem-solving/Skills Training: Helping patients identify triggers, develop coping mechanisms, manage stress, and avoid high-risk situations.
     • Motivational Interviewing: Using patient-centered counseling to explore and resolve ambivalence about quitting.
     • Self-Help Materials: Providing brochures, pamphlets, and digital resources that offer practical tips, success stories, and information on the benefits of quitting.
     • Relapse Prevention Strategies: Preparing patients for potential setbacks and teaching them how to recover from a lapse.
   • Pharmacotherapy: Medications are used to manage nicotine cravings and withdrawal symptoms, making the quitting process less uncomfortable. These include:
     • Nicotine Replacement Therapy (NRT): Available in various forms like gums, patches, lozenges, inhalers, and nasal sprays. NRT delivers nicotine without the harmful chemicals found in tobacco, gradually reducing dependence.
     • Bupropion: An antidepressant that can reduce nicotine cravings and withdrawal symptoms.
     • Varenicline: A non-nicotine medication that works by reducing the pleasure derived from nicotine and easing withdrawal symptoms.
   • Referral: Patients requiring more intensive support can be referred to specialized Tobacco Cessation Clinics (TCCs) or the National Tobacco Quitline Services (NTQLS).

5. Arrange: The final 'A' involves arranging follow-up contacts. This is crucial for sustained abstinence and relapse prevention. Follow-up can be scheduled via phone calls, in-person visits, or digital communication. During follow-up, providers check on the patient's progress, address challenges, reinforce motivation, and adjust treatment plans if necessary.

   • Example: "Let's schedule a call next week to see how you're doing with your quit attempt." or "Please come back in two weeks so we can review your progress."

Additional Procedural Components:

Beyond the "5 A's," several other procedural components bolster stop-smoking services in India:

• National Tobacco Quitline Services (NTQLS):

  • Operated by the Ministry of Health and Family Welfare, this toll-free helpline (1800-11-2356) provides telephonic counseling in various regional languages.
  • Counsellors use structured protocols to guide callers through the quitting process, offering personalized advice and support.
  • A critical feature is the provision of continuous follow-up for up to a year, significantly enhancing the chances of long-term abstinence.

• Community-based and Workplace Interventions:

  • These programs extend cessation support beyond traditional clinical settings.
  • They involve educational efforts through awareness campaigns, implementation of tobacco-free policies in workplaces and public spaces, and the establishment of peer support groups.
  • Interventions are tailored to the specific cultural and social contexts of communities and workplaces, making them more relevant and effective.

• Training and Capacity Building:

  • A continuous procedure involves training healthcare professionals (doctors, nurses, dentists, community health workers) to deliver effective cessation interventions. This includes workshops, online modules, and skill-building exercises focused on the "5 A's," behavioral counseling, and pharmacotherapy.

By meticulously following these procedures, stop-smoking services in India aim to provide a comprehensive, accessible, and effective pathway for millions to overcome tobacco addiction and embrace a healthier future.

Understanding Results

The outcomes of stop-smoking services in India demonstrate varying degrees of success across different intervention models, offering valuable insights into what works and where further efforts are needed. These results highlight the effectiveness of structured support in aiding tobacco cessation.

• Tobacco Cessation Clinics (TCCs):

  • In their initial five years of operation, TCCs reported encouraging results. At a six-week follow-up, 14% of users completely quit tobacco.
  • Additionally, 22% achieved harm reduction, meaning they reduced their tobacco use by at least 50%. These figures underscore the clinics' role in both complete cessation and significant reduction of tobacco exposure.

• Community-Based Interventions:

  • A study conducted in rural Tamil Nadu showcased the potential of interventions tailored to local communities. It reported a quit rate of 12.5% and a harm reduction rate of 21.7% at a two-month follow-up. This suggests that localized, culturally sensitive approaches can be effective in diverse settings.

• National Tobacco Quitline Services (NTQLS):

  • The NTQLS has shown significant success, demonstrating the power of tele-counseling.
  • It achieved a 33.42% abstinence rate after one month of quitting.
  • Crucially, the long-term effectiveness is also notable, with a 21.91% abstinence rate after one year.
  • More recently, in the 2021–2022 period, among those callers who successfully set a quit date, an impressive 38.5% successfully quit tobacco, highlighting the impact of sustained telephonic support.

• Behavioral Interventions:

  • A systematic review and meta-analysis confirmed the overall efficacy of behavioral interventions for tobacco users in India, regardless of whether they smoked, used smokeless tobacco, or both.
  • Specific modalities showed significant positive effects on cessation rates:
    • E-health interventions (digital apps, online resources)
    • Group counseling
    • Individual counseling
  • This indicates that structured counseling, delivered in various formats, is a powerful tool in supporting cessation efforts.

Factors Influencing Quitting Success:

Understanding the factors that influence an individual's likelihood of quitting is crucial for tailoring interventions and improving success rates:

Factors Associated with Higher Quitting Rates:

• No Previous Quit Attempts: Interestingly, individuals with no prior quit attempts sometimes show higher success rates, possibly due to higher initial motivation or less experience with the challenges of quitting.
• Never Consumed Alcohol: Those who do not consume alcohol tend to have higher quitting rates, suggesting that co-occurring substance use can complicate cessation efforts.
• Consumed Tobacco Within 6-60 Minutes of Waking: This group, representing moderate to severe dependence, paradoxically showed higher quitting rates in some studies, possibly because they are more acutely aware of their addiction and more motivated to seek help.

Factors Associated with Lower Quitting Rates (or more difficulty quitting):

• Female Callers: Women often face unique socio-cultural challenges and may have different physiological responses to nicotine, potentially making quitting more difficult.
• Private Sector Workers: This group might experience higher stress levels, longer working hours, or less supportive workplace environments compared to public sector workers, impacting their ability to quit.
• Individuals Consuming More Than Ten Tobacco Units: Higher daily consumption indicates greater physiological dependence, making withdrawal symptoms more severe and quitting more challenging.
• Over 10 Years of Tobacco Use: Longer duration of tobacco use typically correlates with stronger addiction and ingrained behavioral patterns, increasing the difficulty of cessation.
• High Expenditure on Tobacco: Individuals spending a substantial amount on tobacco might have deeper addiction and stronger psychological ties to the habit.
• No Known Co-morbidities: Surprisingly, individuals without pre-existing health conditions (co-morbidities) were sometimes less likely to quit. This could be because the immediate health threat is not as apparent, leading to less urgent motivation compared to those facing tobacco-related health issues.

These results and influencing factors provide a roadmap for continuously refining stop-smoking services in India, ensuring they are designed to maximize success rates for all tobacco users, irrespective of their background or addiction profile.

Costs in India

The cost-effectiveness of tobacco cessation services in India is a critical factor in their scalability and sustainability, especially given the vast population and diverse socio-economic landscape. The investment in these services is not just a healthcare expenditure but a long-term investment in public health and economic productivity.

Intervention Packages at NCD Clinics:

• Unit Cost: The overall unit cost of implementing a comprehensive tobacco cessation intervention package at Non-Communicable Disease (NCD) clinics in North India was estimated to be approximately INR 272 (USD 3.67) per patient.
• Cost Range: This cost can vary, ranging from INR 184 (USD 2.48) to INR 326 (USD 4.40) per patient, depending on factors such as the intensity of counseling, the type and duration of pharmacotherapy provided, and overhead administrative costs. This relatively low cost per patient underscores the potential for widespread implementation, particularly in primary and secondary healthcare settings.

National Tobacco Quitline Service (NTQLS):

• Cost-Effectiveness: The NTQLS is considered a highly cost-effective measure for tobacco cessation in India. Its ability to reach a large number of people across diverse geographies at a relatively low cost per successful quit makes it an invaluable public health tool.
• Average Cost per Counseling Session: The average cost per completed counseling session through the NTQLS was reported as $22.37. This reflects the operational costs, including counsellor salaries, infrastructure, and telecommunication expenses.
• Average Cost per Quitter: More importantly, the average cost per successful quitter via the NTQLS was estimated at $69.96. This figure is remarkably low when compared to quitline services in many other developed countries, highlighting the efficiency and value of India's tele-counseling approach.

Nicotine Replacement Therapy (NRT):

• Daily Cost: NRT, a World Health Organization (WHO)-approved 12-week regimen, is an effective pharmacotherapy for managing nicotine cravings. The cost of NRT can vary, but typically ranges around ₹10-13 per patient per day. This therapy is usually administered over a period of 60-90 days, making the total cost for a full course substantial for many individuals.
• Affordability and Accessibility Efforts: Recognising the efficacy and importance of NRT, efforts are underway to make it more affordable and accessible. This includes advocating for its inclusion in the National List of Essential Medicines (NLEM). Listing NRT in the NLEM would allow for government procurement at lower prices, potentially making it available free or at highly subsidized rates through public health facilities.

Government Initiatives and Subsidized Services:

The Indian government plays a crucial role in making tobacco cessation services accessible and affordable:

• National Tobacco Control Programme (NTCP): Under the NTCP, the government aims to establish Tobacco Cessation Centers (TCCs) in District Hospitals across the country. These centers are designed to provide both free pharmacotherapy and counseling services, removing financial barriers for individuals seeking to quit.
• Integration with Existing Health Programs: To maximize reach, counsellors involved in other national health programs, such as AIDS control and TB control, are also being trained and leveraged to offer tobacco cessation services at the primary level. This integration ensures that tobacco cessation advice and support can be delivered opportunistically during routine health interactions, making it a ubiquitous part of healthcare delivery.

The strategic investment in cost-effective interventions like the NTQLS, combined with efforts to subsidize pharmacotherapy and integrate cessation services into existing public health infrastructure, underscores India's commitment to tackling the tobacco epidemic. While costs exist, the long-term economic and health benefits of successful cessation far outweigh the expenditures on these vital services.

How Ayu Helps

Ayu, as an Indian medical records app, plays a crucial role in empowering users on their journey to quit tobacco by securely storing and organizing their health data, including progress tracking, medication reminders for NRT, and easy access to their cessation journey details to share with healthcare providers.

FAQ

Q1: What are "Stop-smoking services" in India? A1: Stop-smoking services in India are comprehensive, evidence-based programs designed to help individuals quit tobacco use, including both smoking and smokeless forms. They combine behavioral counseling, pharmacotherapy (like NRT), and follow-up support.

Q2: Who can access these services? A2: Anyone using tobacco products and wishing to quit can access these services. They are available through Tobacco Cessation Clinics (TCCs) in district hospitals, primary healthcare facilities, the National Tobacco Quitline Services (NTQLS), and various community and workplace interventions.

Q3: What is the "5 A's" framework? A3: The "5 A's" is a structured counseling tool used by healthcare professionals: Ask (about tobacco use), Advise (to quit), Assess (readiness to quit), Assist (with counseling and medication), and Arrange (follow-up).

Q4: Are these services free in India? A4: Many government-run Tobacco Cessation Centers (TCCs) under the National Tobacco Control Programme (NTCP) offer free counseling and pharmacotherapy. The National Tobacco Quitline Service (NTQLS) is also a toll-free service. However, some private clinics or specific medications like NRT might have associated costs, though efforts are underway to make NRT more affordable.

Q5: What types of support are offered? A5: Support includes individual or group behavioral counseling, self-help materials, pharmacotherapy (e.g., Nicotine Replacement Therapy, bupropion, varenicline), and telephonic counseling via the National Tobacco Quitline (1800-11-2356).

Q6: How effective are these services? A6: Effectiveness varies by service. The NTQLS has shown abstinence rates of over 20% at one year, and TCCs reported 14% complete quits and 22% harm reduction at six weeks. Behavioral interventions, e-health, and counseling generally show good efficacy.

Q7: What if I relapse after quitting? A7: Relapse is a common part of the quitting journey, as nicotine addiction is a chronic relapsing disorder. Stop-smoking services are designed to provide ongoing support, help you understand triggers, and guide you through subsequent quit attempts without judgment. It's crucial to reach out for support again.

Q8: Can these services help with smokeless tobacco cessation? A8: Yes, stop-smoking services in India are specifically designed to address all forms of tobacco use, including smokeless tobacco like gutkha, khaini, and zarda. Behavioral interventions have shown good efficacy for users of both smoking and smokeless tobacco.