Abstract
Background
The tobacco epidemic is one of the biggest public health threats the world has ever faced. World Health Organization has estimated that tobacco use (smoking and smokeless) is currently responsible for the death of about 7 million people across the world each year. The objective of the study was not only to find the effect of group intervention on tobacco cessation but also to describe certain epidemiological factors associated with tobacco cessation and make suitable recommendations to tackle this epidemic.
Methods
A randomized controlled trial was carried out among male employees who were tobacco users in health-care setting in Western Maharashtra. In the study, 60 subjects each in intervention and control arm were taken. Pretested validated questionnaires were used for the study. The intervention comprised of two sessions delivered 5 weeks apart. Control arm received self-help material (Booklet) immediately after baseline data collection. The outcomes were measured using structured interview schedule. The data were analyzed using SPSS, version 20.
Results
Overall, 13.3% of the study subjects had quit tobacco use post intervention. In the intervention group 21.7% of the participants had quit tobacco since past one month and 5% in the control group (relative risk (RR) = 4.33). Low to moderate nicotine dependence (p = 0.023, RR = 6.46) and stage of contemplation (p = 0.018) were found to be important predictors of abstinence.
Conclusion
Community-based group intervention for tobacco cessation is the way forward to tackle the tobacco epidemic.
Keywords: Tobacco use, Group intervention, Tobacco cessation, Nicotine dependence, Abstinence
Introduction
“Tobacco threatens us all. It exacerbates poverty, reduces economic productivity, contributes to poor household food choices, and pollutes indoor air. But by taking robust tobacco control measures, governments can safeguard their countries' futures by protecting tobacco users and non-users from these deadly products, generating revenues to fund health and other social services and saving their environments from the ravages tobacco causes.”1
—WHO Ex-Director General Dr Margaret Chan
The epidemic of tobacco use has emerged as potentially one of the most important public health hazard, that the World faces today. The World Health Organization estimates that about 7 million premature deaths every year are currently attributed to the tobacco epidemic. This figure might increase to about 8 million deaths a year by 2030.2 Tobacco use is responsible for increase in both communicable and non-communicable diseases and is estimated to contribute to 16% of all deaths due to non-communicable diseases.1 Among the communicable diseases, smoking is also associated with an increased risk of death due to diseases like tuberculosis, respiratory tract infections, meningitis, sexually transmitted infections, postsurgical, and nosocomial infections.3, 4 Tobacco use is also related to increase in incidence of cancer by about 50% in men and about 20% in women.5 As per National Family Health Survey (NFHS)—4 (2015–2016), 44.5% of men and 6.8% of women used some form of tobacco in India, while 30.6% men and 29.3% women had attempted to stop using tobacco in any form during the preceding 12 months.6 The Cochrane review on behavioral counseling for smoking cessation revealed that interventions by smoking cessation counselors or health educators had helped the smokers to quit their habit, when these interventions were given outside clinical settings.7
The current study focuses on the effect of group intervention on tobacco cessation among male employees in health-care setting. Group intervention is an orchestrated attempt to convince a group to change their behavior and can help people to learn from each other and provide mutual support to stop tobacco use. The objective of the study was not only to find the efficacy of group intervention on tobacco cessation but also to describe certain epidemiological factors associated with tobacco cessation and make suitable recommendations to tackle this epidemic.
Material and methods
A randomized controlled trial was carried out among male employees who were tobacco users in health-care setting in Western Maharashtra. Subjects who were using tobacco in any form (smoking and smokeless) four or more times a week within the past 6 months were included in the study.8 Subjects who were not likely to stay in the health-care setting for at least 9 months from the start of the study or suffering from chronic respiratory diseases were not included in the study. The study was planned and conducted from January 2016 till October 2017. Ethical clearance for the study was obtained from the Institutional Ethics Committee of the medical college in November 2015. Sample size for randomized controlled trial (RCT) was calculated with 5% level of significance and power of 80%. With anticipated success rates of 15% and 2% in intervention and control arm respectively, the sample size was calculated as 56 subjects in each arm.9, 10 In the study, 60 subjects each in intervention and control arm were taken. The subjects were selected using simple random sampling technique and were randomized into two groups (intervention arm and control arm).
Pretested validated questionnaires were used for the study. Fagerstrom Test for Nicotine dependence (FTND) questionnaires11, 12 (smoking and smokeless tobacco) were administered both before and after 6 months of intervention for assessing intensity of physical dependence. In the study, FTND score of ≤5 was regarded as mild to moderate nicotine dependence, and score of >5 was regarded as moderate to high nicotine dependence. The outcomes were measured using structured interview schedule.
The term abstinence of tobacco use in the study meant participants who had quit tobacco since last 1 month.13 In the study, precontemplation stage was defined as participants who do not wish to quit tobacco in the next year, contemplation stage for participants who wish to quit tobacco in the next year.
For the intervention arm, four groups were formed, and each group comprised of 15 members. The intervention comprised of two sessions delivered 5 weeks apart. Each session lasted for 30 min and included mention of facts related to tobacco, dispelling common myths, explanation of tobacco related burden of disease, and benefits of quitting tobacco. A second session comprised of sharing experiences of group members in quitting tobacco in the last 5 weeks, withdrawal symptoms and measures to overcome them, coping strategies/prevention of relapse, and hazards of second hand smoke. The intervention was delivered by the principal investigator. The intervention group received self-help material (Booklet) at the end of the first session. Control arm received self-help material (Booklet) immediately after baseline data collection. The content of the material included information regarding harmful effects of tobacco, health benefits of quitting tobacco, and advice on how to stop tobacco use. Six months postreceipt of booklet outcome was measured.
We carried out bivariate analysis to find out the predictors of tobacco abstinence. The variables which were found to be statistically significant were thereafter subjected to multivariate analysis, and the actual factors affecting tobacco abstinence were discovered.
The data were analyzed using SPSS, version 20.
Results
The baseline characteristics of the participants were collected, and they were compared between intervention and control group.
Sociodemographic profile: The mean (standard deviation [SD]) age of the participants was 30.42 (8.88). Overall, 54% of the participants were married, and 15.83% were graduates, 66.67% were intermediate, and 16.67% had high school certificate. 81.67% of the participants were skilled workers, and 18.33% were semiskilled. All study subjects belonged to the upper middle class.
Characteristics of the patients related to tobacco use: In the current study, overall 82.5% of the participants were smokers (78.3% in the intervention arm and 86.7% in the control arm), and 17.5% were using smokeless tobacco. 33.33% of the participants were using tobacco for less than 5 years, 36.67% between 5 and 15 years, and 30% were using tobacco for more than 15 years. The mean (SD) age at initiation of tobacco was 19.27 (3.14). 68.3% of the study subjects had low to moderate nicotine dependence, and 31.7% had moderate to high dependence (Table 1).
Table 1.
Characteristics of the participants related to tobacco use.
| Variable | Intervention no. (%) | Control no. (%) | Overall no. (%) |
|---|---|---|---|
| No. of participants | 60 | 60 | 120 |
| Forms of tobacco use | |||
| Smoking | 47 (78.3) | 52 (86.7) | 99 (82.5) |
| Smokeless | 13 (21.7) | 08 (13.3) | 21 (17.5) |
| Years of tobacco use (in years) | |||
| <5 | 20 (33.3) | 20 (33.3) | 40 (33.33) |
| 5–15 | 24 (40.0) | 20 (33.3) | 44 (36.67) |
| ≥15 | 16 (26.7) | 20 (33.3) | 36 (30.0) |
| Mean (SD) age at initiation of tobacco use | 20.17 (3.91) | 18.37 (1.69) | 19.27 (3.14) |
| Nicotine dependence | |||
| Low to moderate dependence | 39 (65.0) | 43 (71.7) | 82 (68.3) |
| Moderate to high dependence | 21 (35.0) | 17 (28.3) | 38 (31.7) |
SD, standard deviation.
Determinants of tobacco cessation: In the current study, overall 80.8% of the tobacco users consumed alcohol in last 1 month. All the participants gave history of peer use of tobacco. 76.7% of the study subjects were in the contemplation stage, and 23.3% were in the precontemplation stage (Table 2).
Table 2.
Determinants of tobacco cessation.
| Variable | Intervention no. (%) | Control no. (%) | Overall no. (%) |
|---|---|---|---|
| Alcohol consumption | 47 (78.3) | 50 (83.3) | 97 (80.8) |
| Peer use of tobacco | 60 (100) | 60 (100) | 120 (100) |
| Stage of change | |||
| Precontemplation stage | 16 (26.7) | 12 (20.0) | 28 (23.3) |
| Contemplation stage | 44 (73.3) | 48 (80.0) | 92 (76.7) |
Summarizing the effects on tobacco cessation post intervention, in the intervention group, 21.7% of the participants had quit tobacco since last one month and 5% in the control group (relative risk (RR) = 4.33). Reduction in tobacco use at 6-month follow-up was found to be 40% in the intervention group and 20% in the control group (Table 3 and Fig. 1).
Table 3.
Effects on tobacco cessation after 6 months of intervention.
| Variable | Intervention no. (%) | Control no. (%) | Relative risk (CI) |
|---|---|---|---|
| Abstinence | 13 (21.7) | 03 (5.0) | 4.33 (3.72–4.94) |
| Reduction | 24 (40.0) | 12 (20.0) | – |
| No change | 23 (38.3) | 45 (75.0) | – |
CI, confidence interval.
Fig. 1.
Component bar diagram showing effects on tobacco cessation post intervention.
In the current study, results of bivariate analysis showed that nicotine dependence (p = 0.018) and stage of change (p = 0.01) were significantly associated with abstinence in the intervention group (Table 4).
Table 4.
Characteristics of participants in the intervention group related to abstinence post intervention.
| Variable | Abstinence (intervention group) |
p value | |
|---|---|---|---|
| YES no. (%) | NO no. (%) | ||
| Age (in years) | |||
| <30 | 08 (21.6) | 29 (78.4) | 0.617 |
| ≥30 | 05 (21.7) | 18 (78.3) | – |
| Education | |||
| Graduate | 01 (11.1) | 08 (88.9) | 0.360 |
| Intermediate | 09 (24.3) | 28 (75.7) | – |
| High School | 03 (21.4) | 11 (78.6) | – |
| Occupation | |||
| Skilled | 10 (21.7) | 36 (78.3) | 0.647 |
| Semiskilled | 03 (21.4) | 11 (78.6) | – |
| Alcohol consumption | |||
| Yes | 9 (19.1) | 38 (80.9) | – |
| No | 04 (30.8) | 09 (69.2) | 0.292 |
| Forms of tobacco use | |||
| Cigarette | 09 (19.1) | 38 (80.9) | – |
| Smokeless | 04 (30.8) | 09 (69.2) | 0.292 |
| Years of tobacco use (in years) | |||
| <10 | 08 (22.9) | 27 (77.1) | 0.525 |
| ≥10 | 05 (20.0) | 20 (80.0) | – |
| Nicotine dependence | |||
| Low to moderate | 12 (30.8) | 27 (69.2) | 0.018 |
| Moderate to high | 01 (4.8) | 20 (95.2) | – |
| Stage of change | |||
| Precontemplation | – | 16 (100) | – |
| Contemplation | 13 (29.5) | 31 (70.5) | 0.01 |
Multivariate analysis was done using ENTER method. In the final model, low to moderate nicotine dependence (p = 0.023, RR = 6.46) and contemplation stage of change (p = 0.018) were found to be important predictors of abstinence. In the current study, the findings were statistically significant for the above mentioned variables, i.e. nicotine dependence and stage of change (Table 5).
Table 5.
Variables showing positive predictors of abstinence.
| Variables | Relative risk (CI) | p value |
|---|---|---|
| Nicotine dependence | ||
| Low to moderate | 6.46 (5.45–7.47) | 0.023 |
| Moderate to high | – | – |
| Stage of change | ||
| Precontemplation | – | – |
| Contemplation | – | 0.018 |
CI, confidence interval.
Discussion
In the current study, overall 68.3% of the study subjects had low to moderate dependence, and 31.7% had moderate to high dependence. In the study conducted by Kumar10 et al., overall 68.8% of the participants had low and moderate dependence, and 31.2% had high and very high dependence. The findings of the study were similar to the current study. An interventional study conducted among industrial workers by Savant14 et al., and overall 40% of the participants had low dependence, 20% had medium dependence, and 40% had high dependence. The higher percentage of high nicotine dependence in the study subjects may be attributed to the nature of the job and low education level compared with the current study.
In the current study, overall 80.8% of the tobacco users consumed alcohol in last 1 month. In the study conducted by Kumar10 et al., overall 69.5% of the study subjects gave history of alcohol consumption. In another clinical trial among degree students by Reddy15 et al., 43.6% of the participants gave history of consumption of alcohol. The increased percentage of alcohol consumption in the current study may be attributed to the younger age group and peer pressure.
In the current study, all the participants gave history of peer use of tobacco. In the study conducted by Kumar10 et al., overall 89.5% of the participants gave history of peer use of tobacco. The findings were comparable to the current study.
In the current study, overall 76.7% of the study subjects were in the contemplation stage, and 23.3% were in the precontemplation stage. In the study conducted by Kumar10 et al., overall 88% of the participants were in contemplation stage and 12% in precontemplation stage. In a community-based tobacco cessation program among women by Mishra16 et al., overall 21.51% of the participants were in precontemplation stage, 60.57% in the contemplation stage, and 17.56% were in the preparation stage. The findings of the above studies were comparable to the current study which reiterate the fact that majority of the tobacco users wish to quit tobacco in the future. However, in one of the worksite tobacco cessation service program among factory workers by Pimple17 et al., overall 82.1% of the participants were in precontemplation stage, only 17.4% were in contemplation stage, and 0.4% in the preparation stage. The probable reasons for a low percentage of participants in contemplation stage could be because of habit formation of smoking in them or their shift pattern of work which required them to be awake during odd hours or stressful environment in the work place or at home.17
In the current study, in the intervention group, 21.7% of the participants had quit tobacco since last 1 month and 5% in the control group (RR = 4.33). A study on Bihar school teachers study Sorensen18 et al. found that the adjusted 6-month quit rate was 19% in the intervention group and 7% in the control group. In one of the randomized controlled trial among male prisoners in India by Naik19 et al., it was found that after smoking cessation intervention, 16% stopped smoking at the end of 6-month follow-up in the study group. The findings of the above studies were comparable to the current study. In a community-based intervention for tobacco cessation in North East India by Bhagabaty20 et al., a very high quit rate of 47% was observed at 8 months postintervention follow-up with only tobacco cessation counseling intervention and regular scheduled follow-up visits. The high percentage of quit rate compared with the current study can be attributed to vigorous community-based tobacco cessation intervention by Medical Social Workers and strict unmissed timely follow-up for 8 months. In a randomized controlled trial conducted in Kerala by Jayakrishnan9 et al., it was observed that self-reported point prevalence abstinence at 12-month follow-up in the intervention and control areas was 14.7% and 6.8% respectively. The decreased quit percentage among the study subjects compared with the current study may be because of rural set up, low socioeconomic status, and high percentage of moderate to high nicotine dependence.
A systematic review was done on group behavior therapy programs for smoking cessation by Stead LF. Thirteen studies compared a group program with self-help program and came to conclusion that tobacco cessation increases with the use of group program (odds ratio = 1.98, 95% CI = 1.60–2.46).7, 21, 22
Conclusion
From the above discussion, we concluded that group intervention is a very effective method of tobacco cessation and definitely more effective than self-help programs. Community-based group intervention for tobacco cessation is the way forward to tackle the tobacco epidemic. Low to moderate nicotine dependence is the most important predictor of abstinence. Hence, targeting the young generation who have just started or planning to use tobacco in the near future will certainly reduce the prevalence of tobacco use in the future.
In the current study, it can be concluded that low to moderate nicotine dependence and stage of change (contemplation stage) are some of the important determinants of tobacco cessation. Identification and classification of the smokers based on the above characteristics and giving them appropriate group intervention and regular information, education and communication (IEC) activities will certainly help the tobacco users to quit tobacco.
Recommendations
Following recommendations are suggested based on the findings of the current study. Every institute/center/organization should identify the number of tobacco users by conducting a prevalence study. The study should also classify the tobacco users on the basis of nicotine dependence, consumption of alcohol, and stage of change (Precontemplation or contemplation stage). Personnel trained in counseling on tobacco cessation should be hired. Various groups should be made each consisting of 10–15 tobacco users. Counseling sessions of 30–45 min each every month for 5–6 months should be provided to each group to achieve higher quit rates. Follow-up should be done at 6 months, 12 months, and 2 years. Individuals in precontemplation stage and in relapse stages should be given targeted focused intervention for helping them to achieve abstinence. Conducive smoke-free environment should be provided by implementing strict laws and bans on tobacco use. Peers and family members using tobacco should also be targeted. IEC activities related to tobacco awareness should be carried out at least once in a quarter and especially for school going students and young adults so that we can prevent our present and future generations from falling prey to a lifelong nicotine addiction.
Limitations
All the study participants belonged to same tertiary care center, and in today's world of information revolution, it cannot be ruled out that the control group might have access to information related to tobacco cessation. It was not possible to separate the participants of both the groups for the whole period of study because all of them worked in the same tertiary care center.
Conflicts of interest
All authors have none to declare.
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