Tobacco Control Issue:
Community‑based tobacco cessation program among women in Mumbai, India
Original Article
Mishra GA, Kulkarni SV, Majmudar PV, Gupta SD, Shastri SS Department of Preventive Oncology, Tata Memorial Hospital, E. Borges Marg, Parel, Mumbai, Maharashtra, India Correspondence to: Dr. Gauravi Mishra, E‑mail: [email protected]
Abstract
BACKGROUND: Globally tobacco epidemic kills nearly six million people annually. Consumption of tobacco products is on the rise in low‑ and middle‑income countries. Tobacco is addictive; hence, tobacco users need support in quitting. AIMS: Providing tobacco cessation services
to women in community enabling them to quit tobacco, identifying factors associated with quitting and documenting the processes involved to establish a replicable “model tobacco cessation program.” SETTINGS AND DESIGN: This is a community based tobacco cessation program of one year duration conducted among women in a low socioeconomic area of Mumbai, India. SUBJECTS AND METHODS: It involved three interventions conducted at three months interval, comprised of health education, games and counseling sessions and a post intervention follow‑up. STATISTICAL ANALYSIS: Uni and multivariate analysis was performed to find out association of various factors with quitting tobacco. RESULTS: The average compliance in three intervention rounds was 95.2%. The mean age at initiation of tobacco was 17.3 years. Tobacco use among family members and in the community was primary reasons for initiation and addiction to tobacco was an important factor for continuation, whereas health education and counseling seemed to be largely responsible for quitting. The quit rate at the end of the programme was 33.5%. Multivariate logistic regression analysis found that women in higher age groups and women consuming tobacco at multiple locations are less likely to quit tobacco. CONCLUSIONS: Changing cultural norms associated with smokeless tobacco, strict implementation of antitobacco laws in the community and work places and providing cessation support are important measures in preventing initiation and continuation of tobacco use among women in India. Key Words: Counseling, health education, tobacco cessation, tobacco quit rates
Introduction Globally about six million people die due to tobacco use annually. [1] Approximately, 250 million adults use smokeless tobacco (SLT) in 11 countries of the World Health Organization (WHO) South‑East Asia Region (SEAR). They account for 90% of global SLT users. [2] The prevalence of tobacco use among the adult Indian population is 34.6% (estimated urban and rural prevalence is 25.3% and 38.4%, respectively); overall 47.9% males and 20.3% females in India, 42.5% males and 18.9% females specifically in Maharashtra consume tobacco.[3] Although smoking is the most common form of tobacco consumed worldwide, India has varied patterns of tobacco use. [4] The use of SLT is much higher (25.9%) when compared to smoking tobacco (14.0%).[3] Tobacco use is influenced by social, cultural, and ritual factors in India.[4] Consumption of SLT when compared to smoking forms is culturally accepted among women. However, with decreasing social and economic restrictions on women and with increase in spending capacity, tobacco use among women is increasing in India and even globally.[5] Consumption of smoking as well as SLT causes cancers of different sites in human body, including the organs of respiratory, reproductive, urinary and gastro‑intestinal systems, acute hypertension, increased risk of cardiovascular diseases and diabetes mellitus and infertility.[6,7] The benefits of quitting can be perceived immediately on discontinuing tobacco use. Both immediate and long‑term health benefits include normalization of the pulse rate and blood pressure, improved respiratory function and reduction in the reproductive adverse effects.[8] Lack of awareness about the Access this article online Quick Response Code:
Website: www.indianjcancer.com DOI: 10.4103/0019-509X.147474 PMID: *******
S54
ill‑effects of tobacco use, ingrained cultural attitudes and lack of widespread cessation facilities maintains tobacco use in the community. Utilization of tobacco cessation services by current users is an important aspect of reducing the risk of tobacco related deaths.[9] Accordingly, tobacco cessation is an important component of the National Tobacco Control Programme (NTCP).[10] Counseling is one of the best approached methods for tobacco cessation.[11] WHO MPOWER has recommended to offer help to quit tobacco as an important approach to counter the tobacco epidemic.[12] Currently, women constitute one of the biggest target groups of the tobacco industry due to their growing spending power.[5] Therefore, unless effective, comprehensive and sustained initiatives are implemented to reduce tobacco use among women, prevalence of females using tobacco is likely to rise. Until date, there are only 24 tobacco cessation clinics (TCCs) in the country, a figure largely insufficient to reach out to 275 million current tobacco users.[13] All TCCs are located in urban areas and some attached to major hospitals. Furthermore, people at the community level are often unaware of the existence of such facility and are hesitant to approach this specialized set‑up. Hence, a TCC providing service at community level will make tobacco cessation counseling easily accessible for the masses at grass root level and also counter the stigma associated with approaching a specialized set‑up. A community‑based tobacco cessation programme was planned and implemented for women in a low socioeconomic community in Mumbai. The purpose of this programme was to create awareness among women in the community regarding the ill‑effects of tobacco, provide tobacco cessation counseling services to help them quit and assess outcome of such an intervention. The processes involved were documented in detail. The goal principally was to establish a model tobacco cessation programme, which could be replicated elsewhere. This programme is registered with the clinical trials.gov with registration number NCT01958255. Indian Journal of Cancer | Dec 2014 | Volume 51 | Supplement 1
Mishra, et al.: Tobacco cessation program among women
Subjects and Methods A community survey to identify women using tobacco was conducted six months prior to initiating this programme, as a part of women cancer screening by the same group of investigators. The current program involved provision of three tobacco cessation interventions at three monthly intervals, followed by a postintervention follow‑up. The total duration of the program was 12 months. Eligible women were contacted by door‑to‑door visit and explained the cessation programme. Informed consent was obtained from women who were interested in participating and their sociodemographic and risk factor history and information about their knowledge, attitude and practices of tobacco habits were obtained by personal interviews and recorded on a structured and pilot tested questionnaire, by trained Medical Social Workers. Women were then invited at community‑based camp place for further interventions. Each of the three interventions was conducted in three sessions. First session of rapport building comprised of games or cultural activity [Figure 1]. Second session comprised of group discussion or health education programme (HEP) on tobacco and adverse effect [Figure 2]. Third session included group counseling to quit the tobacco habits with a focus on benefits of quitting, encouragement to quit, dealing with withdrawal symptoms and encouraging quitters to maintain abstinence [Figure 3].
Figure 1: Cultural activity to encourage participation
Throughout the programme extensive efforts were made to maintain high participation rates. A post‑intervention follow‑up was conducted to assess the tobacco practices at the end of the programme. The main outcome measure recorded was self‑reported tobacco use status. A woman was considered to have quit tobacco, if she did not use tobacco over a period of past 1‑month. The data were entered in SPSS version 18 and analyzed in STATA.
Figure 2: Health education programme
Results During the survey of the earlier screening project conducted in the same area, 340 women tobacco users were identified. Six months later, when the present program was initiated, it was found that 36 women (10.6%) had quit tobacco with a single round of well conducted HEP that was provided as a part of screening services. Hence, 304 women tobacco users were eligible for enrollment in the present program. In house‑to‑house visits of the eligible, 279, 273 (97.9%), 268 (96%), and 260 (93.2%) women were contacted during the first, second and third interventions and post intervention follow‑up, respectively. 25 women could not be contacted throughout the duration of the project, despite making several attempts to trace them. The average compliance to participation in the three intervention rounds among the total enrolled eligible (i.e. 279 women) was 95.3%. The motivational stage of assessment with regards to tobacco cessation during each of the three interventional sessions and during the post intervention follow‑up is shown in Table 1. Reasons for taking to tobacco habits
The mean and median ages at initiation of tobacco use were 17.3 years (standard deviation = 9.11) and 15 years, Indian Journal of Cancer | Dec 2014 | Volume 51 | Supplement 1
Figure 3: Group counseling session
respectively. The main reasons for initiation of tobacco were influenced by family members using tobacco 135 (48.4%), prevalence of tobacco use in the community 93 (33.3%) and peer pressure 65 (23.3%). Among the 271 women who were ever pregnant, 242 (89.3%) consumed tobacco during pregnancy including 18 (7.4%) women who reported to S55
Mishra, et al.: Tobacco cessation program among women
Table 1: Stages of tobacco cessation Motivational stage of assessment Precontemplation Contemplation Preparation Action (quitting) Maintenance Relapse No information
First intervention round (%)
Second intervention round (%)
Third intervention round (%)
Post intervention follow‑up (%)
60 (21.51) 169 (60.57) 49 (17.56) ‑ 1 (0.36)
27 (9.68) 59 (21.15) 136 (48.75) 51 (18.28) ‑ 0
14 (5.02) 20 (7.17) 161 (57.71) 67 (24.01) 06 (2.15) 0
09 (3.23) 17 (6.09) 147 (52.69) 29 (10.39) 58 (20.79) 0
0
06 (2.15)
11 (3.94)
19 (6.81)
have initiated tobacco use during pregnancy. Craving during pregnancy (100%) was the main reason for initiation. 173 women were working either currently or in the past. Of the 26 women working indoors, two reported presence of employees smoking at the workplace. Of the 6 (3.5%) working women who had antitobacco policy at their work place, five reported policy prohibiting smoking tobacco while one reported policy prohibiting use of any form of tobacco inside the workplace.
constipation, craving for tobacco, oral discomfort and irritability. Some 42.3%, 39.1% and 84.2% women who had withdrawal symptoms could quit tobacco after the first, second and third interventions, respectively. Among the enrolled women, 24 never attempted quitting throughout the programme because of its addictive nature (92.5%) and because they thought it provided relief from work pressure (38%) and energy for work (34.8%).
Economics of tobacco use
Association of various factors
252 (90.3%) women mentioned that they purchased tobacco for self‑consumption and 238 of them (85.3%) spend between Rs. 4/‑ and Rs. 25/‑ per month for tobacco. The mean and median monthly tobacco expense was Rs. 21.61/‑ and Rs. 20.00/‑. Place of use
About 77% used tobacco at home only, 13% at home and workplace and at multiple places by 9.8%. Family history
Family history of tobacco consumption was present in 183 (65.6%) women. Smokeless forms when compared to smoking forms were used predominantly by the family members of the participant women. Quit rates and attempts
The overall tobacco quit rate at the end of the programme was 33.5% (n = 260). Among the 87 women who quit tobacco, out of them 95% reported quitting tobacco because of the information received from the HEP and counseling sessions. Among the 279 enrolled women, 69 (24.7%) had unsuccessfully attempted quitting tobacco in the past. Among the women contacted, 167 (61.2% n = 273), 86 (32% n = 268), and 33 (12.7% n = 260) women made attempts to quit tobacco after the first, second and third interventions respectively. Among the 260 women contacted at the end of the study, 140 women had attempted quitting tobacco once, 66 ‑ twice, 21 ‑ thrice, 6‑ 4 times, 2‑ 5 times and 1 attempted quitting 6 times. Among the 87 tobacco quitters at the end of the study, 42 had attempted quitting once, 31 twice, nine thrice, two each had attempted quitting 4 and 5 times, respectively and one had attempted quitting 6 times in the past. Overall, 35.3% women (average of four rounds) had made quit attempts. Withdrawal symptoms
About 49 (29.3%), 22 (25.6%) and 22 (66.7%) women had experienced withdrawal symptoms after they attempted to quit tobacco after first, second and third interventions respectively, the main symptoms being dryness of mouth, S56
Univariate and multivariate logistic regression analysis [Table 2] was performed to find out the association of various factors with tobacco quitting. Univariate analysis showed women in higher age group, who lacked the knowledge that tobacco is injurious to health, higher duration of tobacco use, who used tobacco at multiple locations, had higher monthly expenses on tobacco and higher fragerstorm score were less likely to quit tobacco. When the significant variables of univariate were put in the multivariate logistic regression analysis, age groups and locations of tobacco consumption were significantly associated with tobacco quitting. Women with higher age groups and women consuming tobacco at multiple locations were less likely to quit tobacco. Discussion In the present study, of the 340 women initially identified as tobacco users, 36 (10.6%) women quit tobacco due to the impact generated by a single session of HEP received during the cancer screening program. This shows that even a single session of an effective HEP has remarkable potential to result in tobacco cessation among women never exposed to such an elaborate information in the past. Antitobacco community education programme in Koral district of Karnataka had quit rate of 36.7% at the end of five years.[14] The average compliance to participation was 95%. The satisfactory compliance rates were achieved through extensive efforts by the staff employing various strategies like sensitization of local community leaders, selecting potential places in the community where people were more likely to visit, multiple visits to the women’s houses for invitation, flexible timings of the interventions etc. Repeated contact counseling is crucial for the success of cessation and prevention of relapses.[15] The present study ensured average compliance of 95.2% to the three interventions provided. The average participation rate in the community based group intervention programme in Tamil Nadu was 74.5%.[9] The participation rate for the baseline survey in a community‑based smoking cessation intervention trial in Kerala was 82%.[16] Indian Journal of Cancer | Dec 2014 | Volume 51 | Supplement 1
Mishra, et al.: Tobacco cessation program among women
Table 2: Multivariate analysis showing relation of various sociodemographic and risk factor variables with tobacco quitting Variables
Others (%)
Quitters (%)
Univariate analysis OR
Age groups ≤39 40-49 50-59 ≥60 Mean (SD) Religion Hindu Muslim Others Marital status Married Widowed Single/divorced Education Illiterate Literate without formal education Formally educated Occupation Housewife Service Manual labour Self employed Income 10,000 Knowledge‑tobacco dangerous Yes No/don’t know Tobacco use Betel leaves with tobacco and chewing tobacco Betel leaves without tobacco Masheri Combination Duration of tobacco use ≤10 11-20 21-30 31-40 41-50 51-60 ≥61 Fragerstorm scale 25 Place of tobacco consumption Home only Home and workplace Multiple places Age at initiation of tobacco use
Community‑based tobacco cessation program among women in Mumbai, India
Original Article
Mishra GA, Kulkarni SV, Majmudar PV, Gupta SD, Shastri SS Department of Preventive Oncology, Tata Memorial Hospital, E. Borges Marg, Parel, Mumbai, Maharashtra, India Correspondence to: Dr. Gauravi Mishra, E‑mail: [email protected]
Abstract
BACKGROUND: Globally tobacco epidemic kills nearly six million people annually. Consumption of tobacco products is on the rise in low‑ and middle‑income countries. Tobacco is addictive; hence, tobacco users need support in quitting. AIMS: Providing tobacco cessation services
to women in community enabling them to quit tobacco, identifying factors associated with quitting and documenting the processes involved to establish a replicable “model tobacco cessation program.” SETTINGS AND DESIGN: This is a community based tobacco cessation program of one year duration conducted among women in a low socioeconomic area of Mumbai, India. SUBJECTS AND METHODS: It involved three interventions conducted at three months interval, comprised of health education, games and counseling sessions and a post intervention follow‑up. STATISTICAL ANALYSIS: Uni and multivariate analysis was performed to find out association of various factors with quitting tobacco. RESULTS: The average compliance in three intervention rounds was 95.2%. The mean age at initiation of tobacco was 17.3 years. Tobacco use among family members and in the community was primary reasons for initiation and addiction to tobacco was an important factor for continuation, whereas health education and counseling seemed to be largely responsible for quitting. The quit rate at the end of the programme was 33.5%. Multivariate logistic regression analysis found that women in higher age groups and women consuming tobacco at multiple locations are less likely to quit tobacco. CONCLUSIONS: Changing cultural norms associated with smokeless tobacco, strict implementation of antitobacco laws in the community and work places and providing cessation support are important measures in preventing initiation and continuation of tobacco use among women in India. Key Words: Counseling, health education, tobacco cessation, tobacco quit rates
Introduction Globally about six million people die due to tobacco use annually. [1] Approximately, 250 million adults use smokeless tobacco (SLT) in 11 countries of the World Health Organization (WHO) South‑East Asia Region (SEAR). They account for 90% of global SLT users. [2] The prevalence of tobacco use among the adult Indian population is 34.6% (estimated urban and rural prevalence is 25.3% and 38.4%, respectively); overall 47.9% males and 20.3% females in India, 42.5% males and 18.9% females specifically in Maharashtra consume tobacco.[3] Although smoking is the most common form of tobacco consumed worldwide, India has varied patterns of tobacco use. [4] The use of SLT is much higher (25.9%) when compared to smoking tobacco (14.0%).[3] Tobacco use is influenced by social, cultural, and ritual factors in India.[4] Consumption of SLT when compared to smoking forms is culturally accepted among women. However, with decreasing social and economic restrictions on women and with increase in spending capacity, tobacco use among women is increasing in India and even globally.[5] Consumption of smoking as well as SLT causes cancers of different sites in human body, including the organs of respiratory, reproductive, urinary and gastro‑intestinal systems, acute hypertension, increased risk of cardiovascular diseases and diabetes mellitus and infertility.[6,7] The benefits of quitting can be perceived immediately on discontinuing tobacco use. Both immediate and long‑term health benefits include normalization of the pulse rate and blood pressure, improved respiratory function and reduction in the reproductive adverse effects.[8] Lack of awareness about the Access this article online Quick Response Code:
Website: www.indianjcancer.com DOI: 10.4103/0019-509X.147474 PMID: *******
S54
ill‑effects of tobacco use, ingrained cultural attitudes and lack of widespread cessation facilities maintains tobacco use in the community. Utilization of tobacco cessation services by current users is an important aspect of reducing the risk of tobacco related deaths.[9] Accordingly, tobacco cessation is an important component of the National Tobacco Control Programme (NTCP).[10] Counseling is one of the best approached methods for tobacco cessation.[11] WHO MPOWER has recommended to offer help to quit tobacco as an important approach to counter the tobacco epidemic.[12] Currently, women constitute one of the biggest target groups of the tobacco industry due to their growing spending power.[5] Therefore, unless effective, comprehensive and sustained initiatives are implemented to reduce tobacco use among women, prevalence of females using tobacco is likely to rise. Until date, there are only 24 tobacco cessation clinics (TCCs) in the country, a figure largely insufficient to reach out to 275 million current tobacco users.[13] All TCCs are located in urban areas and some attached to major hospitals. Furthermore, people at the community level are often unaware of the existence of such facility and are hesitant to approach this specialized set‑up. Hence, a TCC providing service at community level will make tobacco cessation counseling easily accessible for the masses at grass root level and also counter the stigma associated with approaching a specialized set‑up. A community‑based tobacco cessation programme was planned and implemented for women in a low socioeconomic community in Mumbai. The purpose of this programme was to create awareness among women in the community regarding the ill‑effects of tobacco, provide tobacco cessation counseling services to help them quit and assess outcome of such an intervention. The processes involved were documented in detail. The goal principally was to establish a model tobacco cessation programme, which could be replicated elsewhere. This programme is registered with the clinical trials.gov with registration number NCT01958255. Indian Journal of Cancer | Dec 2014 | Volume 51 | Supplement 1
Mishra, et al.: Tobacco cessation program among women
Subjects and Methods A community survey to identify women using tobacco was conducted six months prior to initiating this programme, as a part of women cancer screening by the same group of investigators. The current program involved provision of three tobacco cessation interventions at three monthly intervals, followed by a postintervention follow‑up. The total duration of the program was 12 months. Eligible women were contacted by door‑to‑door visit and explained the cessation programme. Informed consent was obtained from women who were interested in participating and their sociodemographic and risk factor history and information about their knowledge, attitude and practices of tobacco habits were obtained by personal interviews and recorded on a structured and pilot tested questionnaire, by trained Medical Social Workers. Women were then invited at community‑based camp place for further interventions. Each of the three interventions was conducted in three sessions. First session of rapport building comprised of games or cultural activity [Figure 1]. Second session comprised of group discussion or health education programme (HEP) on tobacco and adverse effect [Figure 2]. Third session included group counseling to quit the tobacco habits with a focus on benefits of quitting, encouragement to quit, dealing with withdrawal symptoms and encouraging quitters to maintain abstinence [Figure 3].
Figure 1: Cultural activity to encourage participation
Throughout the programme extensive efforts were made to maintain high participation rates. A post‑intervention follow‑up was conducted to assess the tobacco practices at the end of the programme. The main outcome measure recorded was self‑reported tobacco use status. A woman was considered to have quit tobacco, if she did not use tobacco over a period of past 1‑month. The data were entered in SPSS version 18 and analyzed in STATA.
Figure 2: Health education programme
Results During the survey of the earlier screening project conducted in the same area, 340 women tobacco users were identified. Six months later, when the present program was initiated, it was found that 36 women (10.6%) had quit tobacco with a single round of well conducted HEP that was provided as a part of screening services. Hence, 304 women tobacco users were eligible for enrollment in the present program. In house‑to‑house visits of the eligible, 279, 273 (97.9%), 268 (96%), and 260 (93.2%) women were contacted during the first, second and third interventions and post intervention follow‑up, respectively. 25 women could not be contacted throughout the duration of the project, despite making several attempts to trace them. The average compliance to participation in the three intervention rounds among the total enrolled eligible (i.e. 279 women) was 95.3%. The motivational stage of assessment with regards to tobacco cessation during each of the three interventional sessions and during the post intervention follow‑up is shown in Table 1. Reasons for taking to tobacco habits
The mean and median ages at initiation of tobacco use were 17.3 years (standard deviation = 9.11) and 15 years, Indian Journal of Cancer | Dec 2014 | Volume 51 | Supplement 1
Figure 3: Group counseling session
respectively. The main reasons for initiation of tobacco were influenced by family members using tobacco 135 (48.4%), prevalence of tobacco use in the community 93 (33.3%) and peer pressure 65 (23.3%). Among the 271 women who were ever pregnant, 242 (89.3%) consumed tobacco during pregnancy including 18 (7.4%) women who reported to S55
Mishra, et al.: Tobacco cessation program among women
Table 1: Stages of tobacco cessation Motivational stage of assessment Precontemplation Contemplation Preparation Action (quitting) Maintenance Relapse No information
First intervention round (%)
Second intervention round (%)
Third intervention round (%)
Post intervention follow‑up (%)
60 (21.51) 169 (60.57) 49 (17.56) ‑ 1 (0.36)
27 (9.68) 59 (21.15) 136 (48.75) 51 (18.28) ‑ 0
14 (5.02) 20 (7.17) 161 (57.71) 67 (24.01) 06 (2.15) 0
09 (3.23) 17 (6.09) 147 (52.69) 29 (10.39) 58 (20.79) 0
0
06 (2.15)
11 (3.94)
19 (6.81)
have initiated tobacco use during pregnancy. Craving during pregnancy (100%) was the main reason for initiation. 173 women were working either currently or in the past. Of the 26 women working indoors, two reported presence of employees smoking at the workplace. Of the 6 (3.5%) working women who had antitobacco policy at their work place, five reported policy prohibiting smoking tobacco while one reported policy prohibiting use of any form of tobacco inside the workplace.
constipation, craving for tobacco, oral discomfort and irritability. Some 42.3%, 39.1% and 84.2% women who had withdrawal symptoms could quit tobacco after the first, second and third interventions, respectively. Among the enrolled women, 24 never attempted quitting throughout the programme because of its addictive nature (92.5%) and because they thought it provided relief from work pressure (38%) and energy for work (34.8%).
Economics of tobacco use
Association of various factors
252 (90.3%) women mentioned that they purchased tobacco for self‑consumption and 238 of them (85.3%) spend between Rs. 4/‑ and Rs. 25/‑ per month for tobacco. The mean and median monthly tobacco expense was Rs. 21.61/‑ and Rs. 20.00/‑. Place of use
About 77% used tobacco at home only, 13% at home and workplace and at multiple places by 9.8%. Family history
Family history of tobacco consumption was present in 183 (65.6%) women. Smokeless forms when compared to smoking forms were used predominantly by the family members of the participant women. Quit rates and attempts
The overall tobacco quit rate at the end of the programme was 33.5% (n = 260). Among the 87 women who quit tobacco, out of them 95% reported quitting tobacco because of the information received from the HEP and counseling sessions. Among the 279 enrolled women, 69 (24.7%) had unsuccessfully attempted quitting tobacco in the past. Among the women contacted, 167 (61.2% n = 273), 86 (32% n = 268), and 33 (12.7% n = 260) women made attempts to quit tobacco after the first, second and third interventions respectively. Among the 260 women contacted at the end of the study, 140 women had attempted quitting tobacco once, 66 ‑ twice, 21 ‑ thrice, 6‑ 4 times, 2‑ 5 times and 1 attempted quitting 6 times. Among the 87 tobacco quitters at the end of the study, 42 had attempted quitting once, 31 twice, nine thrice, two each had attempted quitting 4 and 5 times, respectively and one had attempted quitting 6 times in the past. Overall, 35.3% women (average of four rounds) had made quit attempts. Withdrawal symptoms
About 49 (29.3%), 22 (25.6%) and 22 (66.7%) women had experienced withdrawal symptoms after they attempted to quit tobacco after first, second and third interventions respectively, the main symptoms being dryness of mouth, S56
Univariate and multivariate logistic regression analysis [Table 2] was performed to find out the association of various factors with tobacco quitting. Univariate analysis showed women in higher age group, who lacked the knowledge that tobacco is injurious to health, higher duration of tobacco use, who used tobacco at multiple locations, had higher monthly expenses on tobacco and higher fragerstorm score were less likely to quit tobacco. When the significant variables of univariate were put in the multivariate logistic regression analysis, age groups and locations of tobacco consumption were significantly associated with tobacco quitting. Women with higher age groups and women consuming tobacco at multiple locations were less likely to quit tobacco. Discussion In the present study, of the 340 women initially identified as tobacco users, 36 (10.6%) women quit tobacco due to the impact generated by a single session of HEP received during the cancer screening program. This shows that even a single session of an effective HEP has remarkable potential to result in tobacco cessation among women never exposed to such an elaborate information in the past. Antitobacco community education programme in Koral district of Karnataka had quit rate of 36.7% at the end of five years.[14] The average compliance to participation was 95%. The satisfactory compliance rates were achieved through extensive efforts by the staff employing various strategies like sensitization of local community leaders, selecting potential places in the community where people were more likely to visit, multiple visits to the women’s houses for invitation, flexible timings of the interventions etc. Repeated contact counseling is crucial for the success of cessation and prevention of relapses.[15] The present study ensured average compliance of 95.2% to the three interventions provided. The average participation rate in the community based group intervention programme in Tamil Nadu was 74.5%.[9] The participation rate for the baseline survey in a community‑based smoking cessation intervention trial in Kerala was 82%.[16] Indian Journal of Cancer | Dec 2014 | Volume 51 | Supplement 1
Mishra, et al.: Tobacco cessation program among women
Table 2: Multivariate analysis showing relation of various sociodemographic and risk factor variables with tobacco quitting Variables
Others (%)
Quitters (%)
Univariate analysis OR
Age groups ≤39 40-49 50-59 ≥60 Mean (SD) Religion Hindu Muslim Others Marital status Married Widowed Single/divorced Education Illiterate Literate without formal education Formally educated Occupation Housewife Service Manual labour Self employed Income 10,000 Knowledge‑tobacco dangerous Yes No/don’t know Tobacco use Betel leaves with tobacco and chewing tobacco Betel leaves without tobacco Masheri Combination Duration of tobacco use ≤10 11-20 21-30 31-40 41-50 51-60 ≥61 Fragerstorm scale 25 Place of tobacco consumption Home only Home and workplace Multiple places Age at initiation of tobacco use
