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© 2021 Indian Journal of Cancer | Published by Wolters Kluwer ‑ Medknow S13
Life rst: Impact of a school-based tobacco- and
supari-cessation intervention among adolescents
in Mumbai, India
Upendra Bhojani, Amiti Varma*, Pragati Hebbar,
Gauri Mandal
*Research Officer, IPH
Background: In India, youth are among the most
vulnerable populations in terms of tobacco uptake
and tobacco-related harms. Schools are an excellent
setting for health promotion, yet there is a dearth
of school-based interventions supporting to youth to
quit tobacco. Further, such interventions are rarely
evaluated for their impact. Thus, we aimed to assess
the impact of the LifeFirst program: an ongoing
tobacco- and supari-cessation intervention delivered to
students from corporation schools in Mumbai.
Methods: We used a prospective quasi-experimental
design with an intervention and a control arm
embedded within an ongoing LifeFirst program of six
sessions. We used a difference-in-difference analysis
with the baseline and endline surveys to assess the
program’s impact on prevalence of tobacco/supari use,
students’ knowledge about tobacco/supari harms, and
students’ refusal skills regarding tobacco/supari use.
Results: We analyzed data from 827 students, who
volunteered to participate in the LifeFirst program
and completed both the surveys. At the end of the
intervention, both tobacco and supari use reduced
among the intervention group while tobacco use
increased among the control group. The difference-
in-difference estimates show a statistically signicant
reduction of 17.9 and 38.1 percentage points in
tobacco and supari use prevalence respectively,
beyond the reduction in the control group.
Conclusion: The LifeFirst program was successful in
reducing tobacco and supari use among participants
and protected students in the intervention group against
new uptake of tobacco. It helped improve knowledge
score as well as refusal skills among students. We
discuss how similar school-based programs should
be considered as part of a multi-strategy approach to
reducing tobacco use among young people in India.
Does MPOWER approach impact adult tobacco
use prevalence in India: Findings from GATS
Sameer Narake*, Prachi Kerkar, Mangesh Pednekar
*Senior Statistician, Healis Sekhsaria Institute for Public Health, Mumbai,
Maharashtra, India
Background: The World Health Organization’s
(WHO) MPOWER is a technical package of tobacco
control measures that assist countries in meeting
their obligations of the WHO Framework Convention
Tobacco Control (FCTC) and are proven to reduce
tobacco use. Between GATS-1 and GATS-2 round
prevalence of adult tobacco use has decreased from
34.6% in 2009-10 to 28.6% in 2016-17. Therefore,
we explore the role of MPOWER strategy in changing
prevalence of tobacco use between GATS-1 and
GATS-2 in India.
Methods: We compared the common questions
from GATS-1 (2009-2010) and GATS-2 (2016-2017)
survey that were directly associated with the WHO
MPOWER strategy. The descriptive characteristics
were calculated. Multivariate analysis was done using
dummy time variable (GATS1=0 and GATS1=1)
as the dependent variable and independent
variable were tobacco, age, gender, education and
occupation.
Results: As compared to GATS-1 in GATS-2,
smoking and mixed use decreased (ranges from
20% to 48%) among men and women, except for
smokeless tobacco use among men. Noticing smoking
decreased at inside of any government buildings or
ofces, enclosed restaurants or public eating places
and any public transportations. Advised by doctor
given to stop smokeless tobacco use was reported
higher by male mixed users (AOR=2.44, 95% CI
=1.50, 3.97) and female SLT users (AOR=1.63
95% CI (1.09, 2.45). Noticing any health warning
on cigarette packages was reported more by male
smokers (AOR=1.78, 95% CI =1.50, 2.10) and by
SLT users. Noticing decreased in any cigarette
promotions was reported by male smoker (AOR=0.70,
95% CI =0.55, 0.89)
Conclusion: India has strong policy measures in
tobacco control, however it needs special attention on
its enforcement of MPOWER on smokeless tobacco
user men.
Areca nut: A silent risk factor for tobacco use
among adolescents
Himanshu Gupte*, Gauri Mandal
*General Manager, Narotam Sekhsaria Foundation
Background: Globally, 600 million people consume
areca-nut, the fourth most commonly abused
addictive substance and a known Class I carcinogen.
Sweetened and avored areca-nut is popular among
PRESENTATIONS (SCIENTIFIC RESEARCH)
ORAL PRESENTATION
Indian Journal of Cancer
Volume 58 | Supplement 1| 2021
S14
children acts as a gateway product for tobacco.
Therefore, it is important that tobacco control
programs for adolescents also address areca-nut. The
objective of the study was to assess 1) use of areca-
nut among adolescents and 2) outcomes of areca-nut
and tobacco cessation intervention.
Methods: LifeFirst, a school-based areca-nut and
tobacco cessation program was implemented from
2013-2019 in 172 slum-based schools in Mumbai.
Orientation sessions were conducted for all the students
of 7th, 8th and 9th standards (age 12-15 years) to
create awareness about ill-effects of areca-nut and
tobacco and encourage current users to voluntarily
register for cessation services. Theme-based group
counseling sessions were conducted with the registered
students. During the program, the students acquired
refusal skills and coping mechanisms. Periodic follow-up
sessions were conducted and at each session areca-
nut /tobacco use status was monitored and recorded.
Results: 18,895 students were sensitized about ill-
effects of areca-nut and tobacco. Of these, 4371
(23%) students registered for the cessation program.
Among them, 3800 (87%) were only areca nut users,
452 (10%) students consumed areca nut along with
some form of tobacco, 80 (2%) only smokeless
users and 39 (1%) only smoking. At the end of the
program, 2489 (66%) of the only areca nut users,
199 (44%) of areca nut and tobacco users, 38
(48%) smokeless users and 19 (49%) smokers’ self
-reported that they had quit their habit.
Conclusion: School based cessation programs are
feasible and effective to help the students to quit their
habit and also to prevent transition from areca nut to
tobacco.
Comparison of two behavioural school based
cessation programs implemented in slums of India
Himanshu Gupte, Gauri Mandal*
*Assistant Manager, Salaam Bombay Foundation, Mumbai, Maharashtra,
India
Background: 14.6% of youth use some form of
tobacco. Two thirds of the smokers want to quit their
habit. With such a high prevalence and increasing
burden among the adolescents, it becomes important
to design and implement cessation interventions which
reach to a larger population with limited available
resources. The objective of the study was to assess
outcomes of a three-month and a six-month school-
based tobacco cessation program.
Methods: LifeFirst, a six-month school-based areca-
nut and tobacco cessation program is implemented
in schools from slum areas of Mumbai. The program
consists of one orientation session for all the students
of 7th, 8th and 9th standard and six theme-based
group counseling sessions with the current areca-
nut and tobacco users. To scale up the program
with limited additional resources a less intensive
SMART model was designed based on the original
six-month intervention. The SMART model consisted
of one orientation session and three theme-based
group counseling sessions. A team of ve counselors
implemented both the interventions and helped the
students to build refusal skills and coping mechanisms.
Results: In 2018-19, 1384 students were oriented in
18 schools through the six-month intervention program
of which 579 (42%) students registered for counseling
sessions whereas through SMART intervention, 3548
students were oriented in 60 schools and 1141 (32%)
students registered. At the end of six-month program,
398 (69%) students and at end of three-month
program 498(44%) self-reported that they had stopped
using areca nut/tobacco.
Conclusion: A three-month intervention is also effective
in helping adolescents quit their areca-nut/tobacco use
and it should be implemented and promoted in low-
resource (nances, human resources etc.) settings to
reach out to a larger number of adolescents.
Are adolescence resilience, family and
schools environmental factors associated with
adolescent’s intention to use tobacco in India?
Maruti B Desai*, Mangesh S Pednekar, Namrata
Puntambekar, Prakash Gupta, Ritesh Mistry
*Statistician, Healis Sekhsaria Institute for Public Health, Mumbai,
Maharashtra, India
Background: Adolescence age between 12– 14
years is a crucial period of life. It is a time when
people become independent individuals, forge new
relationships, develop social skills and learn behaviors
that will last the rest of their lives [1]. Prevalence
of any form of tobacco use is 14% among school
going adolescents in India [2]. We are assessing
the intention to tobacco use among adolescents and
its association with resilience score, family score,
parental score, school score and teachers score.
Methods: A multi-stage sampling household survey
(n=1982) of adolescents (12–14 years) and their
parent/main-caregivers is underway in Kolkata
(n=1038) and Mumbai (n=944) with data collection at
baseline (2018-2019) and 3 follow-ups. Participants
complete questionnaires about intention to tobacco
use and resilience, family, parental, school and
teacher’s factor. Based on the questionnaire, scores
were developed for adolescent resilience score (0-10),
Abstract
Volume 58 | Supplement 1| 2021 S15
family score (0-5), parental score (0-6), school score
(0-4) and teacher’s score(0-6). Descriptive statistics
were calculated using SPSS20.0. Results were
weighted to be population-based.
Results: Adolescent’s intention to use tobacco was
higher in Mumbai than in Kolkata (8.5% vs 7.7%;
p<0.0001). Boys from both cities reported higher
intention to use tobacco than girls. The prevalence
of intention to use tobacco among adolescents was
associated with adolescents resilience score (score
0:-Mumbai-3.9%, Kolkata-3.4%; score 1&above:-
Mumbai-11.2%,Kolkata-10.0%), family score (score
0:-Mumbai & Kolkata-7.3%; score 1&above:-
Mumbai-23.6%,Kolkata-9.4%), Parental score (score
0:-Mumbai-4.3%,Kolkata-7.6%; score 1&above:-
Mumbai-16.3%,Kolkata-7.2%), School score (score
0:-Mumbai-7.4%,Kolkata-6.9%; score 1&above:-
Mumbai-15.3%,Kolkata-8.1%) and teacher’s score
(score 0:-Mumbai-5.4%,Kolkata-9.0%; score 1&above:-
Mumbai-19.7%,Kolkata-4.6%).
Conclusion: All ve scores were strongly associated
with intention to use of tobacco among adolescents
in both cities. Therefore, policy makers should include
this factor in tobacco control measures.
Factors inuencing tobacco use and associated
premalignant conditions among police personnel
Tshering Doma Bhutia, Narayan Lad,
Abhiram Mehendale*
*Project Manager, Salaam Bombay Foundation, Mumbai, Maharashtra,
India
Background: Despite being the significant
stakeholders in tobacco control, police officials in
India are addicted to tobacco. The available evidence
shows that prevalence of smokeless tobacco forms
is significant among the Indian police officials. To
understand various factors inuencing tobacco use
and tobacco induced pre-malignant conditions,
Salaam Bombay Foundation conducted cross-
sectional study among Navi Mumbai Police ofcials
in January 2020.
Methods: Initially meetings were held with Navi
Mumbai Police Commissionerate to receive blanket
permission to organize survey and oral screening
at police stations. After receiving permission, both
survey and oral screening were conducted at each
police station around morning parade time. Informed
consents were obtained separately for participation in
survey and oral screening. Self-administered survey
questionnaire uploaded in tablets was used for
survey. Oral screening was conducted in collaboration
with a dental college in Navi Mumbai.
Results: 295 police participated in the survey and 307
ofcials underwent oral screening. 21% (n=62) police
ofcials participated in the survey self-reported current
tobacco use; but oral screening identied 25.4% (n=78)
current tobacco users. All current tobacco users were
males. The prevalence of current tobacco use was
directly associated with years in police service. Peer
inuence (23%), work pressure (17%) and long duty
hours (17%) were the most common self-reported
reasons for tobacco use. 8.8% (n=27) police ofcials
were diagnosed with pre-malignant conditions that
included tobacco pouch keratosis (70.4%), leukoplakia
(25.9%) and oral sub-mucous brosis (3.7%).
Conclusion: The study revealed that most of the
factors predisposing the police ofcials to tobacco use
are occupational. Tobacco use may predispose some
of them into the pre-malignant conditions which further
predisposes them to oral cancers if not intervened
on time. Thus, making oral screening facilities
available along with tobacco cessation counselling
and treatment of tobacco users is important.
Estimation of relative risk of head and neck and
oral cancer associated with tobacco consumption.
In a cancer registry a retrospective approach.
Anmol Mathur
Associate Professor, D Y Patil Dental College and Hospital, Pune,
Maharashtra, India
Background: Among various cancers, head and neck
(HN) cancer in India is emerging as a major public
health problem. Head and neck and Oral Cancer are
strongly associated with certain environmental and
lifestyle risk factors one among which is Tobacco.
According to World Health Organization, cancer is
growing at an alarming rate and all necessary steps
should be taken to counter this modern day epidemic.
Methods: A retrospective study on the prevalence
of various cancers in the HN and oral cavity regions
was conducted in the Department of Oncology,
S.M.S Hospital, Jaipur, which is a tertiary hospital
where patients from all the districts of Rajasthan
state are being referred, thus the hospital receives
a fairly representative sample of cases across the
State. A total of 4587 Total Body Malignancy cases
were obtained from the out patient department (OPD)
registered, among which HN and OC constituted
1705. Patient confirmed by histopathological
evaluation were, 1476 included in the study.
Results: There were 1223 (83.75%) male and 253
(16.25%) female patients. There were 640 (43.36%)
and 836 (56.64%) HN, and OC cases, respectively.
The most common habit was the combination of all
Indian Journal of Cancer
Volume 58 | Supplement 1| 2021
S16
three, that is, smoking, smokeless tobacco and alcohol,
both in HN (26.09%) and OC (23.68%) cases, followed
by smoking. Among the OC cases, 15.43% consumes
smokeless tobacco, which is high as compared to HN
cancer cases 10.16%. In multivariate analysis HN and
OC cases showed highly significant association (P
< 0.0001) with smoking, smokeless tobacco, alcohol
consumption and the combination of all three forms
ie smoking, smokeless tobacco, alcohol consumption.
Conclusion: This study attempts to quantify and
analyze the spectrum of HN and OC in the region.
A comprehensive effort is needed to identify the
cause of such high prevalence, generate awareness,
adopting preventive measures and treatment
modalities suited to meet this challenge.
Adherence to the tobacco-free educational
institution guidelines in rural schools of Raipur
Rani block of Haryana
Amit Kumar, Sonu Goel, K Gauba, Ashima Goyal, Arpit
Gupta*
*Associate Professor, Oral Health Sciences Centre, PGIMER,
Chandigarh, India
Background: Despite the existence of comprehensive
laws for tobacco control their acceptance and
successful implementation is questionable. With
40% of India’s population below 19 years, tobacco-
free schools (TFS) can be a critical strategy for
preventing tobacco-use among youth. This study aims
to assess the compliance of schools for Tobacco-Free
Educational Institution (TFEI) guidelines among the
schools in RaipurRani educational block, Haryana.
Methods: This cross-sectional observational study
was conducted using census sampling strategy to
include all 84 schools (government and private).
Investigators collected the data regarding the
adherence of these schools for TFEI using a validated
standard nine criteria checklist of TFEI guidelines by
NTCP, Government of India. Sale of tobacco within
100 yards of the school premises was observed.
Results: None of the schools could achieve a
Tobacco-Free Educational Institution status in the
present study. Though the compliance score for
private schools was better than the government
schools. Violations related to ban on tobacco sale
within 100 yards of schools was found among almost
58% of the Government schools.
Conclusion: There exists a substantial gap between
the TFEI guidelines and their adherence in the study
area. An implementation framework along with a
monitoring mechanism for evaluation and compliance
assessment is required.
How has the COVID-19 pandemic affected tobacco
users in India: Lessons from an ongoing tobacco
cessation program
Gauri Mandal, Dinesh Jagiasi, Himanshu Abhay Gupte*
*General Manager, Narotam Sekhsaria Foundation
Background: Tobacco use is detrimental at any time.
However, it is proving to be more dangerous during
the COVID-19 pandemic. Tobacco use may increase
the risk of being infected, increases the chances
of complications, and also increases the probability
of its spread. We assessed the awareness about
this association and the impact of the lockdown on
tobacco use among tobacco users registered before
the lockdown for LifeFirst, a tobacco dependence
treatment program.
Methods: 1016 tobacco users were under active
follow-up in their course of the 6-month counselling
program. From 14 to 28 May 2020, 650 (64%) of
these registered users were contacted by counsellors
for follow-up sessions over the telephone. Semi-
structured questionnaires were filled in during the
calls.
Results: Two-thirds (67%) of tobacco users were
unaware of the association between tobacco and
COVID-19. Only 30% of the users felt that the
current situation had affected their tobacco use, the
commonest impacts being unavailability and increased
prices of tobacco products. While this was seen as
an opportunity to quit by some users, some reported
increased tobacco use due to increased stress. Of
the 219 (34%) tobacco users who quit tobacco during
the lockdown, 51% quit because of the lockdown
and their concern over COVID-19. Abstinence among
those who were aware of the association between the
coronavirus and tobacco was twice that among those
who were not aware.
Conclusion: Awareness activities about the harmful
effects of tobacco during the coronavirus pandemic
have to be strengthened. Measures to motivate and
support tobacco users to quit have to be provided
through cessation services.
Role of machine learning in tobacco cessation: A
systematic review
Rakesh Gupta, Sonu Goel, Mahendra Pratap Singh*
*Technical Officer (Trans-fat), DCM & SPH, PGIMER, Chandigarh, India
Background: More than 50% of tobacco users
in India wanted to quit tobacco use. Conventional
cessation methods, inaccessible cessation facilities,
limitations of tele or phone consultation are few
Abstract
Volume 58 | Supplement 1| 2021 S 17
important impediments in low quit rate of tobacco use.
The recent advancements in machine learning and
articial intelligence have shown unprecedented impact
in healthcare and various other elds. The aim of this
study was to access the role of machine learning in
cessation of tobacco and nicotine dependence.
Methods: To review the studies conducted to find
out the role of machine learning in tobacco cessation.
We conducted a PubMed search with keywords
(tobacco cessation OR smoking cessation OR nicotine
dependence) AND (machine learning). Original
research articles in English language were selected. A
total of 61 studies were retrieved through the search.
Irrelevant studies were excluded from the study.
Results: Studies included in our analysis used
different study designs such as analysis of the
online user conversation, case-control study, cross-
sectional and National Health Survey, clinical trial,
and attendees of cessation program. These studies
successfully demonstrated the role of machine learning
in predicting the quit rate and lapses attempt. Machine
learning were used to classify tobacco user for tailored
tobacco cessation and behaviour change therapy.
Conclusion: Independent studies conducted with
different objectives to analyse the role of machine
learning in tobacco cessation were unanimously
concluded that machine learning can play an
augmenting role in conventional tobacco cessation.
Urgent efforts should be made to equip the tobacco
cessation centres or facilities with machine learning
facility. A one-size-fits-all approach should be
abandoned.
Areca nut addiction in India: A cross-sectional
analysis of global adult tobacco survey
Amit Yadav, Dr Lucky Singh, Dhirendra N. Sinha,
Kurt Straif, Shalini Singh, Prashant Kumar Singh*
*Scientist ‘D’ (Population Studies), ICMR-National Institute of Cancer
Prevention and Research, Noida, Uttar Pradesh, India
Background: Globally, areca nut is the fourth most
abused addictive substance after nicotine, ethanol
and caffeine and highly prevalent in the Asia-Pacic
region. Areca nut use is a well-known risk factor of
oral and other cancers of the upper aero-digestive
tract. This study aims to examine the disparity and
determinants of areca nut addiction in India using
nationally representative sample.
Methods: We used nationally representative Global
Adult Tobacco Survey (GATS) conducted in 2016-17.
Analytical sample size was 74,037 adults aged 15
years and above. We estimated self-reported current
use of areca nut. We examined determinants of areca
nut consumption using multinomial logistic regression,
accounting for complex survey design.
Results: 23.9% adult population consume areca
nut, which accounts for approximately 223.79 million
users in India. Out of total areca nut users, 9.7%
users consumed areca nut with tobacco. Four states
namely Uttar Pradesh (49.9 million), Maharashtra
(26.7 million), Karnataka (19.8 million) and Tamil
Nadu (17.7 million) accounts for half of the areca nut
users in the country. When compared to females,
males were more prone to consume areca nut
without tobacco (RR=1.13; 95%CI 1.07-1.20) and
with tobacco (RR=2.02; 95%CI 1.85-2.21). Age,
marital status, education, occupation, caste, religion
and region were signicantly associated with areca
nut use. However, the direction of association differs
with respect to the use of areca nut with tobacco and
without tobacco.
Conclusions: Our study shows that areca nut use
is widespread in India and many consume areca
nut with tobacco. Furthermore, areca nut addiction
follows the complex pattern by socioeconomic groups
and regional trajectories. Our research highlights
that tobacco control policy efforts would not yield the
desired outcome until greater attention to areca nut
use is reected in the formulated health policies.
Association between nicotine dependence and
biochemical marker veried smoking status
among adults in Gurugram City- An observational
study
Charu Khurana
Senior Lecturer, Public Health Dentistry, FDS, SGT University,
Gurugram, Haryana, India
Background: The number of individuals continuing
to smoke remains a major public health problem
in India. Smoking assessments are done based
on self-reported information or with biochemical
verication. Self-reported measurements are most of
the times unreliable as respondents may be unwilling
to admit to social behaviour that many perceive to
be undesirable. Reliable biochemical markers are
an important adjunct to self-reports for the objective
evaluation of newer approaches in determining
tobacco use.
Methods: A descriptive cross-sectional study was
conducted among a convenient sample of 492
patients visiting dental hospital in Gurugram city.
Tobacco dependence was assessed using the
modified fagerstrom test for nicotine dependence
(FTND) scale. A Carbon monoxide (CO) breath
analyzer was used to assess the amount of CO in
Indian Journal of Cancer
Volume 58 | Supplement 1| 2021
S18
the breath in parts per million with a range from
0-100.
Results: The mean age of the participants was 37.03
± 13.81 ranging from 18 to 80 years. The mean CO
levels were 15.70±6.628ppm. The regular smokers
showed maximum value of 16.71±6.545, followed by
occasional and non-smokers.
Conclusions: The result of the present study showed
that the exhaled CO level had a signicant moderate
correlation with self-reported nicotine dependence.
It may serve as a more objective method to detect
tobacco use and confirm the utility of biochemical
verication across different diagnostic modalities.
Knowledge attitude and practice regarding
Tobacco cessation services among adults (18-35
years) in India
Swati Bachani*, Dushyanth
*Consultant, Indian Institute of Public Health, Delhi, India Indian Institute
of Public Health, Delhi, India
Background: Tobacco smoking is a known cause
of high mortality across the globe. Quitting smoking
early can reduce morbidity remarkably. Tobacco
cessation services (TCSs) help to reduce smoking
addiction which consequently lowers tobacco-related
diseases and deaths. Very few studies estimated the
knowledge attitude and practice about TCSs in India.
Methods: A cross-sectional study was conducted
to estimate the prevalence of smoking along
with knowledge attitude and practice about TCSs
among adults (n=383) aged 18-35 years in India.
A Pre-tested structured questionnaire on Open
Data Kit (ODK) was used to capture information
on demography, smoking and smoking cessation
services. Descriptive analysis was performed to
describe all the information.
Results: Mean age of respondents was 25.3 years
(SD 4.0). Prevalence of smokers (current and past)
was 24.8% with higher prevalence in males (37.1%)
compared to females (9.8%). Knowledge about TCSs
was relatively fair for Nicotine replacement therapy
(NRT) (71.5%) and tobacco de-addiction counselling
(63.7%) as compared to Tobacco cessation toll-free
number (32.4%), de-addiction medicines (44.4%) and
centres (41.8%). Attitude towards availability of TCSs
was positive (77.7%). However, respondents consider
TCSs to be insufcient (15.5%), ineffective (47.1%),
expensive (23.8%) and hard to access (28.7%).
Although 71% thought to quit smoking in past one
year but due to lack of knowledge, practice towards
TCSs were found to be low. Noteworthy factors to
quit smoking were will/self-motivation, health concerns,
social factors, expense on the cigarette. The potential
barrier to quit smoking were smoking routine and
emotional trigger.
Conclusions: Knowledge about TCSs was low
except NRT. Majority contemplated TCSs as
insufcient, expensive and unapproachable which is
why the usage of TCSs remains low. Therefore, it
is recommended to focus on promotional activities
and create awareness of TCSs effectiveness to quit
tobacco.
Knowledge, attitude, behaviour and prevalence of
tobacco use among medical and dental students in
Eastern part of Odisha
Pratap Kumar Jena, E Venkata Rao, Nancy Satpathy*
*Research Scholar, Siksha ‘O’ Anusandhan University, Bhubaneswar,
Odisha, India
Background: Tobacco use and attitude towards
tobacco control among health professional students
is of paramount importance considering their vital
role in tobacco cessation. In this context this study
was carried out to assess the knowledge, attitude,
behavior and prevalence of tobacco use among
medical and dental students in Bhubaneswar, Odisha.
Methods: A cross-sectional study was carried out in
two medical and two dental colleges in Bhubaneswar,
Odisha. About 400 students (female 223) of 3rd year
medical and dental courses participated in the study.
The Global Health Professional Students Survey
(GHPSS) questionnaire was used to collect self-
reported tobacco related data. The data was analyzed
using R package.
Results: The participant health professional
students were in the age group of 19 and 25 years.
The prevalence of current smokers among the
respondents was 15.8% (95% CI: 12%-16%). Among
the students, 36.3% had ever smoked a cigarette
even one or two puffs. 2.8% had smoked their rst
cigarette at the age of 10 or younger. There were
more numbers of smokers among men as compared
to women (24.3% versus 9%). About 86.3% of the
students stated they had received lessons on the
risks associated with smoking during their curriculum
course. Around 85.5% students agreed that tobacco
sales to adolescents should be completely banned.
Among the current smokers, 81% want to stop
smoking cigarettes now. About 88.8% suggested
health professional can be role model for tobacco
users in advising to quit tobacco.
Conclusion: Despite of use of tobacco among
medical and dental students, majority students has
positive attitude in tobacco cessation. The study
Abstract
Volume 58 | Supplement 1| 2021 S19
ndings warrant immediate interventions to empower
medical and dental students with capacity building in
tobacco control and tobacco cessation interventions.
Prevalence of Tobacco among adults in rural
Warangal
Punam Kumari Jha, Manisha Devarakonda*
Kakatiya Medical College, Warangal, Telangana, India
Background: Tobacco use is a major risk factor
for many chronic diseases, including cancer, lung
disease, cardiovascular disease and stroke. It is one
of the major causes of death and disease in India
and accounts for nearly 1.35 million deaths every
year. This study aims at finding the prevalence of
tobacco among adults and the demographic features
of the people living in rural Warangal.
Methods: A cross-sectional study was conducted in
rural eld practice area of Kakatiya medical college
among adults above 18 years of age. Institutional
ethical committee approval and consent of the
study participant was obtained. A semi-structured
questionnaire was used to obtain data. The sample
size was calculated by taking prevalence p as 29%
as per GATS 16-17 and precision of error as 5%. 317
participants were recruited by simple random sampling.
The data collected was uploaded into Microsoft excel
and exported to SPSS V 20 for analysis.
Results: 53.8% to 25-54 years. 90% of the
participants were males and 10% were females.
43.8% of the participants were illiterate, 61% of
the participants were self-employed, 13.8% were
students. 35% (32.5% of males and 2.5% females) of
participants used tobacco. Of the participants who use
tobacco: 42.8% of initiated tobacco between the ages
20-29. 53.5% were illiterate. 64.3% used smokable
tobacco, 28.5% used chewable tobacco and 7.1% use
both. Reason for initiation among 32% was curiosity,
25% stress and 17.5% peer pressure. 14.2% had
family history of tobacco use. 58.8% were asked to
quit smoking by a healthcare worker. 78.5% said that
they attempted to quit tobacco in the past but failed.
Conclusions: A multi-pronged approach is needed to
control tobacco use among young adults in the form
of health education about hazards of smoking and
information about de-addiction centers for the proper
implementation of anti-tobacco policies.
Prevalence of tobacco consumption among
adolescents in India: A systematic review and
Metanalysis
Ajay Gupta
Resident, SMS Medical College and Hospital, Jaipur, Rajasthan, India
Background: Tobacco use is one of the leading
preventable causes of morbidity and mortality.
Tobacco use usually starts in adolescence and
continues into adult life; effect of tobacco consumption
can be seen later in life. This systematic review and
meta-analysis aimed to assess the pooled prevalence
of tobacco consumption among adolescents in East
India.
Methods: We systematically searched 3 databases
PUBMED, Science direct and Mendeley for original
studies published between January 2011 to December
2021 only in English language. All primary studies
that reported prevalence of tobacco consumption in
children were included. Study extraction and quality
assessment were conducted independently by 3
reviewers using a standardised data extraction and
quality appraisal form. A weighted inverse-variance
random-effects model was used to estimate the
prevalence of current cigarette smoking. Funnel plot
were used to check publication bias.
Results: Total of 25 studies were reviewed. The
prevalence of tobacco consumption among school-
going adolescents ranged from 2.2% to 48.8%. The
common risk factor for tobacco usage among school-
going adolescents was found to be peer pressure.
Parents’ smoking behavior, family conflict, stress,
and curiosity were also found to be additional risk
factors.
Conclusions: High prevalence of tobacco
consumption among adolescents was found in India.
This review recommends a need for formulating sale
prevention policies, strict tobacco control policies
at school premises and establishing antismoking
campaigners designed for school-going adolescents.
Smokeless and avored smokeless tobacco
epidemic in India and Bangladesh
Nancy Satpathy
Research Scholar, Siksha ‘O’ Anusandhan University, Bhubaneswar,
Odisha, India
Background: To estimate the burden of flavored
smokeless tobacco use in India and Bangladesh.
Methods: Flavored smokeless tobacco was identied
from the publicly available adult tobacco survey
data. Operationally, any additional ingredient (except
slaked lime) that alters or modies the taste of plain
tobacco was considered as avored one. The data
was analyzed using SPSS and weighted prevalence
estimates were reported.
Results: Use of Smokeless tobacco in India and
Bangladesh were 24.1% (95% CI: 21.7-26.8) and
Indian Journal of Cancer
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27.2% (95% CI: 25.5-29.1) respectively. Prevalence
of flavored smokeless tobacco use in India and
Bangladesh were 17.2% (95% CI: 14.3-20.1) and
27.3% (95% CI: 24.4-30.2) respectively. Gutkha
(8%) and betel quid (7%) were commonly used
avored smokeless tobacco products in India, while
Zarda (18%) and amp; Betel quid tobacco (10%)
were commonly used avored smokeless tobacco in
Bangladesh.
Conclusions: Almost all smokeless tobacco products
are avored one in Bangladesh and more than two-
third smokeless tobacco products are flavored in
India. As tobacco cessation is difcult when avoured
tobacco products are used, tobacco epidemic may
be aggravated in India and Bangladesh. Hence
policy makers should take appropriate action to curb
smokeless tobacco.
Tobacco use surveillance among dentists based
on WHO-MPOWER strategies
Pramada Prabhakar
Post Graduate Student, A. J. Institute of Dental Sciences, Mangalore,
Karnataka, India
Background: India has the highest rates of oral
cancer due to high prevalence of tobacco use.
Literature showed that there is inadequate perceptions
related to harmful effects of tobacco among dentists.
Hence this study aimed to assess the tobacco use
surveillance among dentists based on the WHO-
MPOWER strategies.
Methods: A rapid need assessment survey using
a cross sectional study design was conducted
among dentists working in a tertiary care hospital
of Mangalore, South India. Ethical clearance was
obtained from the Institutional Ethics Committee. After
obtaining informed consent the questionnaires were
distributed to 120 dentists. The data was collected for
a period of 1 month. The questionnaire consisted of
19 questions based on WHO-MPOWER strategies. A
total of 90 questionnaires were returned which was
statistically analysed using SPSS version 16.
Results: Among the 90 dentists, 95% of them
were aware that tobacco consumption is harmful
for health. Cigarettes (33.3%)were more commonly
used compared to other tobacco products. 23.3%
of them have tried quitting smoking in the past
12 months.75% of them had seen the dangers of
smoking in the newspapers and television. 15.6%
had people who smoked inside the house and 27.8%
people had people smoking in their working area.
15.6% led them to quit smoking after seeing the
warning labels on cigarette packs.
Conclusions: The study concludes that the majority
of the dentists use smoked form of tobacco compared
to smokeless forms. Hence more efforts need to be
made to assess them in becoming tobacco free role
models so that they can be supporters to promote
smoke free work places and environment. They can
add their voice and weight to tobacco control efforts
like tax increase campaigns and involve themselves
in prom.
Validity of self-reported smoking cessation with
carbon monoxide cut-off point - A systematic
review and meta-analysis of diagnostic test
accuracy studies
SahanaHegde–Shetiya
Professor & Head, Dr. D Y Patil Dental College and Hospital, Pune,
Maharashtra, India
Background: Exhaled breath CO is an indicator for
smoking cessation. Breath analyser is a device used
to validate the self-reported smoking abstinence of an
individual. Focused Question-At what breath analyzer
carbon monoxide cut-off point among smokers can
self-reported smoking cessation be validated for
various devices?
Methods: The studies eligible were, diagnostic
tests from 1980-August 2020 which were published.
Databases like PubMed, Google Scholar,
Hinari, IndMED, Cochrane and EBSCO were
searched. Articles with only true positives(TP)
and negatives(TN),false positives(FP) and
negatives(FN) were included and data extraction
was carried out on customized excel sheet and
sensitivity, specificity, positive predictive value,
negative predictive value was calculated using C. I.
Calculator: Diagnostic Statistics. Meta-DiSC® version
1.4 was used for meta-analysis and QUADAS
2 tool was used to assess the quality of the
included studies. Studies included were reviewed
independently by three authors and the relevant
data was extracted.
Results: The systematic review of 22 manuscripts of
diagnostic test was carried out, 10 were considered
for meta-analysis. Data was summarised for cut-off
of 0-6 ppm and 7-10 ppm for various exhaled breath
carbon monoxide values. A meta-analysis of 3 pooled
studies at 7-10 ppm using piCO+ smokerlyser device
and any of the Bedfont devices gave Sensitivity
of 93% (CI-90-95), PPV-95 and Specificity of 87%
(CI-81-92), NPV-80. On combining all device’s and
cut-off range from 2ppm-10ppm, the self-reported
abstinence is validated by Vitalograph Inc., at around
9-10 ppm.
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Conclusions: The self-reported smoking abstinence
as reported by the Bedfont CO monitor was validated
at cut-off 6-›7 ppm and above with Sensitivity 93% &
Specicity of 87%. From cut off of 2-6ppm to ›6-›7ppm
there was a jump of 8% for Sensitivity and Specicity.
Baseline results from a longitudinal study of
adolescent Tobacco use in India
Ritesh Mistry*, William McCarthy, Prakash C Gupta,
Trivellore Raghunathan
*Associate Professor, University of Michigan, Michigan, USA
Background: A cohort of early adolescents has been
established in India to study tobacco use initiation in
the context of family and community environmental
factors.
Methods: A multi-stage sampling household survey
(n=1982, 2018-19 baseline) is underway in Kolkata
and Mumbai involving young adolescents (12–14
years old) and their main caregivers. Respondents
complete four annual questionnaires about tobacco
use and individual, family and community risk and
protective factors. Sampling weights were used to
increase representativeness.
Results: The baseline adolescent sample was 50%
female, 92% lived with married caregivers, 15% had
fathers with post high-school education and 73%
lived in households with monthly income of < 15,000
INR. Adolescent tobacco use was rare (0.6% ever
tried and 0.2% past 30-day use), but risk factors
for future use included: intention to use tobacco
(8%), peer tobacco use (37%: 33% Mumbai, 45%
Kolkata, p<0.05), easy tobacco access (18%), and
parent tobacco use (9% mothers and 34% fathers).
Adolescents reported talking to parents about harms
of tobacco use (30%: 34% Mumbai, 21% Kolkata,
p<0.05). Weekly secondhand smoke exposure was
low in homes (16%: 7% Mumbai, 34% Kolkata,
p<0.001) but higher outside homes (52%: 32%
Mumbai, 91% Kolkata, p<0.001). As to community
factors, adolescents reported seeing tobacco ads near
home (26%: 17% Mumbai, 45% Kolkata, p<0.001)
and school (22%: 13% Mumbai, 40% Kolkata,
p<0.001) and reported ‘a lot’ of tobacco retailers near
home and school (17% and 14%, respectively).
Conclusions: Because the adolescent respondents
were young, tobacco use rates were vanishingly
low. Kolkata adolescents reported more peer use,
secondhand smoke exposure and presence of tobacco
ads, putting them at higher risk of future use compared
to Mumbai adolescents. Longitudinal associations
between multilevel factors and adolescent tobacco use
initiation will be examined using the follow-up data.
Understanding politics of tobacco in India through
two decades of parliamentary interactions
Latha Chilgod, Amiti Varma*, Upendra Bhojani
*Research Officer, IPH
Background: India faces the difficult challenge
of balancing strong tobacco-control regulations to
protect the public health while being home to a
protable tobacco industry. This dynamic illustrates
the complexities around tobacco regulation. As the
parliament keeps the government accountable, we
analysed tobacco-related questions to map the varied
concerns of parliamentarians. This work is part of an
ongoing research initiative to better understand the
political economy of tobacco control in India.
Methods: Transcripts were sourced from the
electronic archives of both the Loksabha and the
Rajyasabha of India. The keyword “tobacco” was
used to identify questions about tobacco from 1999
to 2019. The retrieved documents were managed
and analysed using NVivo software. We conducted
content analysis, where our coding was guided
by the research question “varying concerns of
parliamentarians around tobacco” and themes were
identied and rened iteratively.
Results: 729 unique parliamentarians asked 1315
questions about tobacco. From our analysis, we
illustrate the varying concerns around tobacco as the
questions emerged from competing interests around
issues of health, commerce, labour, and agriculture.
Over the two decades, the focus of the questions
shifted from trade to health concerns, consistent
with the introduction of various tobacco control
regulations in India. We also found important state-
level differences in the number and nature of the
questions, with a majority from tobacco producing and
manufacturing states.
Conclusions: We show that parliamentary questions
can be an important tool in studying health
policies and understanding health as a political
process. This study empirically demonstrates how
regulatory measures around tobacco in India are
multi-institutional and are a result of negotiations of
legitimate, competing interests.
Implementation’ of tobacco control policies in
LMICs – A realist synthesis to explain the process
and its facilitators and barriers?
Pragati B Hebbar*, Vivek Dsouza, Upendra Bhojani
*Ph.D. Scholar, DBT/Wellcome Trust India Alliance fellow, Assistant ,
Institute of Public Health, Bengaluru, Karnataka, India
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Background: There has been a growing interest
around implementation and unpacking the ‘black-box’
of how things work over the last few years. Policies
are complex in their design and implementation
because of the number of interacting agents, the
environment and forces that influence in a given
system. There is a dearth of research informing
policy implementation but theory-driven inquiry is
now considered to be a promising alternative. It is
important to systematically understand how and why
implementation.
Methods: A realist synthesis is being conducted to
find the facilitators and barriers of implementation
of select TCPs in low and middle income country
settings. An initial framework of how COTPA
implementation works was developed on the basis
of review of program documents, scoping of relevant
scientific literature and inputs from stakeholders
working with implementers of COTPA. The realist
synthesis will be using sources such as program
documents, parliamentary questions and debates,
program reports, departmental reviews/reports,
minutes of meetings, scientic peer reviewed articles
from select databases, media, websites, social
media and snowballing to other relevant grey and
unpublished literature.
Results: Implementation research and health policy
analysis are scarcely applied in many low-and middle-
income country settings. By the end of this realist
synthesis we aim to develop theories explaining the
facilitators and barriers of implementation of select
TCPs in India.
Conclusions: COTPA which was enacted in 2003 in
the next three years would be completing 20 years
in existence. Such a critical policy review after nearly
two decades of a law being in existence is a timely
intervention to bolster our efforts in tackling the socio-
economic burden of tobacco related illnesses.
Tobacco industry interference index: Assessing
the implementation of article 5.3 FCTC in India for
the year 2019
Adhip Amin
Researcher, Institute of Public Health, Bengaluru, Karnataka, India
Background: This study aims to assess the
implementation of Article 5.3 of FCTC in India during
the year 2019.
Methods: Using SEATCA’s TII Index, this paper
describes and quantifies the extent to which the
Tobacco Industry has sought to inuence the circuits
of policy making and implementation, specically in
the context of health, but also in agriculture, trade
and commerce. A detailed search was conducted
of media reports during the year 2019, industry and
government documents, websites, and press releases
were collated and analyzed. We also consulted
several national and state level tobacco control
practitioners/advocates seeking their inputs.
Results: While we are in an advance stage of
finalizing the incidents and their scoring in order
to develop an overall score for the Index, we, for
now, provide narrative insights on major issues
concerning article-5.3 that we found so far (1)
There were a high number of letters, proposals,
and appeals that were made to the central and
state governments by tobacco and industry
bodies arguing for a reconsideration on the ban
of ENDS products. However, the government
did not accept any of such recommendations.
(2) A number of Government-Tobacco Industry
partnerships for developmental activities were
found. There were also instances of various
tobacco industries engaging in CSR that directly
fit into the welfare policies of the government. (3)
In terms of non-CSR interactions, partnerships,
and collaborations between the tobacco industry
and government: (a) the tobacco industry is
closely involved with the state’s anti-smuggling
imperatives and implementation drives. (b) the
ways in which the t.
Conclusions: A nation-wide policy in line with the
FCTC article 5.3 is need of an hour to prevent
tobacco industry interference in public policy and
implementation concerning tobacco.
Prohibition of e-cigarettes in India: A multicentric
retailer storefront compliance assessment
Shivam Kapoor*, Beladenta Amalia, Renu Sharma,
Rana J Singh
*Technical Advisor (Monitoring and Evaluation), International Union
Against Tuberculosis and Lung Disease (The UNION)
Background: This study aimed to assess the
availability of retailer storefronts that continued to
sell electronic nicotine/non-nicotine delivery systems
(ENDS/ENNDS) in India, and characterise such
retailers following the promulgation of 2019 Indian
Ordinance and Act (Ordinance/Act) that prohibit
ENDS/ENNDS nationwide.
Methods: Discreet observations were conducted of
retailer storefronts across different socioeconomic
zones in nine major cities of India (Bengaluru,
Chandigarh, Dehradun, Delhi, Indore, Kolkata,
Ludhiana, Raipur, and Ranchi) from 28 November
Abstract
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2019 to 22 January 2020 to identify the availability of
ENDS/ENNDS (i. e. electronic cigarettes, e-cigarette
liquid, e-cigarette accessories, heated tobacco
products (HTPs), and HTPs accessories). We report
the number and proportion (%) of retailers that sold
ENDS/ENNDS. Other characteristics of the retailers
are also described, including indirect evaluation of the
retailer’s awareness of the Ordinance/Act.
Results: Of the 199 retailer storefronts visited, 37
(18.6%) sold ENDS/ENNDS and, therefore, did
not comply with the Ordinance/Act. The highest
availability of non-compliant retailers was in Kolkata
(n=26; 83.9%). The majority of the non-compliant
retailers were tobacco retailers (n=35; 94.6%),
sold e-cigarettes (n=22; 59.5%), and e-cigarette
accessories (n=24; 64.9%). Although many of the
non-compliant retailers displayed their ENDS/ENNDS
products (n=33; 89.2%) and did not feature health
warnings related to ENDS/ENNDS (n=32; 86.5%)
in the stores, nearly 90% (n=33) were aware of the
Ordinance/Act.
Conclusions: Despite a nationwide prohibition,
ENDS/ENNDS are still available in major cities in
India, and concentrated in a particular city. Indian
authorities should focus on law enforcement to ensure
that the prohibition is effectively implemented.
Awareness and current use of electronic cigarettes
in India: Findings from 2016–2017 global adult
tobacco survey
Sonu Goel, Nidhi Jaswal*
*Project Coordinator (SMHSP) DCM & SPH, ostgraduate Institute of
Medical Education and Research, Chandigarh, India
Background: Tobacco control efforts are being
influenced with the increase in use of electronic
cigarettes (e-cigarettes) and other electronic nicotine
delivery systems. Although evidence has shown
increase in awareness and use of electronic cigarette
(e-cigarette) in high income countries but less is
known about middle and low income countries.
Methods: Nationally representative household
survey data of 74037 respondents from Global Adult
Tobacco Survey, India (2016-17) was analyzed.
The prevalence of e-cigarette awareness; its current
use and 95% condence intervals were calculated.
Binomial logistic regression analysis was conducted
and prevalence ratios (with 95% CI) were calculated.
Results: Awareness (OR= 2.07; 95% CI= 1.90-2.24)
and use (OR=3.11; 95% CI= 1.19-8.11) of e-cigarettes
was higher among males. Awareness levels reduced
with increasing age. The use of e-cigarettes among
the current tobacco smokers was signicantly higher
(OR= 11.02; 95% CI= 5.15-23.58). The awareness
and use of e-cigarettes was higher in the respondents
belonging to highest wealth quintile.
Conclusions: The awareness and use of e-cigarettes
was higher among males, young adults and smokers.
The males, young adults and heavy smokers should
be specically targeted by information and education
campaigns. Thus, worksites and universities are
potential areas for health promotion, specifically
tobacco cessation. Future research should also
attempt to gather information regarding intensity of
e-cigarette.
Strategic and contested use of food laws to ban
smokeless tobacco products in India: A qualitative
analysis of litigation
Riddhi Dsouza*, Upendra Bhojani
*Consultant (Research), Institute of Public Health, Bengaluru, Karnataka,
India
Background: Unlike other parts of the world, India’s
tobacco consumption pattern is dominated by the
use of smokeless – mainly chewing – tobacco
(SLT). Available in multiple forms and dened by the
geographies that consume them. SLTs – often with
disparate compositions – posit innumerable (public)
health implications, necessitating a comprehensive
regulatory framework. In an attempt to ameliorate
the health effects, states have strategically used food
laws to devise a multipronged governance structure
to c.
Methods: This study identified the two prominent
food laws: PFA 1954 and FSSA 2006 used
to regulate SLT in India. Using the Indian legal
database: Manupatra, we devised a systematic
search technique to generate cases adjudicated by
state high courts and the Supreme Court of India
after independence. Additionally, to ensure that we
were able to review orders that may not have been
documented by Manupatra, we complemented our
search by consulting with tobacco control experts.
We then dissected each case into petitioners and
their claims, respondents and their responses, the
reasoning adopted by the court, and the outcome
of the judgments. Following this, each section was
thematically analyzed.
Results: The study identifies the manner in which
laws peripheral and sometimes unrelated to tobacco
(control) are tactically leveraged by states to
immobilize the Industry’s power complex.
Conclusions: Understanding the intersection of food
laws and tobacco control via litigations is imperative
to comprehend the working of laws beyond the bare
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Volume 58 | Supplement 1| 2021
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text. And, more importantly this interrogation helps
map the loopholes in the legal framework that the
Industry uses to destabilize policy.
Prevalence of tobacco use and level of knowledge
about the harmful effects of tobacco among
medical graduates, postgraduates, and faculty
of a tertiary health care center: A cross-sectional
study.
Pradeep Aggarwal, Mahendra Singh, Yogesh Bahurupi,
Saurabh Kumar*
*MPH Student, All India Institute of Medical Sciences, Rishikesh,
Uttarakhand, India
Background: The global tobacco epidemic is
among a public health threat that world is facing.
In India, nearly 1 million people die from tobacco-
related deaths every year. Recent surveys show
that prevalence of tobacco use among youth and
health care professional students is increasing, and
prevalence of bidis and smokeless products is also
high. The present study is designed to assess the
prevalence of tobacco use among undergraduates,
post graduates and faculty of AllMS Rishikesh.
Methods: A cross-sectional study was conducted
among 225 participants in which undergraduate students
(121) (medical and nursing), postgraduate students (61),
and faculty members (43) of AIIMS Rishikesh were
involved. The mean age of study participant was 26.8 ±
8.04 years. Study was conducted by interviewing the
study participants using a pretested, semi structured
questionnaire after the informed consent was taken.
Results: Overall prevalence of tobacco use among
healthcare professional was 21.33%. Out of total
Under Graduates students, 11.25% MBBS, 2.43%
Nursing students have ever tried tobacco use while
29.5% Post Graduate students have reported that they
have ever tried tobacco. Moreover, it was observed
that 46.5% of Faculty have also ever used tobacco.
Conclusions: The study reflects the worrying
situation and requires health professionals who are
role models for social health to take urgent anti-
tobacco and cessation measures. The perceptions
on the role of doctors in controlling smoking in
the future are promising. This finding may be of
great significance to the strict implementation and
monitoring of smoking-related regulations.