Developing a fully integrated tobacco curriculum in medical colleges in India

Evolution of tobacco control in India: a narrative review of the legislative and regulatory approach

Tobacco is the only consumer product that kills half its users yearly. The challenges posed by tobacco control are limitless especially in a country like India where in addition to smoked forms, other smokeless forms of tobacco are also highly prevalent. Apart from being a health hazard tobacco is also a great environmental hazard. Policies for controlling tobacco use also include policy to prevent people from second hand smoke, which is aimed at improvement of air quality. According to the National Non-Communicable Disease Monitoring Survey, 2017-18, daily tobacco use was 32.8% in adults (18-69 years) and 3.1% in adolescents (15-17 years). Overall reduction in tobacco users by 8.1 Million was seen from GATS-1 to GATS-2, and prevalence amongst youth decreased from 18.4 to 12.4%. GYTS-4 (2019) revealed that 8.5% of students, 9.6% of boys and 7.4% of girls-currently used any tobacco products. This makes tobacco control a priority in India. Tobacco control consists of different approaches such as educational, healthcare, legislative, regulatory and fiscal. In the present article we traverse nearly five decades and decode the evolution of legislative, regulatory and fiscal approaches to Tobacco Control in India. A critical evaluation of all these approaches is described in the format of the MPOWER strategy for Tobacco Control which stands for Monitoring Tobacco use, Preventing people from Second Hand Smoke, Offering help to quit, Waring regarding ill effects of tobacco, Enforcing bans and Raising taxes on tobacco products.

Effectiveness of Medical Student Counseling for Hospitalized Patients Addicted to Tobacco (MS-CHAT): a Randomized Controlled Trial

BACKGROUND

Low-middle-income countries face an enormous burden of tobacco-related illnesses. Counseling for tobacco cessation increases the chance of achieving quit outcomes, yet it remains underutilized in healthcare settings.

OBJECTIVE

We tested the hypothesis that utilizing trained medical students to counsel hospitalized patients who use tobacco will lead to an increase in patient quit rates, while also improving medical student knowledge regarding smoking cessation counseling.

DESIGN

Investigator-initiated, two-armed, multicenter randomized controlled trial conducted in three medical schools in India.

PARTICIPANTS

Eligibility criteria included age 18-70 years, active admission to the hospital, and current smoking.

INTERVENTION

A medical student-guided smoking cessation program, initiated in hospitalized patients and continued for 2 months after discharge.

MAIN MEASURES

The primary outcome was self-reported 7-day point prevalence of smoking cessation at 6 months. Changes in medical student knowledge were assessed using a pre- and post-questionnaire delivered prior to and 12 months after training.

KEY RESULTS

Among 688 patients randomized across three medical schools, 343 were assigned to the intervention group and 345 to the control group. After 6 months of follow up, the primary outcome occurred in 188 patients (54.8%) in the intervention group, and 145 patients (42.0%) in the control group (absolute difference, 12.8%; relative risk, 1.67; 95% confidence interval, 1.24-2.26; p < 0.001). Among 70 medical students for whom data was available, knowledge increased from a mean score of 14.8 (± 0.8) (out of a maximum score of 25) at baseline to a score of 18.1 (± 0.8) at 12 months, an absolute mean difference of 3.3 (95% CI, 2.3-4.3; p < 0.001).

CONCLUSIONS

Medical students can be trained to effectively provide smoking cessation counseling to hospitalized patients. Incorporating this program into the medical curriculum can provide experiential training to medical students while improving patient quit rates.

TRIAL REGISTRATION

URL: http://www.

CLINICALTRIALS

gov . Unique identifier: NCT03521466.

Tobacco Cessation Curriculum in Medical Schools: a Scoping Review

This scoping review aims to identify interventional training courses on tobacco cessation counseling skills of medical students, identify the most appropriate teaching method, and the ideal stage to provide such training. We retrieved articles published since 2000 from two electronic peer-reviewed databases (PubMed and Scopus) and hand-searched reference lists of selected articles. Articles published in English, with a clearly defined curriculum, reporting knowledge, attitude, cessation counseling skills of medical students post-training, and cessation-related outcomes of patients participating in student-led counseling sessions, were considered for inclusion. We used the York framework to guide this scoping review. First, data from studies meeting the inclusion criteria were charted using a standardized form. Subsequently, related studies were organized under three themes that emerged in the review process-lectured-based, web-based, and multi-modal curriculum. We concluded that a short but focused lecture-based curriculum combined with peer role-play or standardized/real patient interactions effectively develops the necessary knowledge and skills of undergraduate medical students to provide tobacco cessation counseling to patients. However, studies consistently report that the gains in knowledge and skills after cessation training is acute. Therefore, continued participation in cessation counseling and periodic review of cessation-related knowledge and skills post-training is warranted.

A scoping review of health professional curricula: Implications for developing integration in pharmacy

BACKGROUND

Integrated health professions curricula aim to produce graduates who are capable of meeting current and future healthcare needs. This is reflected in pharmacy education where integration is increasingly advocated by pharmacy regulators as the perceived optimal way of preparing students for registration as pharmacists. There is, however, no definition of integration. Integration can be described according to a model of horizontal, vertical or spiral integration. It can also be described by the themes used to integrate, such as a systems-based approach or by integrative teaching and learning approaches. The level of integration can also be described.

OBJECTIVE

This scoping review aimed to explore health professions education literature to inform the optimal design of integrated pharmacy curricula. This review asks: what is meant by integration in health professions curricula?

METHODS

The Arksey and O'Malley scoping review framework was utilised. Ovid MEDLINE, EMBASE, Scopus, Web of Science and ERIC were searched. Models of integration, themes for integration, integrative teaching and learning approaches, and level of integration were defined and supported data extraction.

RESULTS

There were 9696 records screened and of these 137 were included. The majority of studies (n = 88) described horizontal integration. Systems-based teaching (n = 56) was the most common theme reported. Various integrative teaching and learning approaches were described, including experiential (n = 43), case-based (n = 42) and problem-based (n = 38) learning. The majority of the curricula could be classified as levels 5-7 on Harden's ladder (n = 102). Perception outcomes were reported for 81 studies, and only 3 reported outcomes beyond perception. Reported outcomes were generally positive and included knowledge gains and increased motivation.

CONCLUSIONS

There is a need for integration to be explicitly defined by curriculum developers and researchers. Attention should be given to describing the model, theme, teaching and learning approach and level of integration. There remains a lack of evidence for integration.

The impact and relevance of tobacco control research in low-and middle-income countries globally and to the US

International and cross-cultural research is critical for understanding multilevel influences on health, health behaviors, and disease. A particularly relevant area of need for such research is tobacco control. The tobacco epidemic is one of the biggest public health threats globally, killing over 7 million people a year. Research critical to addressing this public health problem has leveraged variability in tobacco use, history, product market, and policies across different countries, settings, and populations, particularly in low- and middle-income countries (LMICs) where the tobacco burden is increasing. These efforts are needed in order to advance the science and inform practice and policy in various settings, including the US. Several funding agencies provide support for international research focused on tobacco control in LMICs because of the importance and implications of such research. This paper provides some concrete examples of how such research has advanced our knowledge-base and informed practice and policy globally, particularly in high-income countries including the US. Some prominent themes emphasized in this manuscript include: the development of knowledge regarding the diverse tobacco products on the market; better understanding of tobacco use and its impact among different populations; generating knowledge about the impacts including unintended consequences of tobacco control policy interventions; and better understanding tobacco industry strategies and informing advocacy efforts. In summary, international tobacco control research, particularly in LMICs, is critical in effectively and efficiently building the evidence base to advance tobacco control research, policy, and practice globally, including the US, with the ultimate goal of curbing the tobacco epidemic.

Engaging nurses in smoking cessation: Challenges and opportunities in Turkey

This paper discusses the training of nurses in smoking cessation as part of routine patient care in Turkey. Formative research was carried out prior to training to identify challenges faced by smokers when trying to quit. Site visits to government hospitals and cessation clinics were conducted to observe health care provider-patient interactions involving behavior change. Four culturally sensitive cessation training workshops for nurses (n = 54) were conducted in Istanbul. Following training, nurses were debriefed on their experiences delivering cessation advice. Challenges to cessation counseling included lack of time and incentives for nurse involvement; lack of skills to deliver information about the harm of smoking and benefits of quitting; the medicalization of cessation through the use of pharmaceuticals; and hospital policy which devalues time spent on cessation activities. The pay-for-performance model currently adopted in hospitals has de-incentivized doctor participation in cessation clinics. Nurses play an important role in smoking cessation in many countries. In Turkey, hospital policy will require change so that cessation counseling can become a routine part of nursing practice, incentives for providing cessation are put in place, and task sharing between nurses and doctors is clarified. Nurses and doctors need to receive training in both the systemic harms of smoking and cessation counseling skills. Opportunities, challenges and lessons learned are highlighted.

Tobacco Control in India - Just a Legislative Measure?

abstract.

Developing a smoke free homes initiative in Kerala, India

BACKGROUND

Results of the Global Adult Tobacco Survey in Kerala, India found that 42 % of adults were exposed to second hand smoke (SHS) inside the home. Formative research carried out in rural Kerala suggests that exposure may be much higher. Numerous studies have called for research and intervention on SHS exposure among women and children as an important component of maternal and child health activities.

METHODS

Community-based participatory research was carried out in Kerala. First, a survey was conducted to assess prevalence of SHS exposure in households. Next, a proof of concept study was conducted to develop and test the feasibility of a community-wide smoke free homes initiative. Educational materials were developed and pretested in focus groups. After feasibility was established, pilot studies were implemented in two other communities. Post intervention, surveys were conducted as a means of assessing changes in community support.

RESULTS

At baseline, between 70 and 80 % of male smokers regularly smoked inside the home. Over 80 % of women had asked their husband not to do so. Most women felt powerless to change their husband's behavior. When women were asked about supporting a smoke free homes intervention, 88 % expressed support for the idea, but many expressed doubt that their husbands would comply. Educational meetings were held to discuss the harms of second hand smoke. Community leaders signed a declaration that their community was part of the smoke free homes initiative. Six months post intervention a survey was conducted in these communities; between 34 and 59 % of men who smoked no longer smoked in their home.

CONCLUSIONS

The smoke free homes initiative is based on the principle of collective efficacy. Recognizing the difficulty for individual women to effect change in their household, the movement establishes a smoke free community mandate. Based on evaluation data from two pilot studies, we can project that between a 30 and 60 % reduction of smoking in the home may be achieved, the effect size determined by how well the smoke free home steps are implemented, the characteristics of the community, and the motivation of community level facilitators.