Assessing the readiness to integrate tobacco control in medical curriculum: experiences from five medical colleges in Southern India.

BACKGROUND: Making tobacco cessation a normative part of all clinical practice is the only way to substantially reduce tobacco-related deaths and the burden of tobacco-related morbidity in the short term. This study was undertaken because information on receptivity to integrate tobacco control education in the medical curriculum is extremely limited in low- and middle-income countries. METHODS: From five medical colleges (two government) in southern India, 713 (men 59%) faculty and 2585 (men 48%) students participated in our cross-sectional survey. Information on self-reported tobacco use and readiness to integrate tobacco control education in the medical curriculum was collected from both the faculty and students using a pretested structured questionnaire. Multiple logistic regression analysis was done to find the associated factors. RESULTS: Current smoking was reported by 9.0% (95% CI 6.6-12.1) of men faculty and 13.7% (CI 11.8-15.9) by men students. Faculty who were teaching tobacco-related topics [odds ratio (OR) 2.29; 95% CI 1.65-3.20] compared to those who were not, faculty in government colleges (OR 1.69; CI 1.22-2.35) compared to those in private colleges and medical pecialists (OR 1.79; CI 1.23-2.59) compared to surgical and non-clinical specialists were more likely to be ready to integrate tobacco control education in the medical curriculum. Non-smoking students (OR 2.58; CI 2.01-3.33) compared to smokers, and women students (OR 1.80; CI 1.50-2.17) compared to men were more likely to be ready to integrate a tobacco control education in the curriculum. CONCLUSION: Faculty and students are receptive to introduce tobacco control in the medical curriculum. Government faculty, medical specialists and faculty who already teach tobacco-related topics are likely to be early introducers of this new curriculum.

Smokeless tobacco use among patients with tuberculosis in Karnataka: the need for cessation services.

BACKGROUND: India is home to the largest population of patients with tuberculosis and tobacco users in the world. Smokeless tobacco use exceeds smoking and is increasing. There is no study to date that reports smokeless tobacco use before and after the diagnosis and treatment of tuberculosis. We assessed smokeless tobacco use among former patients of tuberculosis in Karnataka, India. METHODS: We conducted a community-based, cross sectional study among 202 men, who had been diagnosed and treated for tuberculosis (mean age 48 years), selected by multistage, random sampling. Using a semi-structured interview schedule, retrospective smoking and smokeless tobacco use were captured at eight time-points before and after the diagnosis and treatment of tuberculosis. RESULTS: Most patients suspended tobacco use during treatment. A high 44% prevalence of smokeless tobacco use 6 months before diagnosis was reduced to just 8% during the intensive phase of treatment and climbed to 27% 6 months after treatment. The tobacco use relapse rate 6 months after completion of treatment was higher for smokeless tobacco use (52%, 95% CI 41%-62%) than for smoking (36%, 95% CI 26%-45%). We also found that many patients who were advised to quit smoking continued using smokeless tobacco after completion of treatment. Additionally, new smokeless tobacco use was documented. Of the 11 new exclusive smokeless tobacco users, 10 shifted from smoking to smokeless tobacco use as a form of harm reduction. CONCLUSION: Patients with tuberculosis are advised by their doctors, at the time of diagnosis, to quit smoking. Several patients shift from smoking to smokeless tobacco use, which needs to be addressed while providing tobacco cessation services.

Smoking cessation and diabetes control in Kerala, India: an urgent need for health education.

This study documented the tobacco use among male diabetes patients in a clinic-based population of urban India, patient reports of physician cessation messages and patients' perception of tobacco use as a risk factor for diabetes complications. All the 444 male diabetes patients who attended three public sector hospitals in Thiruvananthapuram district, Kerala, were surveyed to ascertain their tobacco use as well as the frequency and content of quit messages received from health staff. A significant proportion (59%) of diabetes patients were tobacco users prior to diagnosis and more than half of them continued to use tobacco, many daily, even after diagnosis. Of the 100 current smokers, 75% were asked about their tobacco use at the time of diagnosis; of those, 52% were advised to quit. However, a lack of patient awareness existed regarding the linkages of smoking and diabetes complications. Notably, 52% of patients did not associate smoking with diabetes complications. Given the magnitude of tobacco use among diabetics, there is clearly a need for more proactive cessation efforts. The times of illness diagnosis, illness flare-ups and emerging illness complications are teachable moments when patients are primed to change their behavior and more motivated to quit tobacco.

Smoking among tuberculosis patients in Kerala, India: proactive cessation efforts are urgently needed.

OBJECTIVES: To document smoking patterns among tuberculosis (TB) patients at eight different points of time before, during and after treatment, and to investigate the frequency and content of the quit smoking messages they received. DESIGN: A stratified random sample of 215 male TB patients from Kerala, India, who had completed treatment in the previous 9 months was surveyed using a pre-tested semi-structured interview schedule. RESULTS: Six months prior to diagnosis, 94.4% of male TB patients were ever smokers and 71.2% were current smokers. Although 87% of patients had quit smoking soon after diagnosis, 36% had relapsed by 6 months post treatment. One third relapsed during the first 3 months of treatment and another third during the next 3 months of treatment. Two thirds of all smokers received cessation advice from primary care physicians, but less than half received advice from others. Less than half of all messages were TB-specific; the rest were very general short instructions. Smoking more than 15 cigarettes/bidis at the time of diagnosis was significantly associated with a lower quit rate during treatment (OR 8.0, 95%CI 2.1-30.9). CONCLUSION: Messages to not smoke often go unheeded among TB patients. Proactive efforts are needed to encourage health staff and DOTS providers to give strong cessation messages.

Smoking behavior among former tuberculosis patients in Indonesia: intervention is needed.

SETTING: Five lung clinics in Jogjakarta Province, Indonesia. OBJECTIVE: To document smoking patterns among tuberculosis (TB) patients before diagnosis and following treatment, to identify smoking-related messages given by health professionals and DOTS providers and to identify predictors of smoking relapse. DESIGN: A cross-sectional survey of 239 male TB patients completed DOTS-based treatment during 2005-2006. Subjects were interviewed at home using a semi-structured questionnaire. Female patients were excluded, as very few smoke. RESULTS: Most TB patients quit smoking when under treatment, but over one third relapsed at 6 months post-treatment. About 30% were never asked about their smoking behavior or advised about quitting. Of relapsed smokers, 60% received only general health messages and not TB-specific smoking messages. DOTS providers are not currently involved in cessation activities. The perception that any level of smoking is harmless for ex-TB patients was a significant predictor for smoking relapse. CONCLUSION: Physicians and DOTS providers should be actively involved in smoking cessation activities among TB and ex-TB patients. Based on these data, the Quit Tobacco Indonesia Project is mounting a pilot intervention to train DOTS providers, who are mostly family members of patients, to deliver smoking cessation messages and reinforce the cessation advice provided by physicians during and following TB treatment.

Introducing tobacco cessation in developing countries: an overview of Project Quit Tobacco International.

Project Quit Tobacco International is a pioneering attempt to develop culturally appropriate approaches to tobacco cessation within the health sectors of India and Indonesia. An overview of the formative research that contributed to intervention development is presented followed by a discussion of the research design adopted to evaluate the introduction of tobacco cessation in medical schools and clinics chosen for pilot testing. Four stages of research and implementation are described as a means of providing colleagues in developing countries with a prototype for future tobacco cessation research and training efforts.

Press coverage of public expenditure of Master Settlement Agreement funds: how are non-tobacco control related expenditures represented?

OBJECTIVE: To examine newspaper reports of Master Settlement Agreement (MSA) allocation decisions outside of tobacco control, focusing on the arguments being put forth in favour of competing claims on MSA funds. The major aims were to identify newsworthy non-tobacco control areas for which MSA funds have been applied and to examine how non-tobacco control spending has been presented through the US press. DESIGN: A qualitative textual analysis was performed on 94 articles taken from a sample of 322 newspapers over a 12 month period (October 2000 through September 2001) that related to the allocation of MSA funds to non-tobacco control causes. Articles were coded for general content areas of MSA allocation as well as for rhetorical and framing devices employed to explain and justify allocation decisions. MAIN OUTCOME MEASURES: (1) Areas of non-tobacco control allocation; (2) rhetorical devices and framing techniques employed in the articles to discuss the allocation. RESULTS: The analysis identified a wide variety of issues for which MSA funds were being appropriated. Three main frames emerged in relation to justifying or appealing for particular spending decisions: (1) funds should be allocated to the needy and/or the deserving; (2) funds should be spent on state development; (3) funds should be put towards helping the state weather a crisis. Claims for each such issue were made using strategies such as presenting the MSA funds as a "windfall", focusing coverage on the merits of the cause rather than the issue of resource allocation, and stressing links between the particular claim and the stated objectives of the MSA. CONCLUSIONS: Press coverage of MSA non-tobacco control spending suggests that the funds have been quickly formulated as fodder for state spending, rather than to support tobacco control efforts. Thus, caution is required in pursuing settlements with the industry where the objective is better funding for tobacco control efforts, particularly in light of the possibility that press coverage of MSA allocation may actually serve as positive publicity for the tobacco industry.

Mot luuk problems in Northeast Thailand: why women's own health concerns matter as much as disease rates.

In this paper, we consider women's illness experiences, above and beyond the presence of clinically identifiable disease. In Northeast Thailand, epidemiological data suggest that the prevalence of major women's reproductive tract infections is relatively low and not a cause for significant public health attention. Conversely, we found that self-reported rates of gynecological complaints are high and a significant women's health concern in rural Northeast villages. Women's embodied experiences and interpretations of these complaints affect their lives dramatically. Moreover, women's responses to gynecological problems (regardless of diagnosed morbidity) constitute an important health issue in their own right. In this regard, we document the dangers of women's self-treatment practices that rely largely on small doses of medically inappropriate antibiotics, the manner in which family life and sexual relations are disrupted by fears that gynecological problems will progress to cervical cancer, health care seeking patterns and expectations from health staff, and most importantly, how women's concerns about the seriousness of recurrent ailments result in substantial suffering. This study demonstrates why attention to women's own health concerns is as important to address in health programs as rates of disease, and why common gynecological problems and work-related complaints are important to take seriously rather than dismiss as psychological or routine and expected. We argue that there is a strong need to conduct ethnographic research on women's health problems as a complement to, and not merely a support for, epidemiological research. An evidence-based approach to health policy needs to be accompanied by a more humanistic approach to understanding health care needs.

Measles immunization acceptance in Southeast Asia: past patterns and future challenges.

Despite substantial increases in immunization rates, measles remains a major health problem in developing countries of Southeast Asia. The authors of this paper undertook separate investigations which examined factors influencing measles immunization acceptance in the rural Philippines, Central Java, Indonesia, and an impoverished neighborhood in Bangkok, Thailand. We briefly summarize the findings of our three field investigations before presenting a synthesizing analysis of the psychosocial and demographic factors which affect measles immunization. We then review trends influencing measles acceptance in industrialized countries to anticipate possible future challenges to measles immunization acceptance in Southeast Asia in an era of increasing globalization and information transfer. We suggest that parental perceptions of the risks and benefits of immunization, philosophical and religious convictions and state and social regulatory policies will profoundly influence measles immunization in the new millennium.

Women and tobacco: moving from policy to action.

A gender perspective contributes to a better understanding of the epidemiological trends, social marketing strategies, economic policies, and international actions relating to women and the tobacco epidemic. Evidence is provided in this article for the negative impact of tobacco use by women and of passive smoking on the health of women and children. Use of tobacco by women is increasing and this is related to the tobacco industry's aggressive advertising, sponsorship and promotion strategies. Policy directions are proposed in this article. At all levels, a multi-pronged strategy--including changes in legislation and fiscal policies, improvements in gender-sensitive health services, and cessation programmes--should be considered. Much more gender-specific research on tobacco use is needed, particularly in developing countries. Women's empowerment and leadership should be at the centre of all tobacco control efforts and are essential for the success of national programmes and the recently introduced Framework Convention on Tobacco Control.

Developing an interactive STD-prevention program for youth: lessons from a north Indian slum.

An intervention developed to teach young men in the urban slums of Lucknow, India, about sexually transmitted diseases is described in detail. This community-based intervention was designed to impart core educational messages and to address preexisting ideas about sexual health and STD-prevention practices among participants. Indicators of knowledge recorded before and after the intervention are presented and evaluated against the scores of a control group. Levels of sexual activity and factors associated with risky sex are discussed. The intervention was successful in raising the young men's awareness of STDs significantly in all areas except for the length of time that symptoms take to manifest following risky sex and the ineffectiveness of washing one's genitals after sex to avoid acquiring STDs. Lessons learned during the intervention are described as a means of informing future STD-education programs, and issues requiring prompt attention are identified.

Contamination of medicine injection paraphernalia used by registered medical practitioners in south India: an ethnographic study.

While considerable attention has been directed at the important role of intravenous drug use in the spread of human immunodeficiency virus (HIV) and hepatitis B, little research to date has been conducted on the role of medicine injections in disease transmission. This is the case despite the fact that (a) the number of medicine injections is several orders of magnitude greater than injections of illegal drugs and (b) the networks of people potentially affected by contaminated medicine injection paraphernalia is far wider. In this article we examine the medicine injecting practices of a random sample of 40 registered medical practitioners (RMP) who have not had formal training in allopathic medicine (do not have MBBS or MD degrees) in Tamil Nadu, India. Attention is drawn to: (a) the lack of vigilance practitioners exercise in maintaining hygienic needles and syringes, (b) their perceptions of what constitutes acceptable hygienic procedure and (c) how patients respond in contexts where they are able to purchase disposable needles and syringes directly from practitioners or from the open market prior to visiting a practitioner. Study results are a cause for alarm and indicate widespread contamination of injection paraphernalia as well as common reuse of disposable needles. The study was confined to RMPs and the researchers strongly suggest that future studies of MBBS trained doctors practising in the public and private sectors be carried out. A structured observation instrument developed to record needle and syringe contamination during the process of injection administration is provided.

Current models of nicotine dependence: what is known and what is needed to advance understanding of tobacco etiology among youth.

Youth smoking has risen dramatically during the last 5 years, leading one to the conclusion that prevention interventions have not been particularly effective. This paper provides an examination of features that define adult nicotine dependence and argues that these features need to be considered in any studied examination of youth etiology and development to nicotine dependence. We review the historical context for the concept of nicotine dependence, features that define the concept and current models of substance dependence more generally. Recommendations for future research are provided.

Social factors influencing the acquisition of antibiotics without prescription in Kerala State, south India.

We investigated the magnitude of self-medication with antibiotics in a peri-urban area of Southern Kerala State, India and factors influencing this practice. First, a random sample of 400 households was surveyed in one primary health centre area near Trivandrum. We found 69.3% (95% CI = 64.8-73.8) of households had at least one person using a pharmaceutical product during the two-week recall period; antibiotics formed almost 11% of the medicines consumed. Next, pharmacy based interview and observation data were collected from 405 antibiotic purchasers sampled from 11 out of the 12 private pharmacies in the area. Seventy-three of these 405 customers purchased antibiotics without a prescription (18%; 95% CI = 14.3-21.7). By combining the household survey and pharmacy observations, we estimate that almost half of 1% (0.41%; 95% CI = 0.24-1.16) of the population, or four people per 1000, is engaged in self-medication using antibiotics in Kerala in any two-week period. Our data show that people least likely to follow this practice are from higher income families, having more education and higher status occupations and receiving the benefits of medical insurance. Conversely, logistic regression analysis indicated that risk of buying antibiotics without a script was associated with education at secondary level or below, the perception that it is expensive to consult a doctor and low satisfaction with medical practitioners. Keralites' self-medication patterns are interpreted broadly using social, cultural, historical and economic perspectives. Solutions to the problem of antibiotic misuse are suggested, proceeding on several fronts: among practitioners, suppliers and marketeers of medicines, and among the population of pharmaceutical consumers themselves.

Trial of a community-based intervention to decrease infestation of Aedes aegypti mosquitoes in cement washbasins in El Progreso, Honduras.

Washbasins and metal drums are important sources of Aedes aegypti mosquitoes in much of Latin America. When manual cleaning was found to be ineffective in eliminating mosquito larvae in a community-based control programme in El Progreso, Honduras, it was decided to develop and evaluate an improved method of removing mosquito eggs based on commonly-available materials. The method, named La Untadita ('The Little Dab', in English), consists of five steps: mixing chlorine bleach and detergent to make a paste, applying the mixture to the walls of the container, waiting 10 min, scrubbing with a brush, and finally rinsing with water. A field trial of the Untadita was conducted in 13 peri-urban neighbourhoods. At the first post-intervention survey, in spite of high levels of exposure to the community-based intervention, high levels of knowledge regarding the Untadita and high levels of its reported use, little or no impact was discernable on mosquito larvae and pupae. The method was then modified by increasing the recommended quantities of bleach and detergent and simplifying the instructions. In the second post-intervention survey, knowledge of the steps and their order increased further; the intervention neighbourhoods had significantly fewer algae on washbasin walls, an indicator of more effective cleaning; and numbers of pupae and 3rd and 4th instar larvae were significantly lower than in untreated neighbourhoods. Effective promotion of the Untadita should be able to control mosquito infestation in many washbasins, especially those in frequent use, thus reducing the need for chemical and biological larvicides that may be either more costly or less acceptable to householders.

Pharmacies, self-medication and pharmaceutical marketing in Bombay, India.

Studies of pharmaceutical practice have called attention to the role played by pharmacists and pharmacy attendants in fostering self-medication and medicine experimentation among the public. Left undocumented is the extent to which clients passively follow the advice of pharmacy personnel or question their motive or expertise. While research has focused on pharmacists and pharmacy attendants as agents encouraging self-medication and medicine experimentation, adequate attention has not been paid to pharmacist-client interactions that are sensitive to the social, cultural, and economic context in which medicine sales and advice occur. This paper highlights the context in which pharmacy attendants engage in "prescribing medicines" to the public in Bombay, India. An ethnographic description of pharmacies and pharmaceutical-related behavior in Bombay is provided to demonstrate how reciprocal relationships between pharmacy owners, medicine wholesalers and pharmaceutical sales representatives (medreps) influence the actions of pharmacy staff. Attention is focused on the role of the medicine marketing and distribution system in fostering prescription practice, pharmacy "counter-pushing" and self-medication. In documenting the profit motives of different players located on the drug sales continuum, it is argued that the economic rationale and the symbiotic relations that exist between doctors, medreps, medicine wholesalers and retailers, need to be more closely scrutinized by those advocating "rational drug use".

Changing patterns of pharmaceutical practice in the United States.

In the United States, contradictions related to medicine use abound in a social environment in which the pursuit of health has become a cultural project. In a marketplace where over half a million health products are available, choices at once seem to foster agency and encourage dependency on medical fixes. The aggressive marketing of medicines as indispensable commodities co-exits with rising concerns among the lay population about what is safe in the short- and long-term. In this paper we broadly consider medication-related practice in the United States as it is affected by social, cultural, and political-economic factors. We direct attention to changes in medicine use related to product proliferation, lowered thresholds of discomfort, the economics of health care, and a revival of the self-help ethic. We also consider the manner in which the demand for and use of medications reflect deeply embedded cultural ideals and emergent perceptions of need. We juxtapose two trends in American thinking about medicines: (1) the perception that "more is better," associated with cultural impatience with illness; and (2) a growing doubt about medicine necessity, safety, and efficacy.

Smoking experimentation and initiation among adolescent girls: qualitative and quantitative findings.

OBJECTIVE: To use qualitative and quantitative findings to describe patterns of smoking experimentation and initiation among adolescent girls. DESIGN: Ethnographic in-person interviews, focus groups, telephone interviews, and a survey questionnaire were used over a one-year period. The paper reports on cross-sectional data drawn from a three-year longitudinal study. SUBJECTS AND SETTING: 205 girls participated in the survey and interviews during year 3 of the study. Girls were drawn from two urban high schools in Tucson, Arizona (USA), and were in grades 10 and 11 (mean ages 16 and 17, respectively) during year 3. RESULTS: Overall, 30% (n = 61) of informants reported that they currently smoked, 7% (n = 15) were ex-smokers, and 63% (n = 129) were "non-smokers". The most frequently cited reasons for smoking were stress reduction and relaxation. Several stress-inducing situations, including family environment, social relations with classmates, and schoolwork, are discussed. The notion of peer pressure is re-examined in the light of teenagers' experience that there is little overt pressure to initiate smoking. Consonant with notions of adolescent autonomy, the theme of independence in smoking initiation and continuation permeated girls' narratives about their smoking behaviour. Girls projected the image that they could control their cigarettes rather than have their cigarettes control them. CONCLUSIONS: Smoking prevention and cessation programmes need to address and counter the smoking/relaxation association, which was identified as an important reason for smoking among adolescent girls. Questions typically used in surveys to measure smoking behaviour do not adequately define the smoking experience as described by teenagers.