|Year : 2017 | Volume
| Issue : 5 | Page : 29-34
Integrated brief tobacco and alcohol cessation intervention in a primary health-care setting in Karnataka
OT Sabari Sridhar1, Pratima Murthy2, KV Kishore Kumar3
1 Assistant Professor, Department of Psychiatry, Chettinad Hospital and Research Institute, Chettinad Health City, Kanchipuram, Tamil Nadu, India
2 Professor, Department of Psychiatry, Centre for Addiction Medicine, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
3 Director, The Banyan and The Banyan Academy of Leadership in Mental Health, Chennai, Tamil Nadu, India
|Date of Web Publication||15-Sep-2017|
O T Sabari Sridhar
Department of Psychiatry, Chettinad Hospital and Research Institute, Chettinad Health City, Kelambakkam, Kanchipuram - 603 103, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Tobacco and alcohol use are important preventable risk factors for noncommunicable diseases and need to be addressed in primary health care. Objectives: To find the effectiveness of Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST)-based brief intervention for alcohol and tobacco in a primary health-care setting in Karnataka. Methods: This study was conducted in 2012 where one primary health center (PHC) in Karnataka was an intervention site and other the control site. One hundred patients each in both control and intervention PHCs took part in the study. In the control PHC, patients were administered the ASSIST questionnaire and given an information pamphlet on tobacco- and alcohol-related harm. In the intervention PHC, ASSIST-based brief intervention was provided for both tobacco and alcohol cessation. At the 3rd month, ASSIST questionnaire was re-administered to record their follow-up score. Chi-square test, paired t-test, and independent sample t-test were used for statistical analysis. Results: Following the initial assessment and intervention, there was statistically significant reduction in mean ASSIST scores for tobacco in both the PHCs. For alcohol, though there was reduction in scores in both PHCs, it was statistically significant only in intervention PHC. There was also a significant reduction in the number of heavy alcohol users in the intervention PHC following assessment and intervention. Conclusions: This study shows that with minimal intervention, there is reduction in the degree of both tobacco and alcohol use and calls for wider and stringent research on the same topic.
Keywords: Alcohol intervention, brief intervention, tobacco cessation
|How to cite this article:|
Sabari Sridhar O T, Murthy P, Kishore Kumar K V. Integrated brief tobacco and alcohol cessation intervention in a primary health-care setting in Karnataka. Indian J Public Health 2017;61, Suppl S1:29-34
|How to cite this URL:|
Sabari Sridhar O T, Murthy P, Kishore Kumar K V. Integrated brief tobacco and alcohol cessation intervention in a primary health-care setting in Karnataka. Indian J Public Health [serial online] 2017 [cited 2019 Sep 19];61, Suppl S1:29-34. Available from: http://www.ijph.in/text.asp?2017/61/5/29/214904
| Introduction|| |
Tobacco and alcohol are two of the most widely used addictive substances that affect lakhs of people and are one of the leading causes of death and disability worldwide. Both have hazardous health consequences resulting from their chronic use, which if left untreated, would create enormous toll of suffering, disability, and economic loss. Studies have shown that tobacco and alcohol use frequently co-occur, both environmental and genetic factors contributing to the overlap. Integrating cessation interventions for tobacco and alcohol into primary care is the most viable approach for closing the treatment gap and ensuring that people get the kind of care they need. Specialist tertiary and secondary care are costly, difficult to access, and offer services mainly to persons with severe problems while primary care is affordable and accessible. Numerous countries have successfully integrated tobacco and alcohol cessation interventions into primary care. Cessation intervention in primary care settings for tobacco and alcohol seems to offer promising results. Psychosocial or nonpharmacological cessation interventions are cost-effective and can be easily done in primary care with proper training.,,,,, To achieve the same, cessation intervention would have to be brief in nature.
Numerous trials in various settings have shown the efficacy of brief alcohol cessation intervention. Many systematic reviews and meta-analysis consistently indicate that brief alcohol cessation intervention conducted in primary care is effective in reducing alcohol consumption.,,,, Preliminary data support the possibility that integrated cessation intervention reduces both tobacco and alcohol use. In India, there have been only a few studies on brief intervention for alcohol and tobacco cessation carried out in the primary health-care setting. Such studies have independently addressed either tobacco or alcohol cessation. One study done in Indian community setting reported that brief cessation intervention had a slight advantage over simple advice in excessive users of alcohol. In a similar study done to assess the effectiveness of brief intervention for smoking cessation, counseling by nondoctor health professional (NDHP) resulted in significantly higher smoking abstinence rates. The present study was carried out to find the effectiveness of integrated brief intervention for tobacco and alcohol cessation in primary care setting in Karnataka.
| Materials and Methods|| |
The study followed a case–control approach to study the effectiveness of integrated brief tobacco and alcohol cessation intervention in a primary health-care setting in Karnataka, India. Two primary health centers (PHCs) near Bangalore, Yemalur, serving a population of 26,240 were selected as the intervention PHC and Doddakannahalli serving a population of 32,752 as the control PHC. There was no blinding done. Ethical clearance for the study was obtained from the Institutional Ethics Committee of the National Institute of Mental Health and Neurosciences, Bengaluru.
One hundred consecutive patients aged between 18 and 75 years, who answered positively to the question “do you use tobacco/alcohol?” and provided informed consent, were recruited for the study from each PHC during the period of January–April 2012. Patients suffering from terminal illnesses, severe psychiatric disorders, and addiction to other substances were excluded from the study.
- World Health Organization-Alcohol, Smoking, and Substance Involvement Screening Test (WHO-ASSIST): This tool, developed with support of the WHO, is designed to be used in primary care settings. ASSIST (version 3.1) is an 8-item questionnaire that takes 5–10 min to administer. For the purpose of this study, we used only the questionnaire pertaining to tobacco and alcohol. ASSIST determines a risk score for each substance which is used to start a discussion (brief cessation intervention) with clients about their substance use. The score obtained for each substance falls into “lower” (alcohol = 0–10 and tobacco = 0–3), “moderate” (alcohol = 11–26 and tobacco = 4–26), or “high” (both alcohol and tobacco >27) risk category which determines the most appropriate intervention
- “Brief intervention for substance use: A manual for use in primary care” by the WHO is a short intervention lasting 3–15 min given to clients who have been administered the ASSIST. The risk scores are recorded on the feedback report card which is used to give personalized feedback and associated health problems. This cessation intervention is based on FRAMES technique and motivational interviewing.
Planning stage of the study
During this phase, through a face-to-face interview with the PHC staff, those who appeared to have basic knowledge, aptitude, and interested to be part of the study were included in the study. Although it was initially planned to involve the doctors in providing brief advice and the NDHPs in providing cessation interventions, due to logistic reasons, study focused only on the later.
Training stage of the study
Training of the NDHP was carried out before initiating the cessation intervention. In the control PHC, one staff nurse and two junior health assistants took part in the training. In the intervention PHC, two junior health assistants and laboratory technician took part.
Supervision and monitoring of the study
PHC staffs were constantly supervised and monitored. Mobile phones were given to them to be constantly in communication with the first author. Weekly, PHCs were visited and problems faced by the staff in carrying out the assessment and interventions were addressed.
Baseline assessments and intervention
In both PHCs, NDHPs asked male patients falling under the inclusion criteria whether they used tobacco or alcohol in their lifetime. If the patient answered yes and consented to participate, he was included in the study. Sociodemographic details were collected, ASSIST questionnaire applied, and the scores were calculated. A feedback report card was given along with leaflets containing information about risks of tobacco and alcohol use. In addition, in the intervention PHC, ASSIST-linked brief cessation intervention lasting 10–15 min was provided. The NDHP was advised to refer patients with high-risk scores to the Centre for Addiction Medicine, National Institute of Mental Health and Neurosciences. Every patient was enquired about their tobacco/alcohol use pattern after 1 month of initial contact by the NDHP. No assessment was done at this stage. However, the patients were explained that they would be contacted after a period of 3 months by author 1. He contacted each patient telephonically and applied ASSIST questionnaire to record their follow-up score.
The completed questionnaires were scrutinized; scores re-checked and entered into data sheet. The software package used for data entry and analysis was SPSS for Windows, Version 16.0. Chicago, USA, SPSS Inc. The change in severity status of patients with tobacco and alcohol use from baseline to follow-up was analyzed using Chi-square test. The comparison of tobacco and alcohol scores over time in control and intervention PHCs was analyzed by independent sample t-test. To study the difference in mean tobacco and alcohol scores between baseline and follow-up, paired t-test was used.
| Results|| |
Sample selection, attrition, and description
One hundred patients each were studied in both the control and intervention PHCs. In the control PHC, 82 patients reported tobacco and 51 had alcohol use. In the intervention PHC, 84 reported tobacco and 38 alcohol use. Eighteen patients in control PHC were using only alcohol, 49 only tobacco, and 33 both alcohol and tobacco. In the intervention PHC, 16 were using only alcohol, 62 tobacco, and 22 using both alcohol and tobacco. Of the 82 patients with tobacco use in the control PHC, 65 (79%) and 69 out of 84 (82%) in intervention PHC were telephonically contactable 3 months after the intervention. Out of the 51 patients with alcohol use in the control PHC, 38 (74.5%) and 31 out of 38 (81.5%) in intervention PHC were contactable at 3 months. Patients were lost to follow-up mainly because they had either changed their mobile numbers or were not contactable.
Both the groups were comparable at baseline, with a mean age of 38 years, mostly married (80%), educated up to 10th standard (42%), and comprising unskilled laborers (61.5%). The participant characteristics are summarized in [Table 1].
|Table 1: Baseline characteristics of study participants in both control and intervention primary health centers|
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With respect to the tobacco users, a significant proportion was in the age group of 20–35 years (49.08%). Across all age groups, a majority of tobacco users fell under the moderate-risk category of ASSIST. Unskilled laborers constituted a majority (59.88%) of high-risk category tobacco users.
Alcohol users tended to be older, with a higher proportion (44.94%) in the age group of 35–60 years. A majority of alcohol users fell under the moderate- or high-risk category. As with tobacco use, a majority of alcohol users (68.54%) with moderate- or high-risk scores were unskilled laborers with low levels of education. The group using tobacco had a higher proportion of unemployed individuals (13.77%) as compared to the alcohol group (6.74%).
With regard to tobacco use, the percentages of high-risk category of tobacco users at baseline (6% and 8.3% in the control and intervention PHC, respectively) declined to 1.5% and 4.3% at follow-up. While 94% in the control PHC and 91.7% in the intervention PHC scored in the moderate-risk category at baseline, at follow-up, the moderate-risk group constituted 98.5% and 94.2% in the respective settings.
In both control and intervention PHC at baseline, nearly a third had high-risk scores on alcohol 37.3% and 28.9%, respectively. High-risk users at follow-up reduced to 34.2% and 19.4% in the respective groups. Alcohol users with moderate-risk scores constituted the majority (53% and 60.5%, respectively) at baseline. At follow-up, the percentage of alcohol users with moderate-risk scores dropped from 53% to 50% in the control PHC and from 60.5% to 45.2% in the intervention PHC. Correspondingly, there was an increase in percentage of scores in lower risk in PHCs, from 15.8% to 35.5% in intervention PHC and from 9.8% to 10.5% in control PHC.
Change in severity status of patients with tobacco and alcohol use from baseline to follow-up
In the control PHC, there was an increase in the number of tobacco users with moderate scores from 61 at baseline to 64 at follow-up, as a consequence of the high-risk category tobacco users at baseline (4) falling into the moderate-risk category at follow-up. However, these changes were not statistically significant. In the intervention PHC, there was a similar increase in the moderate-risk category from 64 at baseline to 66 at the follow-up due to 4 tobacco users moving from high-risk category at the baseline to moderate-risk category at follow-up. These changes were also not statistically significant.
With respect to alcohol use, in the control PHC, four alcohol users from moderate-risk and one from high-risk category at the baseline fell into the low-risk category at follow-up. Similarly, there was fall in the number of alcohol users in moderate-risk category from 23 to 19 at the follow-up and 14–13 in the high-risk category at the follow-up. These changes were not statistically significant on Chi-square analysis. In the intervention PHC, 7 alcohol users from the moderate-risk category at baseline fell into low-risk category at the follow-up; the number of moderate-risk users fell from 18 at baseline to 14 at the follow-up and high-risk scores from 9 at the baseline to 6 at the follow-up. These changes were statistically significant.
Change in tobacco and alcohol scores over time
In the control PHC, there was a statistically significant reduction in mean tobacco scores from baseline (18.89) to follow-up (16.60), and there was reduction in mean alcohol scores as well (baseline mean = 23.50 and follow-up mean = 21.05), which approaches statistical significance. In the intervention PHC, there was statistically significant reduction in both the mean tobacco score (baseline mean = 20.14 and follow-up mean = 17.17) and alcohol score (baseline mean = 20.25 and follow-up mean = 17.16, from baseline to follow-up. Analysis was done using paired t-test [Table 2].
|Table 2: Comparison of tobacco and alcohol scores over time in control and intervention primary health center|
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Paired t-test was used to compare the mean differences in the change of severity scores for tobacco and alcohol between the baseline and 3rd-month follow-up for the intervention and control groups. Although the mean difference in the tobacco severity score was higher in the intervention PHC (2.91) as compared to the control PHC (2.09), the difference was not statistically significant. Similarly, for alcohol, the difference in alcohol severity score between the baseline and 3rd-month follow-up was higher for the intervention PHC (3.09) as compared to the control PHC (2.45). However, the differences were not statistically significant [Table 3].
|Table 3: Differences in the tobacco and alcohol scores between control and intervention primary health center|
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| Discussion|| |
This study explored the feasibility of trained NDHPs providing brief tobacco and alcohol cessation interventions in PHC settings. It is striking that a majority of the patients who participated in this study 82%–84% and 38%–51% reported the use of tobacco and alcohol, respectively. At present, no routine cessation interventions are carried out for tobacco and alcohol at most PHCs, and there is a huge treatment gap. This needs to be urgently addressed, considering that both are important preventable risks for noncommunicable diseases.
ASSIST which was used in this study has been found to be feasible to use in primary care in a number of cultures. Studies have also demonstrated that ASSIST items were reliable.,, A multisite study demonstrated that ASSIST showed good concurrent, construct, and discriminative validity and can screen adequately for low-, moderate-, and high-risk use for most substances. It is a relatively brief, low-cost tool, comprising eight items, covering 10 substances.
Changes in the severity scores following intervention
There was a reduction in the high-risk scores on tobacco use in both control (4.5%) and intervention (4%) PHCs and this resulted in an increase in the proportion of tobacco users with moderate-risk scores in both control and intervention PHC. A proportion of heavy users of tobacco had moved into the moderate-risk category. This was consistent with other studies,,,,, which show favorable outcome with brief intervention for tobacco use though the reduction in severity scores in these studies was not statistically significant.
The postintervention change in the severity of alcohol use was significant in the intervention group. Although there was a similar improvement in the control PHC, it was not statistically significant. It can be inferred that there was a significant reduction in the severity of the alcohol use behavior in the intervention PHC when compared to control PHC. The brief cessation intervention has worked in reducing the severity of alcohol use in those who received it more than in those who did not receive it. Contrary to the previous studies which have found that brief cessation intervention has efficacy in primary care for patients with harmful use of alcohol but not that efficacious for those with heavy use or dependence, in this study, there was reduction in the percentage of patients with high-risk scores of alcohol also (9.5% reduction in intervention and 3.1% in the control PHC). Since both the baseline scores and the follow-up scores of the control and intervention PHC were not statistically different, it can be interpreted that the difference in scores at baseline did not influence the changes in scores following the intervention [Table 4].
|Table 4: Comparison of tobacco and alcohol scores between control and intervention primary health center|
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Comparison of mean Alcohol, Smoking, and Substance Involvement Screening Test scores for tobacco over time
In the control PHC, mean ASSIST score for tobacco at baseline was 18.89 (standard deviation [SD] 4.99). This reduced to 16.60 (SD 4.90) and the reduction was statistically significant. Similarly in the intervention PHC mean ASSIST score for tobacco at baseline was 20.14 (4.55) reduced to 17.17 (SD 5.68) at the 3rd-month follow-up. This reduction was also statistically significant. It is encouraging that just assessment with ASSIST questionnaire along with a leaflet explaining the health hazards of tobacco use as well as brief cessation intervention has led to statistically significant reduction in the mean tobacco scores.
Even though there was reduction in mean ASSIST score in both the groups, the mean difference between baseline and follow-up was greater in the intervention PHC (2.91, SD 4.87) when compared to control PHC (2.09, SD 4.03). However, this difference in the mean difference between intervention and control PHC was not statistically significant. There have been studies which did not find much difference between minimal cessation intervention (3 min advice) when compared with advanced intervention (four 30 min counseling sessions). In the current study also there seems to be not that much difference between the minimal intervention (ASSIST questionnaire with leaflet) and brief cessation intervention in the tobacco users. Another notable point is that patients from the high-risk category moved to the moderate-risk over a period of 3 months. It is known that retaining patients in treatment improves outcomes. A study of patients provided tobacco cessation interventions, showed that the percentage of tobacco users becoming abstinent increased over successive follow-ups.
Comparison of mean Alcohol, Smoking, and Substance Involvement Screening Test scores for alcohol over time
The mean ASSIST score for alcohol at baseline in the control PHC was 23.50 and reduced to 21.05 at the follow-up. This again suggests that just the assessment with ASSIST questionnaire and issuing leaflet can facilitate behavior change and leads to a reduction in the mean alcohol scores. In the intervention PHC, ASSIST score at baseline was 20.25 reduced after brief intervention to 17.16 at follow-up. This reduction in the alcohol mean score in the intervention PHC was statistically significant. It can be inferred that brief cessation intervention had led to even greater reduction in the alcohol scores. This is consistent with other studies which show that brief cessation intervention led to reduction in the severity of alcohol use.,
Implications and future directions
Our study shows that with minimal cessation intervention, there can be reduction in the severity of both alcohol and tobacco uses. This calls for wider and rigorously planned research in this area. Considering that many PHCs in the country have very heavy patient loads, with better training and monitoring, NDHP may play a crucial part in offering cessation intervention. This would be an important strategy for reducing risk for noncommunicable diseases. Whether such interventions require specialized counselors or can be managed by PHC staff is another important area of enquiry.
Hand-holding the NDHPs as well as follow-up assessments was done in this study using mobile phones. The use of modern technology in training, assessments, and intervention is surely gaining ground. Studies have shown that the use of phone calls for intervention was as effective as interventions carried out in person.
Strengths of the study
This was a community-based study that used the WHO-validated tool. Not many studies have been done on integrated tobacco and alcohol cessation intervention in primary care setting, and this study has attempted to address this lacuna. An important strength of this study was that it was carried out in a natural PHC setting, using the PHC staff themselves.
Limitations of the study
Purposive sampling was followed due to logistic reasons. PHCs chosen were semi-urban in character and do not represent average Indian PHC, mostly rural in character. Study design was such that the baseline assessment and the 1st-month follow-up were done by the NDHPs and the 3rd-month follow-up by the researcher. However, this is likely to have reduced the bias that might have resulted if the NDHP themselves conducted the follow-up.
| Conclusions|| |
The NDHP can bring about a significant reduction in the use of tobacco and alcohol in the primary health-care setting by just asking about the use of these substances in a systematic manner and providing information. This study demonstrated a significant reduction in the use of alcohol and tobacco on the ASSIST assessment between baseline and 3 months in both control and intervention groups, with a statistically significant reduction in the number of heavy users of alcohol in the intervention PHC. The findings support a greater role for the NDHPs in the assessment and cessation intervention for substance use at the PHC.
The authors would like to thank Karuna Trust, Bengaluru, and staff of Yemalur and Doddakannahalli PHCs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]