Browsing by Author "Nichter, M"

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    Assessing readiness to integrate tobacco control in medical curriculum: Experiences from five medical colleges in southern India
    (Natl Med J India., 2013-06) Thankappan, KR; Yamini, TR; Mini, GK; Arthur, C; Sairu, P; Leelamoni, K; Sani, M; Unnikrishnan, B; Basha, SR; Nichter, M
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    Assessing the readiness to integrate tobacco control in medical curriculum: Experiences from five medical colleges in southern India
    (NATIONAL MEDICAL JOURNAL OF INDIA, 2013) Thankappan, KR; Yamini, TR; Mini, GK; Arthur, C; Sairu, P; Leelamoni, K; Sani, M; Unnikrishnan, B; Basha, SR; Nichter, M
    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 specialists (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.
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    Confirmation of self-reported non-smoking status by salivary cotinine among diabetes patients in Kerala, India
    (Clinical Epidemiology and Global Health, 2014-05) Mini, GK; Nichter, M; Radhakrishnan, RN; Thankappan, KR
    Problem considered: There are no studies of tobacco cessation reported from low and middle income countries that have tested cotinine against self report in a patient population. We confirmed the accuracy of self report of smoking cessation by matching self reports against salivary cotinine test in diabetes patients. Methods: The study was part of a randomized controlled trial among 224 diabetes patients in Kerala. Salivary cotinine level was measured among 35 diabetes patients who claimed to have not smoked even a single cigarette/bidi in the last 30 days before the test. Biochemical analysis of salivary cotinine was done using the Enzyme-Linked Immunosorbent Assay kit from Salimetrics. Cotinine value of >15 ng/ml was used as the cut-off point. Results: Among the 35 patients, 26 (74%) were found to have a saliva cotinine level 15 ng/ ml confirming self reports of non smoking status. Among the remaining nine patients, four reported being routinely exposed to secondhand smoke in their household or work place prior to cotinine testing. Interviews revealed that 12% of the variance between self report and the cotinine test results was attributable to routine exposure to second hand smoke. Conclusion: Self report of non-smoking by diabetes patients in India was fairly reliable when validated against a cotinine test. Larger clinical trials are warranted to further evaluate the validity of self reported non-smoking status in different patient populations having different education levels.
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    Developing a fully integrated tobacco curriculum in medical colleges in India
    (BMC Medical Edcucation, 2015-05) Yamini, TR; Nichter, M; Mimi Nichter Sairu, MP; Aswati, S; Leelamoni, K; Unnikrishnan, B; Prasanna Mithra, PP; Thapar, R; Basha, SR; Jayasree, AK; Mayamol, TR; Muramoto, M; Mini, GK; Thankappan, KR
    Background This paper describes a pioneering effort to introduce tobacco cessation into India’s undergraduate medical college curriculum. This is the first ever attempt to fully integrate tobacco control across all years of medical college in any low and middle income country. The development, pretesting, and piloting of an innovative modular tobacco curriculum are discussed as well as challenges that face implementation and steps taken to address them and to advocate for adoption by the Medical Council of India. Methods In-depth interviews were conducted with administrators and faculty in five medical colleges to determine interest in and willingness to fully integrate smoking cessation into the college curriculum. Current curriculum was reviewed for present exposure to information about tobacco and cessation skill training. A modular tobacco curriculum was developed, pretested, modified, piloted, and evaluated by faculty and students. Qualitative research was conducted to identify challenges to future curriculum implementation. Results Fifteen modules were successfully developed focusing on the public health importance of tobacco control, the relationship between tobacco and specific organ systems, diseases related to smoking and chewing tobacco, and the impact of tobacco on medication effectiveness. Culturally sensitive illness specific cessation training videos were developed. Faculty and students positively evaluated the curriculum as increasing their competency to support cessation during illness as a teachable moment. Students conducted illness centered cessation interviews with patients as a mandated part of their coursework. Systemic challenges to implementing the curriculum were identified and addressed. Conclusions A fully integrated tobacco curriculum for medical colleges was piloted in 5 colleges and is now freely available online. The curriculum has been adopted by the state of Kerala as a first step to gaining Medical Council of India review and possible recognition.
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    Developing a smoke free homes initiative in initiative in Kerala, India
    (BMC Public Health., 2015-05) Nichter, M; Padmajam, S; Nichter, M; Sairu, P; Aswathy, S; Mini, GK; Bindu, VC; Pradeepkumar, AS; Thankappan, KR
    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.
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    Developing a smoke free homes initiative in Kerala, India
    (BMC PUBLIC HEALTH, 2015) Nichter, M; Padmajam, S; Nichter, M; Sairu, P; Aswathy, S; Mini, GK; Bindu, VC; Pradeepkumar, AS; Thankappan, KR
    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.
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    Doctors' behaviour & skills for tobacco cessation in Kerala
    (INDIAN JOURNAL OF MEDICAL RESEARCH, 2009) Thankappan, KR; Pradeepkumar, AS; Nichter, M
    Background & objectives: Several studies have shown that health professionals' advice for tobacco cessation to tobacco users enhances quit rate. Little is known about doctor's present tobacco cessation efforts in India. We examined doctors' reported inquiry into patient's use of tobacco and assessed their perceived need for training in tobacco cessation. Methods: A cross-sectional survey was conducted in Kerala to collect information on doctor's practices, skills and perceived need for training in tobacco cessation. Pre-tested structured questionnaires were distributed in person to 432 male and 89 female doctors, of whom 264 male and 75 female doctors responded. Results: One third of all the doctors surveyed reported that they always ask patients about tobacco use, three fourths advise all patients routinely to quit irrespective of the smoking status of patients and one tenth offered useful information on how to quit. About 15 per cent reported they received information from medical representatives, 32 per cent reported they had sufficient training and 80 per cent expressed interest in receiving training to help smokers quit. Majority of all doctors surveyed most commonly asked and advised patients to quit tobacco when patients had lung, heart, mouth disease or cancer. Interpretation & conclusions: Most doctors inquired about tobacco use from a minority of their patients, though many reported to advise patients about quitting even without inquiring about their tobacco use status. There are several missed opportunities to promote quitting at a time when patients are motivated to listen.
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    Does increased knowledge of risk and complication of smoking on diabetes affect quit rate: Findings from a randomized controlled trial in Kerala, India
    (Tobacco Use Insights, 2014-12) Mini, GK; Nichter, M; Thankappan, KR
    BACKGROUND: Data on quit rates among diabetes patients are limited. PURPOSE: To find whether positive change in knowledge on smoking-related complications is associated with increased quit rates among diabetes patients. METHODS: We randomized 224 male diabetes patients into intervention groups 1 and 2. Both groups received a standard diabetic-specific smoking cessation message from a doctor. Intervention group 2 additionally received counseling. We compared the positive change in knowledge and the quit rates between the two groups at 6 months. RESULTS: Positive change in knowledge in group 2 was two times higher than that in group 1. The odds of quitting among patients who reported a positive change in knowledge was 2.65 times higher compared to those who reported no positive change in knowledge. CONCLUSIONS: Increasing the knowledge of persons with diabetes about the risks of developing severe complications if they continue smoking leads to significantly higher quit rates.
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    FEASIBILITY OF DISEASE CENTERED SMOKING CESSATION AMONG DIABETES PATIENTS
    (RESPIRATORY MEDICINE, 2013) Thankappan, KR; Mini, GK; Daivadanam, M; Vijayakumar, G; Sarma, PS; Nichter, M
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    INTRODUCING A FULLY INTEGRATED TOBACCO CURRICULUM & TOBACCO CESSATION SKILLS IN MEDICAL COLLEGES
    (RESPIRATORY MEDICINE, 2013) Kumar, TYG; Kavumpurath, TR; Nichter, M
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    Low- level smoking among diabetes patients in India: a smoking cessation challenge
    (Clinical Epidemiology and Global Health, 2018-01) Nichter, M; Mini, GK; Thankappan, KR
    Background: Little research in low and middle-income countries has been conducted on shifts in levels of smoking among those suffering from chronic diseases exposed to cessation messages. We present data on such shifts among diabetes patients participating in a randomized controlled cessation trial in Kerala state, India. The two-arm trial tested the relative effectiveness of diabetes specific cessation messages from doctors and the added value of motivational interviewing by trained cessation counsellors. Methods: Two hundred twenty-four smokers who participated in the trial were followed for 2 years. Intention to treat analysis documented changes in levels of smoking. We defined low-level smoking as 1- 5 sticks per day, medium-level as 6-10 sticks, and high-level as more than 10 sticks. Twenty-three lowlevel smokers were interviewed about why they continued to smoke, and household response to their smoking. Results: At baseline, 32% of the 224 diabetes patients were low-level smokers, 24% medium-level and 44% high-level smokers. At year two 34% of the participants in the trial had quit smoking, 37% were low-level smokers, 16% medium-level smokers and 13% high-level smokers. Forty-nine percent of low-level smokers at baseline continued to smoke at low level. Fifty percent of mid-level and 45% of high-level smokers who did not quit shifted to low level smoking A majority of low-level smokers and their families perceived low-level smoking to be safe. Conclusions: Low level smoking among diabetes patients is common. Proactive and sustained cessation efforts are called for that are attentive to disease complications as teachable moments.
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    Smokeless tobacco use among patients with tuberculosis in Karnataka: The need for cessation services
    (NATIONAL MEDICAL JOURNAL OF INDIA, 2012) Deepak, KG; Daivadanam, M; Pradeepkumar, AS; Mini, GK; Thankappan, KR; Nichter, M
    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. Nati Med J India 2012;25:142-5
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    Smokeless tobacco use among Tuberculosis patients in Karnataka, India: The need for cessation services.
    (The National Medical Journal of India, 2012) Deepak, KG; Daivadanam, M; Pradeepkumar, AS; Mini, GK; Thankappan, KR; Nichter, M
    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.
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    Smoking among Tuberculosis Patients in Kerala, India: Proactive Cessation Efforts are Urgently Needed
    (International Journal of Tuberculosis and Lung Disease, 2008) Pradeepkumar, AS; Thankappan, KR; Nichter, M
    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.
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    Smoking Cessation among Diabetes Patients in Kerala, 8.1India: One Year Follow-up Results from a Pilot Randomized Controlled Trial
    (Diabetes Care, 2014-12) Thankappan, KR; Mini, GK; Hariharan, M; Vijayakumar, G; Sarma, PS; Nichter, M
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    Smoking Cessation Among Diabetes Patients: One Year Follow-Up Results of a Randomized Controlled Trial in Kerala, India (abstract).
    (Diabetes., 2013-06) Thankappan, KR; Mini, GK; Hariharan, M; Sarma, PS; Vijayakumar, G; Nichter, M
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    Smoking cessation among diabetes patients: results of a pilot randomized controlled trial in Kerala, India
    (BMC Public Health., 2013-02) Thankappan, KR; Mini, G; Daivadanam, M; Vijayakumar, G; Sarma, PS; Nichter, M
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    Smoking Cessation Among Diabetic Patients in Kerala, India: 1-Year Follow-up Results From a Pilot Randomized Controlled Trial
    (DIABETES CARE, 2014) Thankappan, KR; Mini, GK; Hariharan, M; Vijayakumar, G; Sarma, PS; Nichter, M
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    The need for cessation of tobacco use among patients with tuberculosis in Kerala
    (NATIONAL MEDICAL JOURNAL OF INDIA, 2009) Thresia, CU; Thankappan, KR; Nichter, M
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    The need for cessation of tobacco use among patients with tuberculosis in Kerala, India
    (The National Medical Journal of India, 2009) Thresia, CU; Thankappan, KR; Nichter, M