smoking, diabetes, cessation, Kerala, India, Counseling

1. Role of additional counselling by non medical
person in context of smoking cessation
among diabetic patients in Kerala, India,
2012
Base on the study “Smoking cessation among diabetes patients: results of a pilot
randomized controlled trial in Kerala, India” by KR Thankappan et al published in
“BMC Public Health” on 18th Jan, 2013
-by
Dr Sayan Das
MPH 8th Cohort
SPH-ICMR,NIE

2. Background
 India- 2nd largest population*
 Diabetes and tobacco use- high prevalence†
 Smoking and diabetes morbidity & mortality- strongly linked‡
 Cardiovascular disease, stroke, diabetes retinopathy, peripheral
arterial disease in a diabetic patient - risk increased with smoking§
 Kerala:
o Highest prevalence of diabetes in India ¶
o 59% of diabetes patient tobacco user prior to diagnosis
o After diagnosis- more than half continues smoking
o Limited access to doctor in India- mainly in rural areas**
* Census of India 2011, † Jha P, Jacob B, Gajalakshmi V, Gupta PC, Dhingra N, Kumar R, Sinha DN, Dikshit RP, Parida DK, Kamadod R, Boreham J, Peto R: RGI-CGHR
Investigators: a nationally representative case–control study of smoking and death in India. N Engl J Med 2008, 358:1137–1147, ‡ Eliasson B: Cigarette smoking and
diabetes. Prog Cardiovasc Dis 2003, 45:405–413. § American Diabetes Association: Smoking and diabetes: position statement. Diabetes Care 2004, 27:S74–S75. ¶
Thankappan KR, Shah B, Mathur P, Sarma PS, Srinivas G, Mini GK, Daivadanam M, Soman B, Vasan RS: Risk factor profile for chronic noncommunicable diseases:
results of a community-based study in Kerala. India. Indian J Med Res 2010, 131:53–63. Thresia CU, Thankappan KR, Nichter M: Smoking cessation and diabetes
control in Kerala, India: an urgent need for health education. Health Educ Res 2009, 24:839–845. ** Rao M, Rao KD, Kumar AK, Chatterjee M, Sundararaman T:
Human resources for health in India. Lancet 2011, 377:587–598.

3. Objective
Effectiveness of diabetic specific cessation counseling by a
non-doctor health professional in addition to a diabetic
specific cessation message to quit, delivered by doctors

4. Methods
Participants:
oEligibility criteria
 Patients from two referral clinics in peri-urban areas of two south
Indian cities of Kerala, India, December 2008 to April 2011
 Male diabetes patient (age ≥ 18 yrs)*
 Native to the clinical catchment area
 Literate
 Willingness to participate in the study
oStudy Size: 224 patients among total 2490 attended patients
oBoth newly diagnosed and long time patients
Ethical clearance: Sree Chitra Tirunal Institute of Medical
Sciences and Technology, Trivandrum, Kerala, India
* Smoking prevalence among female in Kerala is zero percent, International Institute for Population Sciences (IIPS): Global Adult Tobacco Survey India (GATS India),
2009–2010. Mumbai: Ministry of Health and Family Welfare, Government of India, New Delhi; 2010.

5. Methods: Study procedure
Smokers identified using screening tool by counselor
Blood glucose examination done
 Positive patients counselled, written consent taken, go through a
structured interview schedule
 Divided in two groups: Intervention 1 & Intervention 2
Study design: Randomized Control trial – a pilot study
Randomization: computer generated sequence, block size four
 Both groups: 3 minutes counselling by doctor( 2A: ask, advice)
 Intervention 2 Group: additional 30 mins counselling by trained non-
doctor counselor (5A: Ask, advice, access, assist, arrange & 5R:
Relevance, Risks, Rewards, Roadblocks, Repetition)
 Counselling done: 1st visit, 2nd visit after1 month, 3rd visit after 6 month

6. Results
Average age of study patient: 53 yrs (Range: 28-75)
 7.6 % are under 40 yrs- early onset of diabetes in India
 ¾th patients belongs to middle socio-economic status
 Mean age of initiation of smoking 21 yrs(Range: 8-56 yrs, SD: 6.9)
 Smoking status after six months of follow up using intention to treat analysis-
Indicators Interventio
n 1 Group
n(%) n=112
Intervention
2 Group
n(%) n=112
Adjusted
odds ratio
(95% CI)
P value for
adjuster
odds ratio
Quit Rate (7 days
smoking abstinence)
14(12.5) 58(51.8) 8.4 (4.1-17.1) <0.001
Harm reduction (50%
reduction in smoking)
25(25.5) 20(37) 1.9 (0.8-4.1) 0.101
SD: Standard Deviation, CI: Confidence Interval

7. Recommendations
Routine smoking cessation advice by doctors to all
diabetes patients (3 minutes, 2A*)
 Additional counselling by trained non-doctor health
professional (30 minutes, 5A† and 5R‡)
 At least three counselling needed: at 1st visit, after 1
month and after 6 month
5A and 5R cessation protocol is an efficacious way of
reducing smoking
* 2A: Ask & Advice, † Ask, advice, access, assist & arrange ‡ Relevance, Risks,
Rewards, Roadblocks & Repetition

8. Limitations
 Follow up done only for 6 months
 Outcomes are self reported
 Counselors: not blinded to allocation groups
 Women smokers of Kerala: exclude from study
 Large portion of diabetic smokers: ineligible for study
 Only applicable for male, literate, receiving care in that
two specific institutions

9. Thank you