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Management of urinary tract infections is challenged by increasing antimicrobial resistance (AMR) worldwide. In this study, we describe the trends in antimicrobial resistance of uropathogens isolated from the largest private sector laboratory in Ghana over a five-year period. We reviewed positive urine cultures at the MDS Lancet Laboratories from 2017 to 2021. The proportions of uropathogens with antimicrobial resistance to oral and parenteral antimicrobials recommended by the Ghana standard treatment guidelines were determined. The proportion of multi-drug resistant isolates, ESBL and carbapenemase-producing phenotypes were determined. Of 94,134 urine specimens submitted for culture, 20,010 (22.1%) were culture positive. Enterobacterales was the most common group of organisms, E. coli (70.6%) being the most common isolate and Enterococcus spp. the most common gram-positive (1.3%) organisms. Among oral antimicrobials, the highest resistance was observed to ciprofloxacin (62.3%) and cefuroxime (60.2%) and the least resistance to fosfomycin (1.9%). The least resistance among parenteral antimicrobials was to meropenem (0.3%). The highest multi-drug resistance levels were observed among Klebsiella spp. (68.6%) and E. coli (64.0%). Extended-spectrum beta-lactamase (ESBL) positivity was highest in Klebsiella spp. (58.6%) and E. coli (50.0%). There may be a need to review the Ghana standard treatment guidelines to reflect increased resistance among uropathogens to recommended antimicrobials.

Himanshu A Gupte,1 Nilesh Chatterjee,1 Gauri Mandal2 1Narotam Sekhsaria Foundation, Mumbai, Maharashtra, India; 2Salaam Bombay Foundation, Mumbai, Maharashtra, IndiaCorrespondence: Nilesh Chatterjee, Narotam Sekhsaria Foundation, First Floor, Nirmal Building, Nariman Point, Mumbai, 400 021, India, Tel +91-9819472736, Email nileshchatterjee100@gmail.comContext: Areca nut, used alone or in combination with tobacco, contributes to the high oral cancer burden in India. Used widely by adolescents, who perceive it as a harmless substance, areca nut is addictive and considered a precursor to tobacco use. Given its serious implications for addictiveness and physical health, urgent preventive interventions for areca nut use are required in India and South-East Asia. Studies examining the role of health behavior theory in explaining and predicting areca nut use and for development of its prevention among adolescents are scarce.Aim: This study explored the role of the components of Theory of Planned Behavior (TPB) such as attitudes, subjective norms, perceived behavioral control, and intention in predicting areca nut use among adolescents.Settings and Design: Observational study with cross-sectional design conducted with 1884 male and female adolescents attending low-income schools in Mumbai, India.Methods and Material: Self-administered surveys were used to gather data on age, gender, behavioral factors and areca nut use.Statistical Analysis Used: Chi-square and Mann Whitney test for bivariate and logistic regression for multivariate analysis.Results: Around 27.2% of 1884 participants were areca nut users. The mean age of users was 13.75 years. Intention-to-use and perceived behavioral control were statistically significant predictors of actual areca nut use (p< 0.001). The components of TPB such as attitude, perceived subjective social norms, and perceived behavioral control had a statistically significant effect on the intention-to-use areca nut (p< 0.05).Conclusion: This exploratory study indicates that constructs from TPB could help us understand and predict areca nut use. However, more rigorous future research is required to generate insights that help craft effective theory-based behavioral interventions for areca nut prevention and cessation in adolescents.Keywords: areca nut, supari, adolescents, India, theory of planned behavior

Introduction India has 267 million adult tobacco users, the majority of whom are part of the economically productive workforce. Workplaces are ideal settings to influence tobacco use behavior. A 6-month tobacco cessation program was implemented in five workplaces in Maharashtra, India. The study aimed to describe 6-month tobacco cessation outcomes and to identify promoters and barriers for implementing the program. Methods This is an explanatory mixed methods study. Quantitative part involved analysis of routinely collected program data from January 2016 to June 2017 to describe the sociodemographic characteristics, tobacco use patterns and 6-month cessation outcomes. Qualitative part consisted of one-to-one interviews with employees who had enrolled for cessation services (n=16) and one group interview with the counseling service providers (n=5). Results A total of 331 current tobacco users voluntarily enrolled in this program and used predominantly (78%) smokeless tobacco. The self-reported 7-day point prevalence abstinence at the end of six months was 66%. Employees who used smokeless forms of tobacco, had low levels of nicotine dependence, and attended 4 or more counseling sessions, were more likely to quit tobacco use. Support from the management and multiple counseling sessions were described as promoters. Peer pressure, work stress, and inability to quit without medication were the major barriers. Formulating tobacco-free workplace policy was suggested for reducing tobacco use at workplaces. Conclusions The core activities of the program, which included awareness sessions, individual counseling sessions and repeated follow-up sessions as well as support received from the workplace management, played a major role in achieving good cessation outcomes.

Background: Tobacco use is projected to cause more than 8 million deaths annually worldwide by 2030 and is currently linked to 1 million annual deaths in India. Very few workplaces provide tobacco cessation as a part of occupational health in India. In this study, we examined promoters and barriers to implementing an evidence-based tobacco cessation program in a workplace setting in India. Methods: In-depth interviews were conducted with all facilitators (two program coordinators and four counselors) of a workplace tobacco cessation intervention covering implementation efforts in five organizations, including three manufacturing units and two corporate settings. Findings: The identified promoters for implementation of the program were as follows: (a) workplaces that provided access to many individuals, (b) high prevalence of tobacco use that made the intervention relevant, (c) core components (awareness sessions, face-to-face counseling and 6-months follow-up) that were adaptable, (d) engagement of the management in planning and execution of the intervention, (e) employees’ support to each other to quit tobacco, (f) training the medical unit within the workplace to provide limited advice, and (g) efforts to advocate tobacco-free policies within the setting. Barriers centered around (a) lack of ownership from the workplace management, (b) schedules of counselors not matching with employees, (c) nonavailability of employees because of workload, and (d) lack of privacy for counseling. Conclusion/Implications for Practice: This study provided practical insights into the aspects of planning, engaging, executing and the process of implementation of a tobacco cessation intervention in a workplace setting. It provided guidance for an intervention within occupational health units in similar settings.

Introduction Tobacco use is detrimental at any time. However, it is proving to be more dangerous during the COVID-19 pandemic. Tobacco use may increase the risk of being infected, increases the chances of complications, and also increases the probability of its spread. We assessed the awareness about this association and the impact of the lockdown on tobacco use among tobacco users registered before the lockdown for LifeFirst, a tobacco dependence treatment program. Methods 1016 tobacco users were under active follow-up in their course of the 6-month counselling program. From 14 to 28 May 2020, 650 (64%) of these registered users were contacted by counsellors for follow-up sessions over the telephone. Semi-structured questionnaires were filled in during the calls. Results Two-thirds (67%) of tobacco users were unaware of the association between tobacco and COVID-19. Only 30% of the users felt that the current situation had affected their tobacco use, the commonest impacts being unavailability and increased prices of tobacco products. While this was seen as an opportunity to quit by some users, some reported increased tobacco use due to increased stress. Of the 219 (34%) tobacco users who quit tobacco during the lockdown, 51% quit because of the lockdown and their concern over COVID-19. Abstinence among those who were aware of the association between the coronavirus and tobacco was twice that among those who were not aware. Conclusions Awareness activities about the harmful effects of tobacco during the coronavirus pandemic have to be strengthened. Measures to motivate and support tobacco users to quit have to be provided through cessation services.

BackgroundTobacco and areca-nut use among adolescents has been reported from different parts of India. Multiple factors influence initiation of tobacco use among adolescents. Initiation of one product gradually extends to multiple products. Studies on initiation lack documentation of the pathways and experiences post-initiation, which is required to holistically understand behavior patterns of adolescents for planning timely intervention. This study was conducted to trace pathways and identify factors influencing the initiation and continuation of tobacco and areca-nut among adolescents.MethodsIn this two-staged study, we conducted 14 focus group discussions (FGDs) with 166 adolescents studying in grades 7–9 (11–18 years) from six municipal schools in Mumbai, India. They had self-reported areca-nut or smoked or smokeless tobacco (SLT) use. Pathways of initiation were traced through in-depth interviews for 60 adolescents.ResultsFour multi-linear pathways of use were identified: (1) areca-nut only, (2) areca-nut to tobacco, (3) initiation with SLT, and (4) initiation with smoking. Raw or sweetened areca-nut, betel leaf, gutka, masheri, mawa, hookah, cigarette, bidi, and e-cigarettes were products reported to be used. Curiosity, easy access to tobacco products and normalization of tobacco use influenced initiation. Areca-nut acted as a precursor to tobacco use.ConclusionTracing pathways in tobacco use helped to understand reasons for initiation, influences in continuation of use, and experiences of significance to the adolescents. Experiences of adolescents play a critical role in shaping the pathways of tobacco use. Understanding the pathways and influencers will further help to build effective health promotion communication, policies for sale to minors, and school-based cessation interventions.ImplicationsFindings of the study provide an insight into unknown areas of information regarding products used by adolescents, their patterns of consumption, perceptions, and their pathways of initiation and continuation of primary and secondary products. This will help in developing specific public health awareness messages, policies regarding packaging and sale of areca-nut to children and interventions targeted for the adolescents and their specific products of use not just in India but for the South-East Asia region as areca-nut and tobacco use among adolescents is common in the region. The exercise of tracing the pathways provides basis for cessation counseling among adolescents.

Introduction The youth are a vulnerable population-group for tobacco-related harms. Schools are an excellent setting for health promotion; yet there is a dearth of school-based cessation interventions, rarely evaluated for their impact. Here, we assess the impact of the LifeFirst program: an ongoing tobacco and supari (areca nut) cessation intervention delivered to students from corporation schools in Mumbai city. Methods We used a prospective quasi-experimental design with an intervention and a control arm embedded within an ongoing LifeFirst program in select schools. We used a difference-in-difference analysis with baseline and end-line surveys to assess the program's impact on students' knowledge about harms, students' refusal skills, and prevalence of tobacco/supari use. We report our work using the TREND statement checklist. Results A total of 959 students registered in the LifeFirst program. In our analysis, we included 827 students who completed both the baseline and end-line surveys. Postintervention, we found both tobacco and supari use reduced substantially among the intervention group while tobacco use increased among the control group. The difference-in-difference estimates show a statistically significant reduction of 17.9 and 38.1 percentage points in the intervention group for tobacco and supari use respectively, beyond the reduction in the control group. Conclusions The LifeFirst program was successful in reducing tobacco and supari use among the study participants and protected students in the intervention group against new uptake of tobacco. It helped improve knowledge score and refusal skills among students. Implementation and evaluation of similar school-based programs should be considered as part of a multi-strategy approach to reducing tobacco use among young people.

IntroductionAreca nut, commonly known as supari, is widely used in India. In addition to tobacco and alcohol, it has been identified as one of the contributory factors for high rates of oral cancer in the country.MethodsThis qualitative study explored perceptions and practices around the use of areca nut by conducting in-depth interviews and focus group discussions with 61 school-going adolescents in the city of Mumbai, India.ResultsRespondents used low-priced sachets of sweetened, flavored areca nut called supari. They perceived supari as harmless because it was sweet, it had a fresh after-taste as compared to bitter-tasting smokeless tobacco products. How can something sweet be harmful was a common argument offered by respondents. Respondents invariably compared and contrasted areca nut to more harmful and addictive tobacco products; perceiving supari to have milder or inconsequential health effects. Supari use was initiated with friends, a sibling, or a cousin. It was almost always used with friends. Respondents also reported difficulty in refusal to use when offered supari by friends. Parental response to finding out about the child’s supari use was often muted in comparison to extreme reactions associated with the child’s tobacco use.ConclusionsPerceptions of low risk or relative harmlessness of the product, social influence, and the features of the product itself influence adolescents’ use of areca nut. Although more research on perceptions of risk, with larger samples, is required, these findings are useful for school-based tobacco prevention and cessation programs and health policy-makers.ImplicationsThe study findings have implications for prevention and cessation programs, and policymakers. School-based health education programs should allocate special sessions on areca nut use. Focused mass media communication campaigns describing its harms and association with oral cancer are required for the larger community. As was done for tobacco, Indian policymakers will have to evaluate the marketing, commerce, and distribution of areca nut and create appropriate laws. More research, with larger nationwide samples, is required to examine perceptions of areca nut.

Setting and objectives: Tobacco use compromises tuberculosis (TB) treatment outcomes. Tobacco cessation is beneficial to TB patients at the individual level and from the perspective of a larger spectrum of non-communicable diseases associated with tobacco use. We assessed feasibility, effectiveness and provider perceptions on integrating brief tobacco cessation advice into routine TB care by DOTS providers from 27 TB treatment centres run by three non-governmental organisations (NGOs) in urban India. Design: A mixed-methods study (triangulation design) involving analysis of programme data and semi-structured interviews (quantitative) and thematic analysis of focus group discussions of TB treatment providers (qualitative) regarding brief advice and cessation support provided to self-reported tobacco users from August 2015 to July 2017. Results: All 27 centres initiated tobacco cessation. Of 2132 registered TB patients, 377 (18%) were tobacco users, 333 (88%) of whom used smokeless tobacco. There was a progressive drop in documentation of tobacco status at each visit, reaching respectively 36% and 30% at the end of treatment for new and retreatment TB patients. Seven-day point prevalence abstinence at 6 months was 32% among new and 15% among retreatment cases. Enablers for integration included NGO collaboration, supervision and capacity building. Challenges included providers spending 15-45 min per patient (10 min recommended), multiple addictions, documentation load, self-reporting and social normalisation of tobacco. Conclusions: Integration of tobacco cessation into routine TB care in an urban NGO setting was feasible, although without continued support, rigour in documentation declined. This should be scaled up with special attention paid to tackling smokeless tobacco and related operational challenges.

Setting: The introduction of accredited social health activists (ASHAs, community workers) in the community is encouraged by the Government of India as being of universal benefit for maternal and infant health. Objectives: In two informal settlements in Chandigarh, India, one with ASHAs and the other without, we assessed 1) whether ASHAs influenced certain selected maternal and infant health indicators, and 2) perceptions among women who did not contact the ASHAs. Design: This was a mixed-methods study conducted from April 2013 to March 2016 using quantitative (retrospective programme data) and qualitative (free-listing) components. Results: The increase in institutional deliveries from 2013 to 2015 was marginal, and was similar in both areas (86-99% in the settlement with ASHAs and 88-97% in the settlement without). Bacille Calmette-Guerin and pentavalent vaccination coverage were close to 100% in both areas during the 3 years of the study. Antenatal registration in the first trimester increased from 49% to 52% in the settlement with ASHAs and from 53% to 71% in the settlement without. Between 18% and 35% of women did not complete at least three antenatal visits. 'Not knowing ASHAs' and 'not feeling a need for ASHAs' were the main reasons for not using their services. Conclusion: While success has been achieved for institutional deliveries and immunisation coverage even without the ASHAs, their presence plays an important role in improving antenatal indicators.

Introduction This study aimed to test whether school-going adolescents who self-report tobacco and/or supari use are more likely to quit if a school-based psychosocial cessation intervention is added to an existing life-skills and tobaccoprevention program. Methods A quasi-experimental trial with pre-test and post-test 20 weeks after the intervention was conducted with students from low-income families in 12 schools in Mumbai; six schools were randomly assigned to the intervention and the remaining to the comparison condition. Participants were students from grades 7, 8 and 9 who self-reported tobacco and/or supari use. Intervention schools received six sessions of LifeFirst, a psychosocial group-based tobacco cessation intervention program, in addition to SuperArmy, a school-wide lifeskills and tobacco-prevention program. Trained counselors facilitated the cessation intervention, which spanned five months. All students in comparison schools received only SuperArmy. The outcome measures were self-reported use of tobacco-only, supari-only, and tobacco plus supari in the past 30 days. Results The number of all users decreased by 19.1% in the intervention and 18.7% in the comparison schools at post-test. Although this reduction was significant (p

Objective:We investigated short- and long-term indicators of malnutrition and diet before and after the community-based ‘Breaking the Cycle of Poverty’ multidisciplinary intervention.Design:A historically and geographically controlled study using data collected in 2013 and 2016. We compared the prevalence of short-term indicators (anaemia, breast-feeding duration and minimum dietary diversity) and long-term indicators (stunting and wasting) in exposed communities at two time points. We then compared these factors in geographic areas exposed or not exposed to intervention. We conducted logistic regression analyses on the 2016 sample to measure associations between living in intervention communities and child growth indicators.Setting:Berd region, a chronic conflict zone near the north-eastern border of Armenia and Azerbaijan.Participants:Children aged 6 months to 6 years.Results:Analyses included data from 2013 comprising 382 children, and data from 2016 comprising 348 children living in communities where the programme was implemented, and 635 children from unexposed communities. Anaemia prevalence in exposed communities was significantly lower in 2016 v. 2013 (10·9 v. 19·1 %, P < 0·01). Minimum dietary diversity (79·0 v. 68·1 %, P < 0·001) and breast-feeding duration (13·0 v. 11·5 months, P < 0·002) were significantly improved in exposed communities. Prevalences of stunting (11·5 v. 10·2 %, P = 0·57) and wasting (4·8 v. 2·0 %, P = 0·07) were not significantly different. Odds of anaemia were significantly lower (OR = 0·24, 95 % CI 0·16, 0·36) in intervention communities.Conclusions:Exposure to a community-based multidisciplinary intervention reduced the rate of anaemia and improved dietary indicators.

Areca nut and products made from the nut, evaluated by the International Agency for Research on Cancer as carcinogenic to humans since 2004, are being increasingly used in India and South East Asia and exported to many countries. There is thus an urgent need to identify best control policies and research gaps. On 1 February 2018, a group of experts shared their latest knowledge and perspectives on areca nut at Healis-Seksaria Institute for Public Health in Navi Mumbai, Maharashtra, India. By itself, areca nut has been implicated in oral and oesophageal cancer. Areca nut users are also at high risk of oral submucous fibrosis, a debilitating and potentially malignant condition. Users may also suffer adverse health outcomes due to smokeless tobacco, commonly mixed with areca nut. The use of areca nut commonly begins in childhood and often proceeds to use with tobacco. Gutka, a widely consumed, industrially made areca nut product containing tobacco, has been banned in all states and union territories of India, but it is still widely available. Areca nuts contain arecoline, an alkaloid that stimulates various brain receptors, promoting physical dependence. Areca nut alkaloids have also been implicated in carcinogenesis. Other chemicals, introduced during cultivation and processing of areca nuts, contribute to oral submucous fibrosis and cancer. The wide variety of products, different storage conditions and lack of regulation can lead to significant variation in the content of toxicants, carcinogens and alkaloids, making the psychological and physical dependence issues even more challenging. Regulation of product contents is needed as a part of control measures to supplement product bans.

Introduction: In 2013, the National Tuberculosis (TB) Program of Armenia introduced GeneXpert MTB/RIF (Xpert) assay to address World Health Organization (WHO) target of 80% (2020) of notified new and relapse TB cases to be tested with WHO recommended rapid diagnostic methods. This study aimed to assess the change in laboratory diagnostic profile of Mycobacterium tuberculosis after introduction of the Xpert assay from 2013 to 2017. Methodology: Retrospective cohort analysis of all presumptive TB patients’ records retrieved from the National Reference Laboratory database was performed. Results: This study showed increased trend of Xpert coverage for suspected TB cases from 25% in 2013 to 86% in 2017 which is in line with WHO TB global strategy’s target of 80% in 2020. In 4.7% cases, Xpert tested positive while microscopy showed negative results. There was also an improved detection of Rifampicin resistance with increased concordance from 99.1% to 99.4% and decreased discordance from 6.7% to 1.4% between culture and Xpert results. Conclusion: Armenia has achieved the 2020 target; in terms of utilizing the GeneXpert it is on track to achieve the End TB strategy target of 100% by 2025. The next step of this research will be assessment of the impact of GeneXpert and other TB tests utilization on the treatment outcomes in Armenia.

Introduction "Hookah" or waterpipe smoking is becoming popular among youth. It is addictive and associated with multiple, long-term, adverse health outcomes. Availability of flavored hookah, increasing social acceptability, influence of tobacco industry and misconceptions about hookah have contributed to its increasing use among youth. Many adolescents from urban slums of Mumbai do not know that hookah contains tobacco. The aim of the study was to assess the prevalence of hookah and factors associated with its cessation among adolescents from slums of Mumbai. Methods LifeFirst is a tobacco/areca-nut dependence treatment program implemented in 40 schools in slum areas of Mumbai in 2017-18. 4302 students of 7th-9th grades attended orientation sessions about tobacco products including hookah and their harmful effects. Students were informed about the availability of a cessation service and encouraged to register voluntarily for six theme-based group sessions conducted over six months. At the end of the six sessions, cessation outcomes were recorded. Results Of the 1441 students registered for tobacco/areca-nut cessation, 6% were current hookah users (3% of boys and 7% of girls). 65% of them initiated hookah use because of curiosity and 25% due to peer influence. Of the current hookah users, 8% smoked hookah daily. At the end of six sessions, 54% of the hookah users reported stopping smoking hookah while the abstinence was 72% among the rest of the students. Conclusions Hookah smoking is prevalent among school-going adolescents from slums of Mumbai and school-based cessation programs are required to increase awareness and support them to quit.

Introduction Hospitalization is an important setting to address tobacco use. Little is known about post-discharge cessation and treatment use in low- and middle-income countries. Our objective was to assess tobacco use after hospital discharge among patients in Mumbai, India. Methods Longitudinal observational study of inpatients (≥15 years) admitted at one hospital from November 2015 to October 2016. Patients reporting current tobacco use were surveyed by telephone after discharge. Results Of 2894 inpatients approached, 2776 participated and 15.7% (N = 437) reported current tobacco use, including 5.3% (N = 147) smokers, 9.1% (N = 252) smokeless tobacco (SLT) users, and 1.4% (N = 38) dual users. Excluding dual users, SLT users, compared to smokers, were less likely to report a plan to quit after discharge (42.6% vs. 54.2%, p = .04), a past-year quit attempt (38.1% vs. 52.7%, p = .004), to agree that tobacco has harmed them (57.9% vs. 70.3%, p = .02) or caused their hospitalization (43.4% vs. 61.4%, p < .001). After discharge, 77.6% of smokers and 78.6% of SLT users reported trying to quit (p = .81). Six-month continuous abstinence after discharge was reported by 27.2% of smokers and 24.6% of SLT users (p = .56). Nearly all relapses to tobacco use after discharge occurred within 30 days and did not differ by tobacco type (log-rank p = .08). Use of evidence-based cessation treatment was reported by 6.5% (N = 26). Conclusions Three-quarters of tobacco users in a Mumbai hospital attempted to quit after discharge. One-quarter reported continuous tobacco abstinence for 6 months despite little use of cessation treatment. Increasing post-discharge cessation support could further increase cessation rates and improve patient outcomes. Implications No prior study has measured the patterns of tobacco use and cessation among hospitalized tobacco users in India. Three-quarters of tobacco users admitted to a hospital in Mumbai attempted to quit after discharge, and one-quarter remained tobacco-free for 6 months, indicating that hospitalization may be an opportune time to offer a cessation intervention. Although smokers and SLT users differed in socioeconomic status, perceived risks and interest in quitting, they did not differ in their ability to stay abstinent after hospital discharge.

Background According to Global Adult Tobacco Survey -2, 267 million adults consume tobacco in some form in India and 75% of them use smokeless tobacco. Smoking is banned in India in public places including indoor workplaces under the Cigarettes and Other Tobacco Products Act (COTPA). However, there are no regulations for smokeless tobacco use, the most prevalent form. Workplaces offer a unique opportunity to address employees' health and influence their tobacco use behavior. LifeFirst tobacco cessation service was provided at a cement plant with about 2000 employees in Chandrapur, Maharashtra with the objective of promoting and aiding quit attempts of tobacco users. Methods An awareness talk about tobacco and its ill effects and benefits of quitting was provided in groups to 1764 employees (all males). Employees voluntarily registered for the cessation service which included a detailed face to face counseling session followed by four follow up sessions over six months. Tobacco use status was recorded at each session. In addition to this, trainings for “Anti-tobacco champions” and the Medical Team were conducted for incorporating the initiative into the company's Occupational Health activities. An announcement was made by the plant head to make the plant tobacco free within a year. Results 648 employees voluntarily registered for the cessation service. 607(94%) of these were smokeless tobacco users, majority (77%) of them using the local tobacco product “kharra” (mixture of tobacco and areca nut). 552(85%) attended the follow up session at 6 months and 438(68%) of all registered users reported not using any form of tobacco, 50(8%) had reduced use, 60(9%) had made a quit attempt but relapsed. Conclusions By providing tobacco cessation activities within a workplace, employees using smokeless tobacco as well as smoking can be helped to quit their tobacco habit and create an environment conducive to a tobacco free workplace.

Background Tobacco and supari (areca nut or betel nut) use has been reported with a high prevalence among students in secondary schools in Mumbai, India. Supari, which is classified as carcinogenic, is one of the most widely consumed addictive substances in India after nicotine, ethanol and caffeine. A study was conducted to evaluate the efficacy of a school-based psychosocial intervention for all forms of tobacco and supari cessation among students. Methods A quasi-experimental trial with three measurements - at baseline, Post-test1 and Post-test2 was conducted in 12 schools serving students with similar socioeconomic profile in 2015-16. Six schools were randomly selected for the cessation intervention and 6 matching schools were selected based on location and medium of instruction in comparison group. In the interventions schools, students who self-reported tobacco or supari use at baseline were assigned to receive a 6-session group cessation intervention designed specifically for adolescents and school settings. All schools receive a life-skills and tobacco prevention program called Super-Army. Results 1313 students completed the baseline in intervention schools; 212 self-reported tobacco/supari use, of which 133 enrolled and received both Super-Army in classroom and 6 psychosocial cessation sessions in group setting. In comparison schools, 1320 students completed baseline; of which 191 reported tobacco/supari use and received only the Super-Army prevention messages in classroom. At Post-test 1, conducted 4 weeks after sessions ended, reported use in intervention schools dropped by 30% and in comparison schools by 28%. At Post-test 2, conducted 16 weeks later, in intervention schools self-reported use dropped further by 45%. This was significantly different from comparison schools where users dropped by 13%. Conclusions Although classroom-based life-skills curricula have an immediate impact on tobacco/supari use, the addition of a specialized cessation intervention, even if psychosocial in nature without replacement therapy, seems to have a durable effect on reducing use.

Background India has an estimated one million tobacco-attributable deaths annually. Tobacco cessation treatment is effective among hospitalized patients, but little is known about tobacco use among hospitalized patients in India. This study aims to measure tobacco use, interest in quitting, and cessation after discharge at a Mumbai hospital. Methods Cross-sectional survey of patients 15 and older at a Mumbai hospital. Of 7,889 patients admitted from 11/2015-10/2016, 5,038 were eligible, 2,894 were approached and 2,764 participated. Characteristics of smokers and smokeless tobacco (SLT) users were compared and self-reported cessation was assessed 6 months post-discharge. Results Overall, 6.5% (N=179) of subjects were current smokers and 10.2% (N=284) were current SLT users (N=37 were dual users). Most smokers (81.7%) and SLT users (94.3%) reported daily use. The mean number of tobacco products used was 2 (standard deviation=1). Compared to smokers, SLT users were more often older (52 versus 48 years, p=0.002), female (37% versus 1%, p< 0.001), illiterate (14% versus 6%, p=0.01), and less often employed (52% vs 75%, p< 0.001). SLT users less often reported a past year quit attempt (39% versus 54%, p=0.004) or a plan to stay quit after discharge (42% versus 54%, p=0.04). There were no differences in importance of quitting, confidence, receipt of advice to quit, or treatment use. Just 3% reported evidence-based treatment use. Compared to smokers, SLT users less often agreed that tobacco has harmed them (57% versus 70%, p=0.01). Overall, 28% of tobacco users (25% of smokers and 29% of SLT users) reported having quit at 6 months post-discharge. Conclusions Roughly half of hospitalized tobacco users planned to stay quit after discharge and 28% reportedly succeeded. Interventions to connect hospitalized tobacco users with treatment are clearly needed. SLT users may be especially challenging to engage because SLT is viewed as less harmful.

Background The prevalence of tobacco use among children aged 13-15 years is 14.6% and 15.5% of non-users intended to start smoking in the next year. School going children also consume areca nut (“supari”), which is an easily available carcinogenic, psychoactive substance, acting as a gateway product to tobacco use. This current and intended use will exacerbate the burden of tobacco related morbidity and mortality. LifeFirst program was implemented in 15 schools catering to lower socioeconomic population in slum areas of Mumbai in the academic year 2016-17 for helping students quit their tobacco and supari use. Methods Orientation sessions about harmful effects of tobacco and areca nut were conducted using audio-visual aids for 2379 students of the 7th, 8th and 9th grades. Students were informed about the availability of a cessation service within the school and encouraged to register voluntarily. The registered students were divided into groups of 10-15 students each and six group-sessions involving videos, games, role plays and activities were conducted over six months. The sessions were theme based; covering topics like rapport building, ill-effects of tobacco, coping mechanisms, refusal skills etc. The self-reported status of tobacco use was recorded individually during each session. Extended 4-month post-program follow-up was conducted. Results Of the 492 students (84% boys) registered for the program, 88% were only supari users, 10% used supari and tobacco, 2% only smokeless and less than 1% only smoked. 67% were daily users. The mean age of initiation was 11.7 years and 79% were introduced to the product by their peers. 71% reported as not using tobacco and supari at the end of the programme with 12% relapse recorded during extended follow up. Conclusions Providing structured cessation services with positive peer influence facilitated by trained counselors encourages and aides tobacco and areca nut users to stop their habit.

Background Cigarettes and Other Tobacco Products Act, (COTPA) prohibits smoking in public places including indoor workplaces. Despite this, few workplaces in India have documented tobacco free workplace policies being implemented. The policy influences employees about their tobacco use behavior. However, before implementing such a policy, it is important to assess perceptions and readiness of employees. A situational analysis survey was conducted among employees of four organisations to know their readiness about having a policy, their self-reported tobacco use and the need of counseling support to quit tobacco. Methods A structured questionnaire was administered online to 447 permanent staff while face-to-face interviews were conducted among 281 contractual workers from August 2016 to March 2017. Results Majority of permanent and contractual workers agreed that the organization should have a tobacco free policy and that it will have a positive impact on the employees' health. Equal proportion of permanent (55%) and contractual staff (54%) were aware of the existing rules and among them, 84% and 86% respectively were satisfied with them. 26% of permanent and 56% of contractual staff self-reported ever using some form of tobacco while 9% and 38% respectively reported current tobacco use (last 30 days). Fewer contractual (79%) as compared to permanent staff (89%) felt that some action should be taken against violation of the policy. Monetary fine and written warnings were suggested as action by majority from both groups. More contractual (98%) than permanent staff (84%) reported that there should be counseling service at the workplace for tobacco users. Conclusions Both contractual and permanent employees endorsed the need for a tobacco free workplace policy with penal action for violations. However, the differences in tobacco use and perceptions towards the policy of these two groups have to be considered while implementing the policy and offering cessation services.

Background and challenges to implementation While smoking is prohibited in India in public places and indoor workplaces, there is no regulation about smokeless tobacco use in workplaces as per the Cigarette and Other Tobacco Products Act. Very few companies in India have a documented tobacco free workplace policy addressing smokeless tobacco use. Narotam Sekhsaria Foundation was selected for implementing Clinton Global Initiative's Tobacco free workplace policy challenge project focusing on India and including smokeless tobacco use. Five workplaces in Maharashtra with total 5000 employees were approached to be a part of this project. Intervention or response Activities involved a situational analysis, provision of cessation service and formulation and implementation of a policy document according to the guidelines "Smokefree-in-a-box" toolkit developed by the Global Smokefree Partnership. Results and lessons learnt The policy was launched and implemented in only one workplace during one year and 332 employees were provided cessation counselling. Lessons learnt: · Organizations are willing to get involved on a pilot basis in representative units and not willing to for the entire company. · They are interested in the tobacco free policy from the point of view of employee wellness · Organizations are not ready to commit for policy before the cessation services. · Management employees are reluctant to enroll for the cessation services · Coordination with a number of departments at the company level is required. · Proper and effective communication to all employees regarding the tobacco free policy by the decision makers is required. · Integration of tobacco free workplace activities with their internal processes (e.g. Ocuupational Health and Safety, Annual Medical Checkup etc.) ensures acceptability Conclusions and key recommendations Implementing a tobacco-free workplace policy in India is required but challenging. It creates an environment conducive to behavioural change and cessation among employees. Integrating it with internal systems and effective communication from the decision makers makes it feasible to implement.

Background Provision of Anti-Retroviral Therapy (ART) and Opioid Substitution Therapy (OST) are important components of the targeted intervention (TI) programme for people who inject drugs (PWID). Homeless HIV positive PWIDs in Delhi is a key population experiencing gaps in uptake of these services, especially the ART uptake which is reportedly far from 90%, UNAIDS’ 90-90-90 target to end the AIDS epidemic. Objective To assess the gaps and barriers in accessing the ART and OST services uptake among HIV positive homeless PWID in Delhi and to explore experiences and perspectives of the PWIDs and service providers. Methodology We used a convergent parallel mixed methods design which included a cross-sectional quantitative survey and a qualitative study. Two hundred thirty five homeless HIV positive PWID were interviewed and in-depth interviews were conducted with five PWIDs and nine health providers. Results While only 12% of PWIDs were on ART, 80% were availing OST services. The top individual, health system related and structural barriers for ART service access were insufficient and incorrect knowledge (63%), long waiting time (86%) and lack of family support (44%) respectively. Inconvenient timings, stringent registration requirements and negative attitude of health providers were expressed as major barriers of accessing ART services during the interviews while these were not a concern in OST services. Homelessness, poverty, stigma were common barriers for both services. Integrated, ‘single window’ service and provision of additional support like nutrition and shelter were suggested as measures to improve access by both health providers and the PWIDs themselves. Conclusion There is an urgent need for structural and health systems changes to improve access to ART and OST services. These include integrated service delivery, flexibility in timing of the centers, accelerated ART initiation, simplification of bureaucratic procedures, nutritional and social support to all homeless HIV positive PWIDs.

Background India's Revised National Tuberculosis Control Programme (RNTCP) is deemed highly successful in terms of detection and cure rates. However, some patients experience delays in accessing diagnosis and treatment. Patients falling between the 96th and 100th percentiles for these access indicators are often ignored as atypical 'outliers' when assessing programme performance. They may, however, provide clues to understanding why some patients never reach the programme. This paper examines the underlying vulnerabilities of patients with extreme values for delays in accessing the RNTCP in Mumbai city, India. Methods We conducted a cross-sectional study with 266 new sputum positive patients registered with the RNTCP in Mumbai. Patients were classified as 'outliers' if patient, provider and system delays were beyond the 95th percentile for the respective variable. Case profiles of 'outliers' for patient, provider and system delays were examined and compared with the rest of the sample to identify key factors responsible for delays. Results Forty-two patients were 'outliers' on one or more of the delay variables. All 'outliers' had a significantly lower per capita income than the remaining sample. The lack of economic resources was compounded by social, structural and environmental vulnerabilities. Longer patient delays were related to patients' perception of symptoms as non-serious. Provider delays were incurred as a result of private providers' failure to respond to tuberculosis in a timely manner. Diagnostic and treatment delays were minimal, however, analysis of the 'outliers' revealed the importance of social support in enabling access to the programme. Conclusion A proxy for those who fail to reach the programme, these case profiles highlight unique vulnerabilities that need innovative approaches by the RNTCP. The focus on 'outliers' provides a less resource- and time-intensive alternative to community-based studies for understanding the barriers to reaching public health programmes.