“STOP the PUFF! Tayo’y mag bagong BAGA, SIGARILYO ay ITIGIL”: A Pilot Community-based Tobacco Intervention Project in an Urban Settlement

Introduction

Tobacco use continue to be one of the leading cause of death and disability worldwide. Around 8 million deaths worldwide each year are tobacco related, 7 million of which are attributed to direct tobacco use while around 1.2 million are due to exposure to secondhand smoke.    There are around 1.1 billion smokers worldwide and 80% of these live in low- and middle-income countries [1] .  The Philippines is one of the countries in the Western Pacific region with the highest prevalence of tobacco use [2]  and seven out of the 10 leading cause of mortality in the country is tobacco related. [3]  The Philippine government has intensified its efforts to curb smoking, focusing mainly on policies that target the wider determinants of health such as smoking bans, graphic health warnings and sin tax law. These efforts have resulted to a significant decrease in the prevalence of smoking from 17.3 million in 2009 to 15.9 million in 2015.  Also, the number of smokers who are interested in quitting increased by 16.3% from 2009 to 2015.  However, those interested in quitting that were seen by a health care provider did not increase significantly and only around half made a quit attempt. More importantly, the quit success rate did not increase. [4]  This demonstrates a wide disparity between the number of smokers who want to quit and the number who are able to quit successfully.  This gap may be addressed by strengthening health care interventions especially among smokers that are heavily dependent on nicotine.  There may be a need to complement national policies with programs that target the specific needs of smokers.

Brief Tobacco Intervention (BTI), also known as brief advice, is a strategy that is proven to be effective, practical and doable in the community setting. [5]  Unfortunately, cessation experts in the country are few and healthcare workers with training on tobacco interventions are limited. 

The primary objective of the project was to establish smoking cessation intervention in the community by empowering health workers and community volunteers on giving BTI and to improve access to cessation support by establishing a referral mechanism to smoking cessation services. The project also aimed to promote smoking cessation in the community through health education activities that promote smoke-free behavior and encourage smoking cessation among current smokers.

Review of Related Literature

Studies have shown that the outcome of quit attempt is related to various individual, socio-cultural and environmental factors. [6-13]  Some factors were consistently shown to be related to quit success but there are certain factors that differ in every population.  Studies done among smokers in South Africa, USA and South Korea showed that higher educational level is related to quit success. [6-8]   However, in a similar study done in Brazil, this was correlated with failure. [9]  Being married was associated with quit success in the studies done in USA and in South Korea [7,8]  however, this was not seen in the study done in South Africa. [6-10]    It can be surmised therefore, that cultural, social and behavioral aspects of smoking that affect quit outcomes may be unique in each population or community (Table 1, Appendix A).

DiGiacomo et al [14]  recommends a multi-faceted approach in smoking cessation, taking into consideration the individual and socio-cultural factors that are unique to each community.   These factors are usually not targeted by national policies that focus on the wider determinants of health. Community-based interventions, on the other hand, may better address these factors. There is also evidence that community-based interventions and those that are tailored to specific indigenous groups have greater retention and quit success rates compared to center-based interventions. [14-20]  These suggest that establishing a community-based smoking cessation intervention is effective and feasible (Table 2, Appendix A). 

Methodology

The project was done in three phases as described in Table 3. A health needs assessment and situational analysis were done in the first phase. This involved an appraisal of the attributes of the community and an analysis of the specific needs of the community pertaining to tobacco control.  This was done primarily through review of secondary data, focus group discussions (FGDs) and informal interviews. The primary goals of the FGDs were to understand the general views of the community on tobacco, determine the level of awareness on its effects and identify misconceptions on tobacco use and smoking cessation. The findings were used to modify the design of the training and health education modules to better fit the needs and attributes of the community.

Phase 2 of the project involved the conduct of BTI training for health workers and volunteers in Munting Ilaw health center.  The training was done in two separate sessions to align with the health workers' schedule and minimize interruption in the delivery of services of the health center. The target number of participants was 30, in accordance with the WHO recommendations. [5]  The general objective of the seminar and workshop is to capacitate the participants on the method of conducting brief tobacco intervention.  The module used was adopted from the BTI module of the Department of Health [21]  and modified based on the result of the situational analysis. It consisted of 5 modules namely: 1. Building the Momentum; 2. Brief tobacco Intervention Essentials; 3. Not ready to quit; 4. Ready to quit; and 5. Staying quit or relapse.  The description, contents, methodology and resources of the modules are summarized in Table 5 (Appendix B). Gaps in knowledge, concerns and misconceptions identified during the FGDs were given emphasis during the training.  Possible referral mechanisms to smoking cessation services were discussed at the end of the session.

Phase 3 of the program involved health promotion activities such as information campaign on the dangers of smoking and promotion of smoking cessation services.  This was done in the form of a lay fora.

The actual schedule of the conduct of activities is presented in Table 4.

Observations and Results

A. Health Needs Assessment

1. Health Profile of the Community

The project was implemented in Phase 1-K Kasiglahan Village, Barangay San Jose, Rodriguez Rizal where a memorandum of agreement exists between Barangay San Jose and the University of Santo Tomas, Master in Public Health (International) program. Kasiglahan Village is situated in Barangay San Jose which is one of the eleven barangays in Rodriguez Rizal.  Although originally an agricultural land, the area has undergone massive development over the recent years and is now considered as an urban area.  It is the 6^th most populated barangay in Rodriguez with a population of 124,868 in 2015.  This population has grown quite rapidly over the past few decades largely due to the development of relocation sites that catered to displaced families from Quezon City and other cities surrounding the Pasig river.  Kasiglahan Village is one example of these developments, with residents mostly relocated from Quezon City areas. [22] 

There are several health facilities within Rodriguez Rizal. The Rural Health Unit is manned by the rural health officer, physicians, nurses, midwives, sanitary inspectors and malaria officers.  There is a 25-bed infirmary (Montalban Infirmary) that is located in Kasiglahan Village and a government health facility (Casimiro Ynares Sr. Memorial Hospital). Other private health providers likewise exist which include hospitals, lying-in clinics and multi-specialty clinics. Each barangay has at least one health center with some having satellite health centers.     Hospitals outside of the municipality are also easily accessible through jeepneys and other public utility vehicles. Based on the interviews with the residents and health workers from Kasiglahan Village, patients needing tertiary care are usually brought to hospitals in Metro Manila such as East Avenue Medical Center in Quezon City and Amang Rodriguez Memorial Medical Center in Marikina City.  These hospitals are what they deem as the most accessible and capable of providing higher level of healthcare.

Munting Ilaw Health Center is a satellite health center of Barangay San Jose and is located in Kasiglahan Village.  It is tasked to provide basic health services to the residents of Kasiglahan Village such as maternal and child health, family planning, immunization, and nutrition.  It also houses a directly observed treatment short-course (DOTS) clinic for the management of tuberculosis. It is manned by nurses, midwives, barangay health workers, municipal health workers and volunteers.

The leading causes of morbidity in Rodriguez Rizal in 2012 include: 1. Animal Bite; 2. Acute upper respiratory tract infection; 3. Pulmonary tuberculosis; 4. Dengue; 5. Asthma; 6. Acute rhinitis; 7. Acute gastroenteritis; 8. Hypertension; 9. Body injuries and 10. Pharyngitis.  Mortalities are mostly due to cardiac causes such as myocardial infarction.  Other causes of death include community acquired pneumonia, cancer (mostly of the lung), intra-cerebral hemorrhage, pulmonary tuberculosis and non-disease related deaths due to body injuries and gunshot wounds. [22] 
 

2. Tobacco cessation services and policies in the community

None of the existing health facilities within the municipality have an existing tobacco cessation service and there is no smoking cessation clinic anywhere in the municipality and in nearby areas.  The municipality has a newly drafted tobacco-free resolution; however, it has not been fully implemented at the time of the implementation of this project.  There is an existing ordinance prohibiting smoking in public spaces.  This is strictly implemented in the city proper and major establishments but not so much in the communities.
 

3. Tobacco interventions from the perspective of health workers.

The FGD was attended by 24 health workers. The goal of the discussion was to determine the general perception of the workers on smoking cessation interventions and the usual practices in the health center in order to identify possible strategies to integrate BTI in their existing programs.

None of the health workers had attended any seminar on or related to BTI.   Advise on smoking cessation and inquiry regarding the smoking status is not customarily done in any of the existing programs of the health center, except in the TB Directly Observed Treatment Short-Course (TB-DOTS) clinic wherein the smoking status of each patient is included in the patient’s record. Even so, giving advice is done inconsistently.  

Most did not know that BTI can be integrated in all of their programs and only a few recognized the relevance of  BTI in their particular line of work (i.e. family planning, nutrition). None were aware of the existence of the National Quitline and no referral mechanism to cessation providers exists.  
 

4. Understanding the perspective of current smokers.

FGDs were done to better understand the predicament of smokers in the community.  FGDs were done instead of formal interviews with structured questionnaire to allow free flow of thoughts and ideas and thereby be able to capture aspects that are not obtained by the Philippine Global Adult Tobacco Survey (GATS).  

Most of the participants initiated their smoking habit during their teen years and curiosity was the most common reason for trying.  Most had the initial intention to just satisfy their curiosity but eventually got hooked to habit.  One of the participants started using chewed tobacco at the age of five. Her parents were tobacco farmers and it was customary for them to chew tobacco leaves while farming. She transitioned to cigarette smoking during her teen years and maintained the smoking habit until adulthood. All of them agreed that it was easy to initiate and maintain the smoking habit because tobacco products were widely available, easily accessible and, at the time of their smoking initiation, very affordable.  They are aware of the ill-effects of tobacco on their health, however, there is a general perception that these ill-effects are unlikely to happen to them.  And if it does, they are resigned to accept it as an inevitable consequence of their smoking habit. Most are willing to quit “when it is absolutely necessary”, however, they do not foresee that they will be able to do so in the near future. This implies that the motivation to quit is generally low. When asked about possible motivations for them to quit, answers included: further price increase in tobacco products, development of health complications and total smoking ban. Tobacco products are also prioritized over other necessities such that they will go to the extent of borrowing money or forego one meal in order to sustain the smoking habit. There is a deep understanding of the current tobacco control policies and the intentions of such policies.  However, these did not seem to deter the smoking habit as they were able to adapt to these policies.  The smoking ban is not strictly enforced in the community; hence they are able to smoke freely while they are in the community.  When going to the city proper or while at work where smoking ban is strictly enforced, they are able to decrease their cigarette consumption.  The graphic health warnings on cigarette packages was likewise not enough to dissuade them from smoking because they usually buy individual sticks instead of packs.  Others cover graphic warnings in the packaging while some think that the pictures are not real and were only meant to scare them. None of the participants had ever received advice from health workers but most of them will likely avail of smoking cessation services if it is available in the community.  None were aware of the National Quitline and most are quite skeptic if it is functional.   
 

5. Lessons from the former smokers.

Similar to the FGDs with smokers, the questions during the discussions with former smokers revolved around the initiation of the smoking habit, knowledge of the ill effects of tobacco and views on current national and local tobacco control policies and how it influenced their quit journey.  In addition to these, the discussion also focused on the motivation/s for quitting and the challenges encountered during their quit journey.

The common motivation to quit was health reasons since all of the participants were diagnosed with a tobacco-related illness that led to the decision to quit.  Most of the participants were only given very brief advice by their physicians and all were able to quit completely, unassisted (“cold turkey” style), and without using any pharmacologic treatment for tobacco dependence.  The biggest challenge for most of them was seeing other people smoke, especially during gatherings and special occasions. The urge to relapse into the smoking habit was easier to resist after a few weeks of being tobacco-free. Although they fully support the existing tobacco control policies, most claim that it had little impact on their motivation to quit.  The graphic health warnings had some influence in their decision to quit, but seeing real patients with tobacco related illnesses on TV was a stronger motivation for them.  When asked about their views on providing cessation services in the health center, most deemed it unnecessary since smokers will quit unassisted for as long as they are motivated.   To encourage smokers to quit, they think that it is important to find the right motivation because it is easier to quit when the motivation is strong.
 

6. Protecting the non-smokers.

​​​​​​The discussions with non-smokers, particularly the ones who are exposed to second-hand smoke in their homes, focused on questions about their feelings about the smoking behavior of their loved ones or household members and how they think it will affect them and the other members of the family.  The participants were also asked how they deal with the smoking behavior of the household member/s.

Most of the participants were spouses of smokers.  All of the participants do not condone the smoking behavior of their spouses; however, they feel that their sentiments and objections to the smoking habit are being disregarded.  They are fearful of the ill-effects of smoking to the health of their spouses and their children as well.  As most of their spouses are breadwinners, the smoking habit is a source of anxiety and worry about the future of the family should their spouse develop a tobacco related illness.  Unfortunately, these feelings of fear, apprehension and anxiety are often invalidated.  Attempts to encourage the spouses to quit smoking are seldom done because discussions on the need to quit often leads to disagreement and tension in the household.  Most of the participants are aware of the ill-effects of second-hand smoke, but they are not aware of third- and fourth-hand smoke. They are receptive of the idea of having a cessation service in the community, however, they are not sure if their spouses will avail of the service or comply with the recommendations.
 

B. Brief Tobacco Intervention Seminar And Workshop

At the start of the training, each of the participants were asked to write their job designation, job description and their perceived role in tobacco control.  Most of the participants recognized their role as a source of information while a few recognized that they can be role models.  The other roles that they can assume in tobacco control were discussed during the training.  The first session consisted of modules 1 and 2 and was given mostly in a lecture format. This involved discussions on the mechanism of nicotine addiction, harms of tobacco, benefits of quitting, common misconceptions and the general approach to BTI. The second session consisted of Modules 3 to 5 and involved a discussion of the specific steps in giving brief tobacco intervention. An algorithm on how to approach each patient at various stages of quitting was presented in a workshop format wherein a video demonstration was presented after each lecture and the participants were asked to present a return demonstration. Feedback was given by the facilitator and also solicited from the rest of the audience.    At the end of the session, the importance of a referral system to smoking cessation providers and clinics was discussed. Since there is no existing referral mechanism yet in the community, the participants were asked to brainstorm on the possible referral mechanism specifically in Rodriguez Rizal. These mechanisms were presented to the whole group and they were made to choose the most feasible, efficient and plausible mechanism. A pre- and post-test was also done evaluate the effectiveness of the training in terms of improving knowledge. Out of the 34 attendees, only 25 were able to accomplish both the pre- and post-test. It was evident that after the workshop, the mean test scores of the participants significantly improved (p<0.001). At an average, their test score increased by 2.08 points which translates to a 20.8% increase in baseline knowledge (95% CI: 1.35 to 2.81).  To somehow ensure that the knowledge will be translated into practice, posters, guide cards and education materials were given to the health center and rural health unit (Appendix C).
 

C. Community Health Promotion And Education

The community health education and promotion was done in conjunction with the health education and promotion activity for non-communicable diseases in the community. The findings in the FGDs were taken into consideration and misconceptions identified were corrected in the lay fora. The activity consisted of short lectures interrupted by games to break monotony and to maximize attention span and retention of concepts. The National Quitline was promoted and participants were encouraged to urge the smokers in the community to utilize this service. Education on how to give very brief advice while avoiding conflicts in doing so was also given. A pre- and post-test was done to measure the effectiveness of the lecture in augmenting the participant’s knowledge.  Out of the 58 attendees, 37 completed the pre- and post-test.  It was evident that after the lecture, the mean test score of the participants significantly improved (p<0.001).  At an average, the test scores increased by 2.73 points which translates to a 27.3% increase in baseline knowledge (95% CI: 2.18 to 3.28).

Discussion

The tobacco quit success rate in the Philippines continue to be dismal despite the government's efforts to curb smoking. Nearly half of smokers who are interested in quitting were not given proper advice by a health care provider. [4]  In the community, several factors contribute to this (Figure 1).   There is an apparent lack of cessation services.  Health workers are not trained on brief tobacco intervention and a referral system to cessation support services is not in place.  Misconceptions on tobacco cessation is also rampant even among health workers.  Like in the rest of the country, tobacco products are widely available and easily accessible. On the contrary, access to nicotine replacement therapies is limited.  The prices of cigarettes, even with the surge due to the sin tax law, are still affordable.  There is an apparent lack of motivation for smokers to quit despite the graphic warnings and other policies that restrict access to tobacco products and decrease opportunity to smoke. Although a smoking ban exist, this is not uniformly enforced.  These factors all contribute to the problem which is a low quit success rate. This in turn result to a myriad of complications such as high prevalence of smoking, high mortality and morbidity from tobacco related illnesses, ultimately leading to greater economic cost.

The objective tree (Figure 3) represents the possible solutions to the problems identified.  The outcome that this project envisions is a high quit success rate in the community.  However, not all of the interventions identified can be accomplished by this project.  Restrictions to tobacco products, price increase and policies on the use of nicotine replacement therapies would need to be addressed by national and/or local government programs and policies. Instead, this project focused on community-based interventions such as the establishment of smoking cessation intervention and referral mechanism in the community health center and health education and promotion activities in the community.

In 2003, the Philippines, being a member of the WHO Western Pacific region, was required to implement the strategies in the WHO Framework Convention on Tobacco Control (FCTC). Bourne from this treaty, the Philippines drafted its National Tobacco Control Strategy (NTSC) for the years 2011-2016.  It’s three main strategies focused on: 1. Promotion and advocacy for the complete implementation of the FCTC; 2. Mobilization for public action; and 3. Strengthening the organization capacity. [23]  This project is consistent with the activities specified under strategy 3 namely: human resource development, smoking cessation and tobacco dependence treatment, public awareness and education.  Likewise, it is consistent with one of the social sectoral objectives of the municipality which is "to implement sustainable preventive healthcare programs to lessen incidence of diseases caused by unhealthy lifestyle".  [22] 

Conclusion and Recommendations

The tobacco problem is centuries old and cannot be solved overnight.  It is indeed complex and full of challenges.  It was found in the situational analysis that the smoking habit can be initiated at the age of five.  This means that tobacco use is not freely chosen and therefore there is a need to alter the general environment through interventions that target the wider determinants of health. Such policies already exist; however, it is essential to strengthen these policies and complement it with clinical interventions. According to the European Society of Respirology [24] , in order to achieve a smoke-free society, tobacco cessation should be supported from policy to clinical perspective. Community based interventions have been consistently shown to be effective in improving quit success rates. Although establishing a formal smoking cessation clinic in the community is ideal, the task may be challenging in a low resource setting as it will entail additional resources.  Providing training to the existing health workforce and integrating brief tobacco intervention with the existing programs of the community health center may be more feasible. Likewise, creating a referral mechanism to smoking cessation providers and clinics may augment the efficiency of smoking cessation efforts in the community.  

The project aimed to address the clinical aspect of tobacco control by establishing tobacco cessation services in the community. This pilot project has shown that providing brief tobacco training among health workers is feasible. There is a need to assess whether this knowledge is translated into practice and whether the training created attitudinal change as well.

Recommendations

It is important that tobacco control remain a priority despite the countless other health problems that need attention. Especially because 5 out of the top 10 causes of mortality in the municipality are tobacco related and 4 out of the 5 causes of mortality are due to tobacco related diseases [22] . A local smoke-free policy is essential and its prompt implementation is encouraged. Stricter and consistent enforcement of the smoking ban is likewise encouraged. Continued health education is necessary to contradict misconceptions on tobacco cessation. BTI training should likewise be cascaded in other health centers, with priority given to at least the head nurse and TB-DOTS nurses. Regular updating of the seminar, on a yearly or every two years basis, is likewise necessary. Once smoking cessation services are fully integrated in the programs of the health centers and more cessation providers are available, smoking cessation clinics in key institutions in the municipality can be established. In the meantime, while smoking cessation clinics are not yet available in the municipality, it is recommended to promote the use of the National Quitline.

Limitations

Tobacco control is multi-faceted and this project mainly focused on the clinical aspect. Although an increase in the knowledge of the participants was documented, whether this knowledge was translated into practice was not assessed. Measuring the impact of the project in terms of increasing quit success rate is likewise ideal but beyond the scope of the project.   

Conflict of Interest Statement

The project was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Ethics Approval and Consent to Participate

Not applicable.

Acknowledgement

The authors would like to acknowledge the people and institutions that were instrumental in the accomplishment of this project.

• For their assistance, insights and valuable inputs:

Honorable Glenn Evangelista, Chairman of Barangay San Jose

Dr. Ma. Carmela V. Javier, Municipal Health Officer of Rodriguez Rizal 

Community leaders of Phase 1K, Barangay Kasiglahan, Rodriguez Rizal

Dr. Leilani B. Mercado-Asis, Program Head, Master in Public Health (International), UST Faculty of Medicine and Surgery

• For providing the module for Brief Tobacco Intervention Training and health promotion and education materials:

Philippine College of Chest Physicians, Council on Control for Tobacco and Air Pollution

Dr. Glynna Ong-Cabrera, Chairperson

Dr. Marie Charisma Dela Trinidad

Ms. Riza SJ San Juan, RN, Nurse Coordinator, Smoking Cessation Program, Lung    Center of the Philippines

Counselors and staff of the DOH National Quitline

• For their unwavering support throughout the conduct of this project from its conception to its realization:

UST FMS Master in Public Health (International) classmates and mentors