Improving the standards of tobacco cessation intervention

3-nazeemaNazeema Sheerin Muthu
Freelance Research Consultant for Tobacco dependence and its treatment
3-flag Jordan
26 May 2015

Please share with us some information about your background:

I got my Ph.D. in Translational Biomedicine, conducted my research at the neuropsychopharmacology lab headed by Professor Christian Chiamulera, who is pioneer in Nicotine Dependence Studies at University of Verona, Italy.

Professor Christian’s motivation as well as my familiarity with Sudan (I had stayed in Khartoum for a year earlier to my departure to Italy) made me to choose Khartoum as an outstation to do a part of my doctoral project during my study in Italy.

My assignment in Sudan was “Assessment of smoking status, tobacco dependence and cue reactivity – a diagnostic tool for practice and implementation research.” The experience was noteworthy and provided ample opportunity to practice/apply lab protocols and techniques to the behavioral intervention. This also helped me gain experience with current initiatives regarding tobacco dependence and prevention of tobacco use among youth in developing countries such as Sudan by the government, hospitals, and health centers as well as United Nations agencies such as the World Health Organization.

After my doctoral degree, I returned to Sudan as a freelance consultant working with the Federal Ministry of Health to continue my contribution by strengthening the tobacco control program in the country. I volunteered with planning and policy making for the initiation and the establishment of tobacco cessation centers in Khartoum based on FCTC article 14, and for the documentation of action plans for national level tobacco control program in accordance with FCTC article 12,13 &14.

At present I am in Amman, Jordan as a freelance consultant doing voluntary work by helping local NGO’s and universities in project design and proposal writing for tobacco-free initiatives and to help strengthen the available tobacco dependence treatment programs.

How did you get involved with tobacco dependence treatment? What was the driving force?

There are two main reasons which triggered me to conduct research on nicotine dependence for my doctoral program. The first reason was the experience I had in Eritrea, where I worked for nearly four years in a teaching assignment with the Ministry of Education. I witnessed nicotine dependence among the students and teachers (chewing tobacco inside the classrooms) and there was no counseling or proper guidance available to motivate to quit tobacco. The next incident was an alarming growth among teenagers on the use of tobacco in Sudan that I witnessed when I lived in Sudan for a year and there was not even a single cessation center in the country.

So, even before finishing my PhD, I had a wonderful opportunity to choose Khartoum as an outstation to do part of my doctoral project. I had to initiate the very first tobacco cessation clinic in Sudan, since I needed an active tobacco cessation center and there was none in Khartoum. With the complete support of Hospital committee (Dr. Ahmed Elsayed & Dr. Omer Elhaj), Ministry of Health and WHO, the very first cessation clinic was established at Al- Shaab Teaching Hospital, at Khartoum, Sudan.

After the completion of my PhD, I went back to Khartoum and continued to work for establishing more cessation centers and helped the Federal Ministry of Health and some private hospitals to design and implement the cessation programs of nicotine addiction.

Please tell us about your work with tobacco dependence treatment:

Cessation interventions are the weak point in the tobacco control program worldwide. Strengthening the FCTC article 14, which insists the use of low cost and reliable protocols that could increase the success rate of the cessation outcome, is my priority. Tobacco reward and withdrawal induce conditioned value to smoking-associated stimuli. There is now accumulated evidence that stimuli that signal tobacco smoking can trigger physiological, psychological and behavioral reactivity in smokers.

So, with the support of my research outcome, I initiated the inclusion of a diagnostic tool for the assessment of tobacco use and the level of reported craving of tobacco users at different situations across conditions, as a part of the intervention. As my experience is in the eastern Mediterranean region, I have included a specific craving assessment, which helps smokers to overcome the withdrawal consequences during the holy month of Ramadan. This provides a daily support to the psychologist/physician to improve the quality and the success rate of the treatment and, in perspective, for an early assessment of risk to relapse of tobacco use (cue reactivity assessment).

At the end of the assessment, the tobacco users not only realize their degree of dependence but also the specific risk situation where/which they are more prone to relapse even after a prolonged abstinence. So, this specific case history helps the tobacco user to motivate them to continue the follow up. This type of individual and intense documentation of tobacco users with accurate prediction of relapse likelihood could be an important clinical tool used to influence treatment selection or duration and thus reduce the cost of pharmacotherapy.

What is the main focus of your work?

My interest has always been a research-based approach towards public health. However, I have recently prejudiced myself to work more for a “smoke-free” environment. My area of focus is “to apply systematic and cost-free (less cost) approaches for behavioral intervention on tobacco dependence.” I achieve this result by implementing research-based diagnostic tools as a tobacco assessment protocol to increase the success rate and reduce the cost of the treatment.

Currently, I am designing project proposals on the impact of tobacco use on neonatal mortality considering high use of tobacco among women population in Jordan. The project is an equity-based approach aiming at reaching rural and disadvantaged population of Jordan villages.

I also focus on protocol design, developing questionnaires for nicotine and tobacco dependence and for cue reactivity assessment, proposal writing, work planning and organization for periodic assessment of smokers.

In my previous workstation, I have also assisted government and private hospitals to set up smoking cessation units. I have done capacity building on data collection, result analysis and interpretation of cessation programs to increase the value of treatment and motivation to quit and to reduce the cost of the treatment. I have participated and contributed significantly for the awareness program on nicotine and its dependence.

I also focus on:

  • Increase the importance of tobacco control like any other emergency health program.
  • Increase the awareness among people about nicotine, nicotine dependence, health risks of tobacco use, the importance of quitting smoking, and tobacco dependence treatment.
  • Increase the quit rate among health professionals and insist every physician motivate their patients to quit because it is important for every health worker to know not only about the cessation interventions but also the cause of tobacco dependence.
  • Include study materials of tobacco dependence and its treatment as a curriculum in every year of medical school and include a mandatory practice in smoking cessation during their training period.

Please share your experience with TDT work in Khartoum, Sudan:

The experience of my work with TDT in Khartoum was so rewarding and useful. While working toward my PhD., I set up the first cessation center in the country. I used my research-based package of assessment tools, which included a questionnaire to measure the craving to tobacco use due to tobacco-related and non-related cues, along with other measures to assess the tobacco dependence status. I attempted to figure out the role of smoking-related and non-related cues in craving tobacco even after long abstinence.

Two issues have been addressed in the study:

  • Developing a package of diagnostic tools to classify nicotine and tobacco dependence for individual tobacco smokers/ smokeless tobacco users which can be utilized for clinical tobacco cessation purposes.
  • Developing an assessment scale to predict the risk environment of tobacco smoke/smokeless tobacco for clinical use at tobacco cessation centers.

I conducted the assessment during the Ramadan fasting period, which is considered to be very critical for the tobacco users. With the help of my collaborator in the hospital, I visited the entire inpatient ward, visitor’s area, and outpatient ward to reach the tobacco users, and create awareness of and encourage visits to the new cessation clinic.

Two main findings were obtained: All the tobacco users crave and relapse from quitting when they see other people smoke or chew tobacco. They crave more than the highest Likert scale (Likert scale 4, based on peer-reviewed publications) immediately after ending the fasting during Ramadan month. When asked, in spite of their willingness to quit during the holy month, the subjects showed helplessness and the lack of motivation to quit.

After my PhD, I went back to Khartoum to continue what I had initiated during my previous visit as a research student. I worked as a consultant for Federal Ministry of Health, Khartoum, Sudan, to strengthen the tobacco control program in the country. I volunteered in the planning and policy-making with the Federal and State Ministry of Health with the technical support of WHO, for i) strengthening the available cessation program and initiate new tobacco cessation centers in Khartoum (FCTC article 14) ii) documentation of action plans for national level tobacco control program in accordance with FTCT article 12, 13 & 14 for the proposal to set up additional cessation centers in hospitals, universities, primary health centers in Khartoum by the committee (State and Federal Ministry of Health and WHO, Sudan).

Further, I was doing capacity building for the members of the cessation clinics through orientation and training on assessment, data collection, report writing for referral intervention for further treatment (FCTC article 12). Orientations were given to the health workers, which included the importance of using the package of diagnostic tools in the cessation intervention.

My intention was to help the Ministry of Health reduce the use of nicotine replacements or use only psychological counseling because of very limited or no funding available to provide free pharmacotherapy.

Apart from assisting the Ministry of Health, I was instrumental in the inclusion of assessment of the status of tobacco use and cue reactivity as one of the parameters in the health check up camps, which was successfully carried out in one of the free medical camps organized by Dr. Ahmed Elsayed, Senior heart Surgeon and Professor at Alzaeim Alazhari Medical University, Khartoum and made a great impact on the awareness on health risk due to tobacco use.

What are some of the challenges you have faced in your work?

The main challenge I faced was to bring female tobacco users to the cessation clinic. The relatively lower percentage of women smokers in comparison with men attributed to social and cultural disapproval of women who smoke. This cultural barrier – women do not want to be identified as smokers — also prevented them from accessing appropriate cessation services and centers. Another challenge I faced was with nicotine replacement therapy. In low-and-middle-income countries, the cost of NRT is more expensive than the cost of cigarettes.

Another major challenge is to work without any funding. I have volunteered a majority of my time during and after my Ph.D. working with NGOs, universities, government and private hospitals. Funding has been major barrier in carrying out professional work at larger scale.

What are some success stories as a result of your work?

The main success in my experience is the initiation of first tobacco cessation clinic at Al-Shaab teaching hospital, Khartoum, presently directed by Dr. Omer Elhaj.

The development of assessment tools to find out the specific risk situation in every tobacco user served as a self -help for the tobacco user to learn about their dependence and it further motivated them to quit tobacco use.

Increasing the awareness of motivation to quit through World Heart Day was very successful as more than 100 tobacco users indicated a willingness to quit immediately after completing the cue reactivity questionnaire I developed.

Within two years of completing my PhD., I have been nominated two times for Jarvik-Russel Early Career Investigator Award from SRNT (for 2015 and 2016).

I am an active member in SRNT board and reviewer of abstracts for the SRNT conference. I am also an active member of International Union Against Tuberculosis and Lung Diseases.

What do you ultimately hope to accomplish?

My ultimate hope is to improve the standards of cessation intervention, which is the weaker part of tobacco-free initiatives worldwide. So, in accordance with FCTC article 14, I focus on developing minimum standards for setting up and operating cessation centers so TDT would be cost effective and easily and readily accessible to the needy in low-and-middle-income countries.

I also try to advocate the inclusion of Nicotine/Tobacco Risk Education in school and university curriculums in developing countries where awareness of nicotine addiction is not reachable to the most vulnerable through digital media.

I continue to volunteer to contribute my experience to create a smoke-free environment and give the future world a healthy breath. Wherever I go, my passion is to ultimately include the innovations in the routine to improve the community health.