Quitline Activity in Rajasthan , India

Rajasthan is the Western State in Indiathe largest area-wise with a population over 70 million (2013). It has an urban-rural ratio of 1:3 and male-female ratio of 1:928. The tobacco control in the State follows the norms set by FCTC and, in turn, by the Ministry of Health and Family Welfare, Government of India, New Delhi through the Cigarette and Other Tobacco Products Act, 2003 (COTPA)3. All notified rules of COTPA: Section 4 (Prohibition on smoking in Publicand Workplaces and Public Transport); Section 5 (Ban on Direct and Indirect Advertisement, Promotion and Sponsorship); Section 6 (6aBan on sale of tobacco products to and By the Minors; and 6bBan on sale of Tobacco products within 100 yards of the perimeter of any educational institution); and, Section 7 (Depiction of specified health warnings

[including Pictorial warnings] on tobacco products packages) have been notified at the State-level too.
But, their enforcement needs further strengthening in all 33 districts of the State that have a district coordinating committee for tobacco control besides a State-level Coordinating Committee at the capital city, Jaipur.The State has highest tax countrywide (65%), uniformly on all retail tobacco products.Besides prohibition on sale of Gutka since 2012, this year the State has banned sale of loose cigarettes and has ordered closure of tobacco selling shops on the last day of every month.
The State has been awarded twice in succession (to the Medical & Health Department in 2013 for tobacco control measures; and, to the Finance Department in 2014 for highest taxation on retail products countrywide) by the WHO through the Director General's award for a State Government in SEARO Region.Besides, it is the recipient of the same award in the Individual category too in 2013 (for Dr. Rakesh Gupta, a former surgical oncologist, now working full-time in tobacco control for over 14 years with models of Smoke-free District City, Tobacco-free Workplaces and Tobacco Treatment Protocol to his credit).

The demographics reported by Global Adult Tobacco Survey in October 2010 for the State of Rajasthan 4 :
-About 32% of its adult population uses tobacco in any form; -About 50% males and ~13% females use tobacco with current tobacco smoking by 18.8% adults (malefemale ratio of 5.7:1) and current use of SLT by 18.9% adults (male-female ration of 3.37:1).
-Almost 67% need to consume tobacco within half an hour of waking up.
-The average age at daily initiation of tobacco use is 17.3 years with 17.7 years in males and 14.1 years in females.
-The exposure to second-hand smoke is higher at home vs. public places-~74% vs. ~40% respectively.
-Surrogate advertisement, sponsorships and promotions are a significant concern.These focus more on SLT (~60%) vs. smoked ones (between ~30%-40%).On the other hand, over 90% adults believe on harmful effects of tobacco, second-hand smoke and SLT.
Tobacco cessation is in its infancy through only a very few apex medical institutions in its capital city; and, in the 2 districts running the National Tobacco Control Program (NTCP) through a counselor in each of these.Overall ~50% to ~60% current tobacco users desire to quit-more in smokers' category vs. those using SLT.The health professionals advise smokers more (~40%) vs. users of SLT (~30%).

Introduction of Quitline
Quitline (Figure 1) is a part of the 104 Health Information Helpline in Public Private Partnership of PS with Medical & Health Department, Government of Rajasthan, Jaipur-PEHAL (Pehal is a word in Hindi language that means "the Initiative").
Telephonic Tobacco Cessation in the State of Rajasthan was kicked off in January 2013 following a state governance proclamation to make the State Tobaccofree; and, persuasions as its follow-up by a quitline resource based in the city-(the first author who has been volunteering for PEHAL since then.
The quitline service runs all seven days, from 7am to 9 pm while its Health Helpline that runs round the clock, all seven days of a week registers all those who call in the interim to quit for a call by the quitline staff the next morning.
It is a reactive service.On their very first call to the service and prior to the counseling in the same sitting in the majority, the intake session (to note for their demographics and willingness to quit) is carried by a Health Advisory Officer (HAO)-a qualified paramedic (nurse) serving the service for other medical ailments.
The call is then transferred to any of the 3 counselors (Figure 2) trained specifically through education, training, monitoring and evaluations by the first author through weekly/ fortnightly sessions.The counselors (Figure 3) are supported duly by the paramedics trained only for the follow-ups.Their bench strength is being increased to both current and anticipated increase the frequency of follow-ups of the callers.
PEHAL now has scripts for the Single Session and Follow-ups.The data is currently being captured on the excel sheet after concluding the calls.To meet with its increasing needs and challenges of inadvertent omissions, although it has been decided to integrate the scripts in the software, its cost is the barrier currently.
The policy proposes follow-up to the Single Session delivery after a week, 1 month, 3 months, 6 months and  .2016.17.S2.19 Quitline Activity in Rajasthan, India at 1 year to record for successful quit, failure to quit and relapse.As part of follow-up policy, those who do not respond or have phones switched off are called twice again after 2 hours; and, the next day again around the same time.If there is no response even then, the caller will have to make a call for resumption of the service; but, they are kept on roaster for follow-up after 6 months and after 1 year respectively.

Cessation service overview 2
In the year 2013, the service had 1525 clients calling solely to quit tobacco.The tobacco users calling for alcohol or any other de-addiction assistance (#26), categorized ineligibles, have been excluded in this report.
Largest numbers of callers, in order of frequency, were  from the districts of Alwar, Banswara, Jaipur, Jalore and Jodhpur (http://www.mapsofindia.com/maps/rajasthan/districts/).The majority of the callers were in 2 nd and 3 rd decade of their life (82.44%;Table 1).The users of the SLT were 2.97 times more than the smokers: The loss to follow-up was observed in 1001/ 1525 (65.64%) was due to change in their phone nos., switched off phones, caller non-availability despite several calls and/or someone else responding for him/her.
A success rate of ~58.01%(304/524) among responders at the follow-up after 18 months is highly significant for the State of Rajasthan that otherwise has a quit rate of 11% for former ever daily smokers and 8.2% for former ever users of SLT.If the quit rate for all callers is considered (19.94%; 304/1525), the success is over 11 times higher than the current quit rate of 1.7% for former daily smokers and 1.6% former daily users of SLT.
The web and mailing services are currently unavailable.The current government in the State is yet to decide on the free availability of Nicotine Gum and Bupropion (in sustained release form), a decision that was anticipated a year ago in line with the policy of the previous government to provide free medicines to all.No self-help material is available presently.

Call system i) Call system
The calls lend on server.It goes for the free extension to forward the call to the first level where details of caller are being captured by a HAO; and, if the caller desires to quit, the call is forwarded to one of the counselors.
PEHAL consists of internet protocol private branch exchange (IP-PBX), CTI middle ware, interactive voice response (IVR) and recording server with following  -The function of CTI middleware: Order and data exchange between telephone exchange and Computer, Data analysis, Call processing/Divide and manage work process in Center, Integrate Management Solution for control and analysis all CTI call center system.
-The function of IP PBX recording server: -Support all recording and optional recording type -Support making list of recording files, play, sending and delete function -Support searching by File name, agent number, custom call number, date, etc.
-Monitoring for real time check recording server status -Recording statistics and log management function  doi.org/10.7314/APJCP.2016.17.S2.19 Quitline Activity in Rajasthan, India counselors.The 5 HAOs, initially trained for the conduct of follow-ups, are being used for the primary counseling as well, whenever the numbers of calls increase or to give them more experience.

Activities for Quitline Promotion
Quitline promotion (Figure 7) until September 2014 was done rather scantily through the print media only; and, only in some parts of the State.The Information, Education and Communication (IEC) activities have recently been given a stronger push by its State Director.
The awareness of Quitline has been on increase steadily following collaboration by PS with RCF to communicate to the masses its 104 Toll Free service through both print and electronic media through a press conference held on World No Tobacco Day 2014, (Figure 8): Between September to November 2014, RCF collaborated with the State TV channel (Doordarshan Rajasthan, Jaipur; Figure 9) for a 10 episode series on "Society and Tobacco" under its regular social program-Samajik Sarokar (A Social Concern).It worked with 2 objectives: i) To initiate the desired change in the societal norm that tobacco use is a disease and a tobacco user is a patient; and, ii) To promote the use of toll-free State Medical Helpline "104" by the callers statewide to quit tobacco.
Their impact was evident through an increase in calls post-telecasts but these missed on sustainability (Figure 10).
The videos have been posted on Face book page of RCF (https://www.facebook.com/rajasthancancerfoundation?ref=hl)5 and YouTube6 (https://www.google.co.in/ #safe=active&q=Youtube+dr.+rakesh+gupta+society+an d+tobacco) for a wider use at no cost by the organizations and masses inhabiting the Hindi-speaking belt of Northern and Western India: In 2015, RCF has also begun working with the City Radio with the aims stated above to motivate people quit through toll-free service-104.

Future Development
The service aims to: -Bring improvement in the delivery overall; and, for higher quality; -Advocate with the Medical and Health Department of the State Government to improve its utility by enhancing its IEC; -Get funded to upscale the existing service and replicate it in 5 more states where PS collaborates with the respective State Governments (Assam, Chattisgarh, Jharkhand, and Karnataka); and, -Advocate with the Ministry of Health, Government of India, to allocate quitline-specific budget to enable these states to integration and sustain quitline in their Health Information Helpline.

Introduction of Research and it's Outcome Related Quitline Activities
It wishes to undertake research into following areas: -Supportive factors and barriers for quit; -Achievement of Quitline: number of calls and quit rate; -Relapse pattern by day after first quit attempt; -Reasons of relapse; -Factors associated with relapse; and -Satisfaction on Quitline service.

Facing Challenge
The Major challenges have been: -Availability of specific fund allocation to upscale its activities and work for its replication in other 4 states of India to be able to provide an evidence of its feasibility and outcomes; and, -Optimal support and coordination with the State health system for increasing its awareness and IEC.

Figure 4 .
Figure 4. Snapshot of the Counselors Worksheet

Figure 9 .Figure 6 .
Figure 9.The Statewide mass Awareness through TV Serial-Society & Tobacco; a Session in Progress ii) Staffs and training Staff: Following is the staff strength overall to serve and backup for the counselors as necessary, But in a limited manner currently: -Doctors (MBBS): 8 -Health Advisory Officers (HAOs-all qualified nurses): 60 -Counselors (MSW/ MA Psychology/Nurses): 8 Trainings: After their initial training by a retired senior physician in early 2013, the counselors are being trained by the first author since April 2013.Besides creating the scripts for the Single Session and the Follow-ups, he is engaged in the evaluation of the quality of the service through the regular interactions with the supervisorsthe other two authors of this report; and, also through the direct interaction with counselors during their weekly training sessions through their group interactions for monitoring of the calls and continuing education.In the year 2014 due to staff attrition or alteration in the placement, the service has an entirely new team of 3 DOI:http://dx.

Table 2 )
:-The function of IP-PBX: call transfer, pulling call, return call, call forward, hold call, call back, group general directory number.