1. Lekan Ayo-Yusuf, DDS, MPH, PhD Integrating Quitlines with tobacco control policy and Health Care System: Perspectives from resource-poor settings 09/14/2011

2. Presentation organized into three sections: Opportunities for expanding quitlines in the LMICs in general and in Africa in particular A case for integrating quitlines with health systems in LMICs. Quitlines as central source of tobacco policy information & treatment services in South Africa – successes and challenges.

3. Discovery (telephone counselling works Delivery (need to deliver the service efficiently)

4. Opportunities for expanding QL in LMICs In Africa, male smoking 17.7% and female 2.8% There are only 2.3 physicians & 10.9 nurses per 10 000 population Whilst access to health services remains a problem for poor households, overall attendance at health clinics for rural populations has improved substantially in recent years, as a result of the use of mobile clinics. Research also show that in typical rural districts of Africa, up to 80% of households make regular use of mobile phones (McKemey et al. 2003; DFID. http://www.telafrica.org/telafrica/index.html).

5. Key Global Telecom Indicators for the World Telecommunication Service Sector in 2010 (all figures are estimates) GlobalHICSLMICsAfrica Arab States Asia & Pacific Europe The Americas Mobile cellular subscriptions (millions) 5,2821,4363,8463332822,649741880 Per 100 people76.2%116.1%67.6%41.4%79.4%67.8%120.0%94.1% Fixed telephone lines (millions) ( 1,1975066911333549249262 Per 100 people17.3%40.9%12.1%1.6%9.4%14.0%40.3%28.1% Source: International Telecommunication Union (October 2010)International Telecommunication Union http://mobithinking.com/mobile-marketing-tools/latest-mobile-stats#subscribers via: mobiThinkingmobiThinking

6. Mobile phone network and health Project Masiluleke takes advantage of the 120 spare characters on free please call me SMS messages to provide HIV/AIDS education and awareness in South Africa and resulted in tripling of call volume to HIV/AIDS helpline. TB patients in Thailand/Phillipines/SA were given mobile phones so that healthcare workers could call these patients on a daily basis to remind them to take their medication (SIMpill). Medicine compliance rates reached 90% due to the introduction of this remote monitoring application. SMS can be used as client-initiated or provider-initiated referral from health facilities to quitlines instead of faxes that are rare. mHealth for Development: The Opportunity of Mobile Technology for Healthcare

7. Why integrate QL with existing Healthcare System infrastructure in LMICs? Conditions under which quitline work best prevails in LMICs; –Tobacco users are likely not to have been lectured to death thus are more likely to be voluntary participants of offer to help. –Quitlines are likely primary intervention for tobacco users in LMICs. –Expanding quitlines are now likely to be seen as important public health intervention in LMICs, considering the recent high-level commitment to the control of NCDs in LMICs while addressing the epidemic of TB

8. Effect of smoking on tuberculosis incidence in WHO regions highlights the need to promote cessation. Basu S et al. BMJ 2011;343:bmj.d5506 ©2011 by British Medical Journal Publishing Group

9. Why integrate QL with existing Healthcare System infrastructure in LMICs? Contd….. Barriers (31 Lusaka HCP): 75% and 85% felt lack of time and not knowing where to refer In LMICs, clinical interventions may be limited by –Healthcare providers own smoking –Low numbers of healthcare providers –Overcrowded clinics and competing priorities –Limited number of people trained in tobacco use treatment –Policy environment not supportive of treatment demand These highlight the need for QL to be resource for treatment information for providers and policy support, while offering treatment services.

10. Number of Quitters = Number of Quit Attempts X % successful Price Smoke-free policies* Clinician advice* Counseling** Medications* Counter Marketing/H.warnings

11. SA as case study – successes & challenges Smoking in SA was historically the highest, but SA is now globally recognized regional leader in tobacco control Growing tobacco consumption in 18 Sub-Saharan African countries Source: ERC statistics

12. 13.9% Black 18.1% TOTAL (29% M: 9% F) 36.1% Coloured* 30.8% White 21.9% Indian/Asian * Mixed race. Smoking declined from 35% in 1995 to the current levels Prevalence of Adult smoking, by race/ethnicity – SA 2010

13. TELEPHONE QUITLINEs Delivering counseling by phone in SA Launched in 1995 with the first tobacco control legislation. Accessible (85% Households own a cell phone) Not toll-free (does it matter with m-lines?) Funded by government and number is on all smoked product packages. Limited health insurance funding, but accessed by employers.

14. When a Client Calls the QUITLINE Counselor or Intake Staff Answers –Caller is routed to language-appropriate staff (staff generally multi-lingual). –Answering service after hours (After 5pm and weekends) with call back follow-up. Brief Questionnaire –Contact and demographic information –Smoking behavior (e.g., cigarettes per day) –Choice of services SA Quitlines have broad reach (~14,000 calls per annum OR ~0.28% reach Vs. median for Canadian quitlines=0.27%; US=1.18%)

15. Services provided: - Reports on contraventions appropriately referred -Information on TC policy & medications provided (to tobacco users, proxy callers or health professionals) -Treatment offered (reactive i.e. client-initiated) –Quitting literature mailed within days (also on web) –Individualized telephone counseling trained counselors (could be contacted on mobile in some instances for additional support) When a Client Calls the QUITLINE (contd) Many SA healthcare providers are not familiar with tobacco quitlines and free medications are not offered.

16. CharacteristicsOdds Ratio 95% Confidence Interval Advised by HCP No1.0 Yes2.561.45-4.51 Employment Employed1.0 Unemployed2.211.17-4.18 Housewife/Pensioner/St udents 0.920.49-1.69 Health status Not hypertensive1.0 Hypertensive0.380.15-0.93 Use of quit lines Never heard of quit lines 1.0 No phone/Too expensive to phone 2.460.66-9.15 Not interested0.750.41-1.36 Called/attempted to call9.942.40-41.08 Smoking not allowed at home No1.0 Yes1.671.24-2.25 Health-risk knowledge1.081.02-1.14 Factors associated with making a quit attempt in the past year among South African smokers in 2010 HCP advise is associated with quit attempts, but only 23% Smokers ever advised

17. National survey of 641 smokers during 2010 All smokers (n=20) that reported calling quitline were all urban residents. Significantly more likely to be under 35yrs. Have made at least one quit attempt. Financially stressed (monthly income < minimum household needed to get-by). Characteristics of quitline callers in SA 29.5% SA smokers have not heard about QL.

18. In sum SA National quitline serve as a central resource for tobacco-use treatment services and information that can reach the wider population (one-stop service). There is only limited cessation services offered within the health system (Is QL a disincentive for roll-out of services?). The development of national guidelines for treatment that links QL is imperative

19. Thank You