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ORIGINAL ARTICLE
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“Once a smoker, always a smoker: Primary care physicians” views on integrating smoking cessation with antitubercular treatment in primary health centers – A qualitative study


1 Department of Public Health, K S Hegde Medical Academy, Nitte (Deemed to be University), Mangaluru, India
2 Department of Community Medicine, A J Institute of Medical Sciences and Research Centre, Mangaluru, India
3 Department of Community Medicine, K S Hegde Medical Academy, Nitte (Deemed to be University), Mangaluru, India
4 Department of Pulmonology, K S Hegde Medical Academy, Nitte (Deemed to be University), Mangaluru, India
5 Department of Biostatistics, K S Hegde Medical Academy, Nitte (Deemed to be University), Mangaluru, India

Date of Submission08-Mar-2022
Date of Decision11-May-2022
Date of Acceptance14-May-2022
Date of Web Publication05-Sep-2022

Correspondence Address:
Sanjeev B Badiger,
Department of Community Medicine, A J Institute of Medical Sciences and Research Centre, Kuntikana, Mangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmhhb.jmhhb_60_22

  Abstract 


Although smoking and tuberculosis (TB) pose a health threat in low- and middle-income countries, they are less recognized as public health problems. Lack of awareness among smokers about smoking cessation services and health-care professionals not viewing apparently – healthy smokers as the candidates for smoking cessation treatment are some of the significant barriers. This qualitative study explores the opinions and views of primary care physicians (PCPs) on integrating smoking cessation programs with the ongoing antitubercular treatment in primary health-care settings of India. The study employs a deductive qualitative design using a purposive sampling method to recruit physicians to implement the Directly Observed Treatment Short Course for TB patients in primary health-care settings. A semi-structured, open-ended questionnaire was developed based on the Consolidated Framework for Implementation Research to conduct in-depth interviews of eight PCPs. Although smoking cessation intervention is noticeable in the primary health centers, lack of uniformity in service deliverables, nonusage of nicotine replacement therapy, shortage of human resources, and meager readiness of the patients to quit smoking are a few encounters. PCPs advocate early identification of smokers, delegation of responsibilities to grassroots level health-care workers, and collaboration with the nongovernmental organizations and private sector.

Keywords: Health personnel, pulmonary, qualitative research, tobacco use cessation, tuberculosis



How to cite this URL:
Purushothama J, Badiger SB, Kumar N, Baikunje N, D'Souza N, Olickal JJ, Dmello MK. “Once a smoker, always a smoker: Primary care physicians” views on integrating smoking cessation with antitubercular treatment in primary health centers – A qualitative study. J Mental Health Hum Behav [Epub ahead of print] [cited 2022 Oct 1]. Available from: https://www.jmhhb.org/preprintarticle.asp?id=355595




  Introduction Top


In low- and middle-income countries, tobacco use and tuberculosis (TB) pose a public health threat.[1] Tobacco use in India has a high prevalence of 28.6% among adults, and mortality is estimated at 1.3 million annually.[2] The incidence of TB burden in India was 2.69 million cases in 2019, which was the highest globally.[3] However, the relationship between smoking and pulmonary TB does not recognize them as public health problems.[4] This disheartening evidence highlights the need for counseling and pharmacological treatment for TB patients to quit smoking.[5] This qualitative study explored the opinions and views of primary care physicians (PCPs) on integrating smoking cessation with antitubercular treatment in low-resource primary health-care settings in India. The study adopted the qualitative method to analyze the views and opinions of PCPs about smoking cessation and its leeway of integration with antitubercular treatment. It was likewise appropriate to develop a novel conceptual framework for integrating these two services.


  Methods Top


Study design

The study employs a deductive qualitative design.

Study sampling, study setting, and participants

A purposive sampling strategy recruited experienced PCPs implementing Directly Observed Treatment Short Course (DOTS) for TB patients in the eight primary health centers (PHCs) of Dakshina Kannada district Karnataka State of Southern India. The PCPs represented rural and urban practices and personal characteristics (both the genders and diverse age groups).[6] Initially, the sample size was six participants, but later was extended to eight until data saturation was evident. The study was conducted between January and February 2022.

Study variables, data collection, and investigator expertise

Participants' knowledge about the association of smoking with TB, their opinion on the magnitude of the problem, clinical experiences, challenges faced, and suggestions to improve the existing system were some of the variables. A semi-structured, open-ended in-depth interview (IDI) guide was based on the Consolidated Framework for Implementation Research (CFIR) constructs which were used to conduct a qualitative study on health workers' and TB patients' views on implementation of smoking cessation in routine TB care (IDI guide included as a supplementary file).[7] This method develops evidence-based practices from design to evaluation. The CFIR comprises 39 constructs divided into five domains (Intervention characteristics, outer setting, inner setting, characteristics of individuals, and process of implementation).[8] A few codes were contextually added to the framework (doctors' clinical experience, patient condition due to smoking, and doctors' beliefs). In-depth interviews (IDIs) were executed in the English language. Each audio-recorded interview lasted 20–30 min, and verbatim transcription was done. One of the two interviewers (JP) who conducted the interviews has 4 years of experience conducting IDIs and focus group discussions related to tobacco control programs. Another interviewer (JJO) has conducted more than five qualitative research studies with three articles published in reputed journals. The two interviewers (JP and JJO) underwent training by the corresponding author (SB), who has qualitative research experience in HIV/AIDS programs with four publications and is also a reviewer of qualitative studies in leading journals.

Data analysis

Transcripts were imported into QDA Miner Lite software and coded according to the CFIR constructs using the deductive content analysis method. The quotes were identified to suit the appropriate codes. Two researchers performed the coding separately to agree. In case of disagreement, opinion was taken from the third researcher. Based on the codes under each theme, the CFIR framework on smoking cessation for TB patients and the joint TB-tobacco collaborative framework were developed.

Informed consent and confidentiality

The participants received information about the research, and written informed consent was obtained. The interview data were kept confidential. Anonymity was secured by coding the interviews, and any information that disclosed the participant's identity was excluded from the transcripts.

Ethical approval

This study is a part of a randomized controlled trial conducted to determine the effectiveness of nicotine replacement therapy for smoking cessation in TB patients. Ethical clearance was obtained from the Institutional Ethics Committee.


  Results Top


Eight PCPs (coded as P1, P2,… up to P8) participated in the interview, among whom six were men. All the participants were aged between 30 and 40 years, except one above 50 years. Two participants worked in urban areas, while six worked in rural areas. One participant worked in the district hospital's DOTS center, and the others worked in PHCs. The results comprise the participants' quotes coded according to their respective themes in the CFIR framework.

Intervention characteristics

Strengths and advantages

National TB Elimination Program (NTEP) has an effective TB treatment regimen and also collaborates with the tobacco cessation center (TCC) to register TB smokers for the cessation program. Patient-counselor meetings every month at the PHC assured patient cooperation with the doctor for smoking cessation. The doctors found it easy to trace the local patients during home visits to ensure regular follow-up.

“The noncommunicable disease (NCD) cell, TB center, and TCCs are now working as a team. Any patient coming to the DOTS center will be sent to the NCD cell and tobacco cessation center. Any patient coming to the tobacco cessation centerwill be referred to DOTS and NCD. So, everything will be screened.” (P2: 31 years, male, 5-year experience).

“In the first interaction, or when they (patients) come after a week or 10 days for a follow-up after starting antitubercular therapy, that willingness or enthusiasm to be in (smoking) abstinence is there. So, the cooperation from the patient side is there.”(P6: 37 years, male, 8-year experience).

Quality and success

Doctors ensured that smoker TB patients would be referred to the tobacco cessation center to get counseling. Health education was provided at the sub-center about the ill effects of tobacco, such as cancer and TB.

“Usually, we do programs in educating them (patients) in the sub-center level. We make sure that we talk about other diseases like cancer and TB. With this, TB elimination would be even more effective.”(P5: 30 years, female, 5-year experience).

Complexities and challenges

Migrant patients were added to the complex treatment structure and followed up as they could not be traced due to false contact details provided to the doctors. Self-reporting or the family's information about the patient's smoking history was invariably incorrect.

“The problem in our district is that we have many migrants. They will not be very comfortable with our treatment and counseling. So, they will continue their bad habits and substance abuse, which will be a burden for our district.” (P2: 31 years, male, 5 years' experience).

The feedback mechanism between the DOTS and tobacco cessation centers was weak because treatment outcomes were not discussed between the two offices. Apart from this, the shortage of human resources was a challenging situation.

“They (TCC) do not give feedback to us because we only treat TB at the DOTS center. At the hospital, the DOTS center will always be busy because all the patients will be referred here.”(P8: 35 years, male, 5-year experience).

Physicians' clinical experiences

Patients restarted smoking after they recovered from TB cough symptoms due to DOTS. However, cough due to smoking was not addressed, and posttubercular complications arose due to smoking.

“Because the DOTS system has been very well planned and built for many years now, any smoker would be identified and advised to stop smoking. But usually what happens, because of effective antitubercular therapy, all TB-related symptoms start subsiding within 2, 3, or 4 weeks. So, the patient feels energetic as before. That is the time when they (patients) tend to think that any way they have become alright and they risk (smoke) again.”(P6: 37 years, male, 8-year experience).

Outer setting

External influences, patient needs, and peer pressure

Smoker TB patients surround external influences such as population characteristics, culture, personal needs, and peer pressure, which amplify the urge to smoke. Smoking and high disease burden were the norms among friends, parents, and relatives with a male predominance.

Addiction and patient condition due to smoking

Due to high dependence, patients find extreme difficulty quitting smoking. Excessive cough, severe TB symptoms, and unhealthy lungs were common among TB smokers.

“They (female patients) told me that they were smokers from childhood. Fathers would ask them to go and light bidis from the firewood. So, when they come back, they try to smoke and just have that puff to see how it tastes. So that is how they ended up smoking and continue even today. Now they cannot stop it.”(P4: 54 years, female, 23-year experience).

“Once a smoker, always a smoker. It is easy to tell that you have to quit. Unless there is fear in him that something will happen to him, most of them don't quit even when taking the treatment.” (P3: 38 years, male, 9-year experience).

“You rarely see smokers quit smoking as soon as they (patients) are diagnosed with TB. We try, we counsel, but most of them don't quit. They continue to smoke.”(P3: 38 years, male, 9-year experience).

“They will be having some cough which they tend to ignore because they think that its normal for a smoker to cough, and their friends and colleagues also have a cough. So, it will not be a big issue for them.” (P6: 37 years, male, 8-year experience).

Inner setting

Team culture and leadership

Coordination between TB and tobacco programs is pleasing due to the government's political commitment since the Revised National TB Control Program became NTEP.

“Maybe if budget restrictions are not there, there is a good method to assess whether a person is smoking or not objectively. It is called a carbon monoxide monitor. The cost is not huge, but if there is the political commitment from the government side or policymakers, that makes good use of, which will positively reinforce the patient.” (P6: 37 years, male, 8-year experience).

Priority and goal setting

Due to the pandemic in 2019, the focus shifted toward treating COVID patients. As a result, other programs, including NTEP, have been affected. This gap can be minimized by strategically identifying all the smokers during active case finding.

“Alcohol and smoking are very much related to TB. Both tobacco and alcohol should go hand in hand to affect the elimination program, which is going to be in 2025 at least. If we do our best, at least 80% of the burden can be reduced. This goal is our dream.” (P4: 54 years, female, 23-year experience).

Feedback and implementation climate

Interventions were delayed due to a delayed influx of patients to the clinic as they were unaware of TB symptoms. Hence, there is a need for effective health education programs at the grassroots level. Counseling sessions, recording smoking history, house-to-house visits, etc., are some of the routine activities done at the PHC level.

“It's a mistake on our part also. We start talking about the ill effects of smoking only when the patient comes with the ill effects. Till then, we are not telling anybody. Even in schools, we have not seen anybody talking about tobacco. Nobody talks in detail. Only one or two lines will be there.” (P3: 38 years, male, 9-year experience).

“Screening from the smokers' end mostly may not be happening as it's a mammoth task because the smoking rate is quite high. When the screening is happening from the TB end, a suspected case of TB having cough for a predefined duration, we frequently come across a smoking population.” (P7: 36 years, male, 6-year experience).

Characteristics of individuals

Patient attributes

Most TB patients are destitute or belong to a lower socioeconomic status which predisposes them to TB. Smoking rates are higher in this population when compared to the upper classes.

“Nine out of 10 TB patients come to us are from low socioeconomic status. We have many needy patients who have TB and are smoking. Even the deaths happening to TB are mostly in the low socioeconomic status. Nobody is well to do. At the same time, food is also one of the reasons. Many of them are from the poverty level. So, food intake, everything will be affected.” (P1: 34 years, male, 8-year experience).

Patient knowledge and self-efficacy

Patients have poor knowledge about the ill effects of smoking. As a result, their treatment compliance is poor, which might lead to unfavorable treatment outcomes.

“Some people don't come because they say that they don't have TB. Some say that 'I don't smoke, or I smoke occasionally, so I don't need to go (to the tobacco cessation center).' Some say that 'I will smoke, I don't want any counseling, I am not ready to stop.'”(P2: 31 years, male, 4-year experience).

Doctors' beliefs

Doctors believe that patients follow their advice based on the severity of the disease. Hence, they instill a fear of disease complications among the patients.

“I feel it depends on the severity of the disease. If it is very severe and patients suffer too much. They will listen to what the doctor says. If it is mild, at that period, they may follow our advice and later they might relapse.” (P5: 30 years, female, 5 years' experience).

Process of implementation

The derivative of the four themes (intervention characteristics, outer setting, inner setting, and characteristic of individuals) is the implementation process [Figure 1].
Figure 1: CFIR framework for smoking cessation interventions for TB patients. TB: Tuberculosis, CFIR: Consolidated framework for implementation research, PHC: Primary health centers, OPD: Outpatient department, NGO: Nongovernmental organization, CHC: Community health centre, ASHA: Accredited social health activist, ANM: Auxiliary nurse maid

Click here to view


Planning

Strengthening the identification process and subsequent referral of smokers from the community level to the tobacco cessation centers shall improve the service utilization. Providing nicotine replacement therapy as the first line of treatment for TB patients improves the cessation rates.

“I think identifying smokers is not always after the patient is diagnosed with TB. We should identify a smoker before they are diagnosed with TB. We have to identify patients, counsel, and rehabilitate them at that stage so they should not end up with TB or COPD (chronic obstructive pulmonary disease).”(P5: 30 years, female, 5 years' experience).

Executing and reflecting

Only a few centers provide counseling with NRT. This service should be rationalized across all the centers. Since smoking cessation needs continuous behavioral support, frequent patient–doctor interactions can boost the patients' morale and help them quit smoking.

“We are only involved in the NCD, DOTS, and tobacco cessation. If all outpatient departments are ready to refer patients to TCC to give counseling, that will be good. I think integration is needed. We need separate human resources. We have the pressure to look after other programs. We have to engage separate staff for that. If the patient follows properly, it would be good. I think one person has to be there at the Taluka level. I don't think each PHC needs one person. One person is more than enough for 2–3 PHCs.”(P5: 30 years, female, 5 years' experience).

Stakeholders (identified by the primary care physicians)

According to the PCPs, stakeholders for this program, such as patients, health-care providers, nongovernmental organization (NGOs), and other health agencies, can support this initiative at the community level. The public–private mix is a successful model for effective TB elimination. This model should be extended to smoking cessation services.

“It is difficult to identify the smokers only at the government level. When the private and public sectors join hands together, 80%–90% (can't say 100% due to lack of access in remote areas and hilly areas) of them can be identified and make them TB free by doing the survey. In private and government, PPM means public–private mix will help in a small way.”(P7: 36 years, male, 6 years' experience).

“When NGOs, private, or health agencies join hands with us, it will be highly beneficial. We are ready to help in all possible ways. We need cooperation from the people, or organizations, or NGOs, as we get some strength and it will motivate us. Without their cooperation, it is complicated to work.”(P8: 35 years, male, 5 years' experience).

Influencers

ASHA workers and ANMs are the key players at the grassroots level in implementing all the health programs. They can be delegated to identify smokers and refer them to the PHCs for a comprehensive smoking cessation program.

“Unless we start identifying TB or do something about tobacco control at the village level, this problem will not get solved. Why is the death happening? Because there is a delay in the diagnosis. If there is an early diagnosis, we should be able to save the patients. But ASHAs and ANMs, at the same time, are burdened with so many other things. They say that they cannot concentrate on these small things like smoking. We need someone who devotes their time to this because we have 2025 planning anyway to eliminate TB. At least now we have to take up that.”(P4: 54 years, female, 23 years' experience).


  Discussion Top


This study intended to collate the views and suggestions of PCPs to integrate smoking cessation with the TB elimination program at the primary care level. The PCPs provided essential counseling support to their smoker TB patients to enable smoking cessation. The patients initially cooperated with the doctors by acknowledging their willingness to quit smoking but did not sustain them eventually. Motivational interviewing for TB patients to quit smoking showed higher quit rates supposedly due to the novel exposure of the patients to this intervention.[8] Most of the participants (except one) did not talk about NRT as an intervention as they did not practice it. This practice gap should address proximately to improve the cessation service network at PHCs. Health-care providers can powerfully influence patients' interests, conditions, and cultures, to help them quit smoking. Although all the dental and medical interns were familiar with NRT, 100% of the dental and 98% of the medical interns were unaware that NRT must be used for smoking cessation. The fundamentals of NRT should educate health-care professionals through workshops or by continuing education programs.[9] In our study, PCPs expressed that the patients mistook reduced cough symptoms due to anti-TB treatment as complete recovery, and hence, they relapsed into smoking. Two weeks of anti-TB treatment significantly reduce cough frequency.[10]

Our study reveals the peer pressure, high level of dependence among smokers, and doctors' perception of the capability of smokers to quit. The outer setting of this framework is similar to the core concept of a socioecological model for smoking behavior. This framework has multiple levels of influence, such as intrapersonal (biological and personal history), interpersonal (peers, intimate partners, and family), organizational (workplace), and policy (pricing and restrictions) factors.[11] Because of the low rates of quitting smoking, governments need to encourage smokers to quit by providing more assistance.[12] There is a need for health education about the ill effects of smoking at schools. A tobacco-free village project in Maharashtra trained its teachers to conduct classroom sessions on the harmful effects of smoking, and students learned how to refuse if an adult asked them to buy tobacco.[13] Poverty, smoking, and TB have had an association since time immemorial. Male gender, ethnicity, lower level of education, and poverty were associated with conjoint alcohol and tobacco use among TB patients.[14]

Based on the current scenario, PCPs suggest early identification of smokers before they develop TB disease. Integration of smoking cessation with TB program by utilizing dedicated human resources at community health centers and upward, partnering with NGOs, the private sector, and engaging grassroots-level health-care workers can provide a 360° implementation approach for smoking cessation of TB patients. The authors have developed a joint TB-collaborative tobacco model for smoking cessation among TB patients based on the doctors' views [Figure 2]. Further research is needed to corroborate this study's understanding of the patient's perspectives on smoking cessation.
Figure 2: Joint TB tobacco framework for smoking cessation of TB patients. TB: Tuberculosis, PHC: Primary health centers, DOTS: Directly observed treatment short course, ASHA: Accredited social health activist, NRT: Nicotine replacement therapy

Click here to view


Limitations of the study

The participants did not code two of the CFIR model constructs (trialability and cost). As it is a qualitative study, generalizability is limited to the study setting and population. The study used only IDIs for the data analysis, and hence, methodological triangulation was not possible.


  Conclusion Top


Although smoking cessation is noticeable in the PHCs, lack of integration and uniformity in service deliverables, nonusage of NRT, shortage of human resources, and most importantly, meager readiness of the patients to quit smoking are a few encounters. PCPs advocate early identification of smokers, the delegation of responsibilities to grassroots-level health-care workers, and collaboration with NGOs and the private sector for efficient service delivery.

Acknowledgment

The authors acknowledge the District Health and Family Welfare Society, Dakshina Kannada District, Government of Karnataka, for the administrative support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Supplementary file

In-depth interview guide

In-depth interview guide

  1. Do you think tobacco smoking is a problem among tuberculosis patients in your PHC area? (Probe: what is the magnitude of the problem in your work area?)
  2. According to you, if tobacco smokers develop TB disease, do you think TB disease will aggravate? (Probes: how does smoking aggravate TB disease; what will be the level of severity among these patients; what will be the prognosis of the antitubercular treatment for smokers)
  3. What is the sociodemographic profile of TB smokers in your work area?
  4. Are there any schemes or programs for TB patients to identify their smoking status and provide cessation services? (Probe: Are there any specific guidelines for the programs)
  5. What are the measures taken to help TB patients quit smoking? (Probe: in your clinic, how has been the clinical experience with your patients about smoking cessation)
  6. What are the good practices and challenges in providing smoking cessation to TB patients? (Probes: are the patients' readiness to quit smoking satisfactory; how easy or difficult is it for patients to quit smoking with only brief advice)
  7. Have you observed any limitations or disadvantages in the existing system? (Probes: do you think implementing this program as it is effective or does it require any change; is there any false reporting of the patients about their smoking status)
  8. Do you have separate human resources for this program, or do you practice this service by yourself? (Probe: is there a need for separate human resources at primary health center level)
  9. How do you think the two services can be integrated successfully at the primary care level? (Probes: are there any leadership concerns in the existing system, what goals can you set for the program in future; do you think patients will be able to comply to the new guidelines if introduced)
  10. What kind of cooperation are you getting from the TB patients to quit smoking?
  11. What are your suggestions to improve the rate of smoking cessation among the TB patients?
  12. What may be the role of grassroot level healthcare workers in smoking cessation? (Probes: how helpful have the grassroot level healthcare workers been in this program; is there anybody else at grassroot level who can support this initiative)
  13. Can you suggest a flow chart to integrate TB elimination and tobacco cessation program starting from identifying the smokers till they quit smoking?
  14. Is there anything else you would like to say?


Thank you for your cooperation



 
  References Top

1.
Marshall AM, Barua D, Mitchell A, Keding A, Huque R, Khan A, et al. Smoking prevalence among tuberculosis patients: A crosssectional study in Bangladesh and Pakistan. Tob Induc Dis 2020;18:70.  Back to cited text no. 1
    
2.
Ministry of Health & Family Welfare Government of India. Global Adult Tobacco Survey 2016-2017; 2017.Available from: https://mohfw. gov.in/sites/default/files/GlobaltobacoJune2018.pdf. [Last accessed on 2022 Feb 21].  Back to cited text no. 2
    
3.
Central TB Division – Directorate General of Health Services. India Tb Report National Tuberculosis; 2020.p. 292.  Back to cited text no. 3
    
4.
van Zyl Smit RN, Pai M, Yew WW, Leung CC, Zumla A, et al, Global lung health: The colliding epidemics of tuberculosis, tobacco smoking, HIV and COPD. Eur Respir J 2010;35:27-33. doi: 10.1183/09031936.00072909. PMID: 20044459; PMCID: PMC5454527.  Back to cited text no. 4
    
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Mahishale V, Patil B, Lolly M, Eti A, Khan S. Prevalence of smoking and its impact on treatment outcomes in newly diagnosed pulmonary tuberculosis patients: A hospital-based prospective study. Chonnam Med J 2015;51:86-90.  Back to cited text no. 5
    
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Panaitescu C, Moffat MA, Williams S, Pinnock H, Boros M, Oana CS, et al. Barriers to the provision of smoking cessation assistance: A qualitative study among Romanian family physicians. NPJ Prim Care Respir Med 2014;24:14022.  Back to cited text no. 6
    
7.
Safaeinili N, Brown-Johnson C, Shaw JG, Mahoney M, Winget M. CFIR simplified: Pragmatic application of and adaptations to the Consolidated Framework for Implementation Research (CFIR) for evaluation of a patient-centered care transformation within a learning health system. Learn Health Syst 2020;4:e10201.  Back to cited text no. 7
    
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Louwagie GM, Okuyemi KS, Ayo-Yusuf OA. Efficacy of brief motivational interviewing on smoking cessation at tuberculosis clinics in Tshwane, South Africa: A randomized controlled trial. Addiction 2014;109:1942-52.  Back to cited text no. 8
    
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Gaidhankar S, Sowmya NK, Preeti KB, Mehta DS. Knowledge, attitude, and implementation of nicotine replacement therapy by dental and medical interns in Davangere city: A cross-sectional survey. Indian Soc Periodontol 2020;24:567-71.  Back to cited text no. 9
    
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Proaño A, Bravard MA, López JW, Lee GO, Bui D, Datta S, et al. Dynamics of cough frequency in adults undergoing treatment for pulmonary tuberculosis. Clin Infect Dis 2017;64:1174-81.  Back to cited text no. 10
    
11.
Brown JM, Anderson Goodell EM, Williams J, Bray RM. Socioecological risk and protective factors for smoking among active duty U.S. military personnel. Mil Med 2018;183:e231-9.  Back to cited text no. 11
    
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Abdullah AS, Husten CG. Promotion of smoking cessation in developing countries: A framework for urgent public health interventions. Thorax 2004;59:623-30.  Back to cited text no. 12
    
13.
Chatterjee N, Patil D, Kadam R, Fernandes G. The tobacco-free village program: Helping rural areas implement and achieve goals of tobacco control policies in India. Glob Health Sci Pract 2017;5:476-85.  Back to cited text no. 13
    
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Peltzer K. Conjoint alcohol and tobacco use among tuberculosis patients in public primary healthcare in South Africa. S Afr J Psychiatry 2014;20:21-6.  Back to cited text no. 14
    


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