This was a cohort study assessing a field based intervention.
Settings
The burden of TB remains enormous in Indonesia. In 2012, there were an estimated 460,000 (185 per 100,000) incident cases of TB and 67,000 patients died from this disease. A total of 328,824 new and relapse TB cases were notified in 2012 [8]. Tobacco use is the leading cause of disease and premature death in Indonesia. WHO estimates that smoking kills 235,000 Indonesians annually and secondhand smoke takes another 25,000 lives. Smoking is largely unregulated and 61.4 million (36.1 %) of adults currently use tobacco. Smoking prevalence has increased among males to 67.4 % in 2011 from 53.4 % in 1995 [9]. The intervention was piloted in Bogor city, which had a population of 800,000 in 2012 [10], a smoke-free policy that was established in 2010 and 25 government health centres providing primary health services.
Study population
Of the 25 health centres that provided DOTS services, 17 satisfied the criteria for piloting the intervention: 1) providing a written commitment to join the intervention, 2) having attended the initial training on smoking cessation and smoke-free environments in 2010, and 3) having registered at least 5 new sputum smear-positive TB cases in 2010. All consecutive new sputum smear-positive TB patients (aged ≥15 years old) diagnosed and registered in the 17 health centres between 1 January 2011 and 31 December 2012 were enrolled in the intervention. They were recruited within 7 days of commencement of anti-TB treatment.
Establishing 100 % tobacco-free health care facilities
We obtained written commitment from the Director of the City Health Office and the Head of each participating health centre to create tobacco-free services. Tobacco-free was defined as the absence of tobacco advertisement, promotion and sponsorship, the absence of any indoor or outdoor active smoking in the health facility, and the display of “No smoking” signage at the main entrance of the facility and removal of smoking-related accessories and items, such as ashtrays, smoking areas and cigarette butts. A total of 80 health facilities (including 17 DOTS health centres) participated in the tobacco-free initiative. An ABC orientation programme was conducted for all health staff at the health centres. Compliance of the 80 health facilities with their tobacco-free health care policy was assessed twice a year by the City Health Office and No Tobacco Community (civil society based in Bogor) using a standard checklist (Fig. 1). Assessment was usually conducted during the busiest hours.
Establishing ABC smoking cessation intervention
A = Ask about smoking behaviour of TB patients via a face-to-face interview was conducted by health staff at each visit. At zero month of anti-TB treatment, they were asked: i) Do you smoke? ii) Have you smoked at all-even a puff-in the last three months? iii) Does anyone smoke inside your home? At all follow-up visits they were asked: i) Have you smoked at all-even a puff-in the last two weeks? ii) Does anyone smoke inside your home?
B = Brief advice which included personalised and general information was offered immediately at the DOTS clinic by the health staff at each visit. For smokers, personalised information consisted of 1) quitting smoking now you can recover properly from TB, and 2) as soon as you quit, your coughing and sputum will decrease. General advice for smokers and non-smokers included 1) smoking and secondhand smoke is very harmful for your and your family’s health; it causes diseases such as cancer, heart disease, chronic obstructive pulmonary disease, asthma, childhood pneumonia, and 2) to improve your and your family’s health, please quit smoking (for smokers) and do not allow anyone to smoke inside the home.
C = Cessation support was provided along with brief advice at each visit. Patients were advised to i) tell family, friends, and colleagues that they are quitting; ii) remove smoking accessories from home and workplaces; and iii) make their home smokefree and avoid secondhand smoke, and they were given health education leaflets, pamphlets and “No smoking” signage to display at home.
Creating smokefree environments at home
Exposure to secondhand smoke was assessed and monitored as described above under ABC sections. TB patients were asked at zero month and at all follow up visits whether anyone was allowed to smoke inside the home, and whether “No smoking” signage was displayed at the main entrance of their home. Information obtained from the patient was verified with a family member that had accompanied the patient to the health centre. A telephone call was made to the patients’ closest family member to confirm that the home environment was smokefree if the patient had attended the health centre unaccompanied by family members.
Monitoring and evaluation
A standard smoking cessation intervention card and register were adapted from The Union Guide 2010 (7). Information included in the smoking cessation intervention card were: age, sex, time from waking to first cigarette, as well as elements related to the intervention, such as frequency of ABC offered, smoking status, whether anyone smokes inside the home, confirmation of quit status by a family member and display of no smoking signs at home. The information was recorded from baseline to month six. ABC was offered for 5 to 10 minutes within the usual DOTS services. Information was updated on a monthly basis when patients were given ABC. Information related to TB diagnosis and treatment was obtained from the TB register, which is available at each health centres. Information from the smoking cessation intervention card was transferred to the register on a quarterly basis. Staff from the health centres also made random visits to some patients’ homes to see whether they had created smokefree environments at home. A standard checklist (Fig. 1) was used to monitor the tobacco-free status of the health care facilities. Quitting status and exposure to SHS were assessed by patients self-reporting during the period of anti-TB treatment and validated at month 6 through interviews (face-to-face or by telephone) with the family member that was closest to the patient. Telephone numbers were recorded in the smoking cessation intervention card and also available on the patient’s TB treatment card.
Definitions and outcome measures
Current smoker was defined as 1) a patient at enrolment who has smoked in the last 3 months, even a puff, and 2) a patient at follow-up visit who has smoked in the last two weeks, even a puff, and has not made any attempt to quit (for at least 24 hours) since the last visit.
Ex-smoker was defined as a patient at enrolment who used to smoke but has not smoked in the last 3 months, not even a puff.
Never smoker was defined as a patient who has never smoked, not even a puff.
Smokefree was defined as zero evidence of smoking: absence of active smoking, the display of “no smoking” signage, and absence of smoking areas/rooms, ashtrays, cigarette butts and the smell of tobacco smoke.
Tobacco-free was defined as zero evidence of smoking and the absence of tobacco advertising, promotion, sponsorship and sales.
Quitter was defined as a smoker at baseline who has not smoked at all, even a puff, in the last 2 weeks at the follow-up visit(s).
Relapsed smoker was defined as a smoker at baseline who has tried to quit during the ABC intervention but has relapsed (has smoked in the last two weeks before the current visit but has made at least one quit attempt lasting at least 24 hours since the last visit).
Lost to follow-up was defined as a patient who did not attend the follow-up visit and whose status was unknown.
Died was defined as a patient who has died of any cause during anti-TB treatment.