Integration of Medical Colleges under National Tobacco Control Program—A Public Health Priority

Dear Editor, India is a country with a huge burden of tobacco in terms of its 267 million users, ~3,500 resultant deaths daily (~13 lac every year), and the high economic costs attributable to tobacco (1,04,300 crores in 2011).[1] The country not only ratified the WHO FCTC promptly but it has also equipped the governance at the national and state levels to control tobacco through (1) The Cigarettes and Other Tobacco Products Act of 2003 (COTPA) and (2) the National Program for Tobacco Control (NTCP). The NTCP was established in 2007-08 during the 11th five-year plan to strengthen tobacco control (TC) for effective control of tobacco. One of its priority aims was to "help people quit tobacco."[2] In the 12th five-year plan, the NTCP, with its revised objectives, aimed to reduce tobacco use below 5% by the end of its term.[1] India has over 700 medical colleges (MCs).[2] While these have moved from the teaching of community health through the departments of "Preventive and Social Medicine" to "Community Medicine" and now in some AIIMS to "School of Public Health," the empowerment necessary for the medical students to translate their theoretical knowledge of national health programs into their implementation by working at the primary healthcare level is missing.[3,4] Similar is the situation in the context of implementing NTCP at the district—as well as state—levels. To substantiate this aspect, a prospective qualitative study was undertaken in Rajasthan by a Jaipur-based NGO, Rajasthan Cancer Foundation (RCF). Fifteen out of 19 currently functional government MCs were visited between mid-March and mid-May this year (the year 2023; Figure 1) under the directive of the Medical Education Department (ME), Government of Rajasthan to the Offices of the Principals and Controllers of these MCs [Annexure 1].Figure 1: Mapping of the chronology of the travels (~4,500 km) undertaken between mid-March and mid-May 2023Through the facilitation with the assigned Nodal Officers for each of these 15 medical [Annexure 2], a pre-fixed 4-point agenda that was approved by the ME department beforehand was followed uniformly by the visiting faculty (himself a subject expert and a mentor in TC in the state and nationally) with the principal, pre-assigned heads of the departments and medical students present in an interactive manner: Establishing a tobacco-free college campus and a self-sustainable stand-alone TCC in MC hospital. Empowering MCs to collaborate and support the District TC Committees (DTCCs). Sensitize the Medical students and the faculty on some vital issues related to tobacco. Send a press note through the District PRO for community sensitization on the activity held and the need for strengthening TC in the district locally. At the end of sensitization session, the participating medical students (usually a batch of ~ 100-150 students from sixth to eighth semesters, but sometimes the numbers went up to ~ 300 students, and in some colleges, the students addressed were from second to fourth semesters) were asked within 5 minutes to respond briefly to following four-point questionnaire: Did you already know about TC? Y/N; 1(b) How? New learning from today's session Mention one step that you can take now Propose one step your MCs can undertake now. A qualitative assessment of their responses collectively gave the following observations: Just about 30% of students are aware of the tobacco epidemic and TC activities. Less than 20% know about the adverse effects of tobacco, and still a lesser percentage about the benefits of quitting. All participating students and faculty welcomed and desired to make their college premises tobacco-free. Engagement of the community medicine department as the nodal department appeared appropriate and feasible. There was concurrence to either establish tobacco cessation clinics and/or strengthen the existing ones for all tobacco-using patients and other tobacco users attending these hospitals on a sustainable basis. Based on these outcomes, it was suggested to the ME department that: All these MCs should work to be tobacco-free through an in-house policy through a concurrence and a work plan to be executed within a timeline varying between 6 months and 1 year. The work plan should broadly focus on (1) Sensitization of the entire staff and all students to assist these not only achieve but sustain their tobacco-free status as well and (2) Quitting should be mandated by all their health workers, staffs, and students enrolled at least 2 months before the end of the timeline. All MCs should have stand-alone TCC established in the next 3 months for establishing its working through a Systems Approach—Screen, Treat, and Follow-up. The staff assigned to run the TCCs can be trained online. Holding at least three follow-up training-cum-review sessions can be considered useful for improving the quality of the cessation service. The Principals and Controllers of all MCs should be designated to serve as the Vice-Chair of the Local DTCC hereafter. The Secretary (Chief Medical Health Officer—CM and HO) of the local DTCC shall coordinate with both the Chairman (the District Collector) and the Vice Chairman to hold DTCCs regularly and strengthen all the activities assigned to the DTCCs under NTCP. The Head of the Community Medicine department should be the Nodal Person for the respective MC to stay connected and assist the local DTCC through the infrastructure and the trained human resources available with the MC. Additionally, he should also serve as a guide, facilitator, master trainer, and researcher to measure the compliance of COTPA enforcement and provide outcome-based analyses to strengthen, modify, and/or innovate the ways to work in TC toward its Endgame. The integration of MCs under NTCP requires priority and simultaneous consideration of both (1) the Ministry of Health and Family Welfare and (2) the M and H and ME departments in the State of Rajasthan. It is hoped that the office of the MD, NHM, will manage it subsuming it in the Flexi-pool for NCDs.[1] Also, it will give the nation a huge boost to reduce the burden of tobacco that, besides preventing a huge economic loss (1773.4 billion INR; 27.5 billion USD),[5] will also help to significantly decrease ~ 13 lac (1.3 million) premature deaths that occur every year. To conclude, the case study undertaken in Rajasthan to integrate MCs under NTCP to further strengthen TC appears timely for its national consideration and replication in other states and/or UTs countrywide. Besides, it has benefits to be able to (a) utilize the human resources and the infrastructure of the MCs at no additional cost and (b) sustain the TC activities at the level of the districts in a professional manner and as per the needs of public health management. That it will help India to be healthier and more productive with the elimination of the premature loss of lives due to avoidable suffering and deaths caused by tobacco needs no emphasis. Financial support and sponsorship Cancer Relief and Research Society, Udaipur (CRRSU), Rajasthan Cancer Foundation, Jaipur (RCF) and Shikshit Rojgar Kendra Prabandhak Samiti, Jhunjhunu (SRKPS). Conflicts of interest There are no conflicts of interest.