Can mHealth and AI amp up tobacco cessation efforts?
If we compare the GATS 1 (Global Adult Tobacco Survey) with the GATS 2, all parameters related to tobacco cessation show a downward trend. While the sustained efforts by the government through implementation of national programs such as NTCP, COTPA, and NOHP; ratification of strategic frameworks such as WHO's MPOWER or FCTC; or multilateral collaboration with global health organisations, NGOs, and other stakeholders, the efforts fall short in responding to the tobacco scourge prevalent in the country.
28.6 % of the people aged 15 and above use tobacco in India, the use of smokeless forms being double that of smoked forms. This can be attributed to the social acceptability of smokeless tobacco (SLT), especially among women in old times. Tobacco continues to hold cultural value in local traditions, where it is offered to guests and gods with equal reverence.
The second largest consumer—and third largest producer—of tobacco, India is home to 72.7 million smokers. It is responsible for 13.5 lakh deaths, 1.5 lakh cancers, 4.2 million heart diseases, and 3.7 million lung diseases every year. With a 20 % share of the global burden load, India is touted as the oral cancer capital of the world.
Also Read | From tea stalls to tumours, tobacco affordability fuelling cancer epidemic in India
Secondhand smoking (SHS), caused by the inhalation of toxic fumes when somebody is smoking in the vicinity, compounds the problem further. It contributes to 14% of total tobacco deaths, with the brunt falling squarely on the most vulnerable—women, children, and older people. Almost half of the non-smoking women and over one-third of pregnant women are exposed to tobacco smoke in India and Bangladesh.
According to GATS 2, despite 85.6% of people being aware of the detrimental effects of SHS, 38.7% of people working at home and 30.2% working indoors were exposed to smoking. A 2023 report by WHO on global tobacco epidemic believes that physical distancing—whether it be designated smoke rooms (DSRs) or ventilation—fails to protect from the exposure of SHS.
The smoke residues from 7000 chemicals, including over 70 carcinogenic substances, cling to physical surfaces long after a cigarette is stubbed out. Through case studies of popular smoke ban laws in Atlanta and Finland, WHO FCTC's Section 8 advocates for strict legislation for a smoke-free environment to protect our basic right to breathe in clean air.
Also Read | Two decades after India's public smoking ban, challenges persist in tobacco control
Dependency on tobacco
Multiple studies have shown that dependence on tobacco and bidis significantly impairs individuals' ability to quit. The wide availability of locally-produced tobacco brands in India further complicates regulation of nicotine content. Moreover, Big Tobacco is frequently accused of deliberately maintaining high nicotine levels to promote addiction.
Furthermore, the tobacco industry lobbying has actively obscured critical information and deflected public discourse from the health risks linked to tobacco use. This has resulted in manufacturing of narratives, such as conflating the harms of tobacco smoking with air pollution. What harm will one cigarette cause when the level of pollution amounts to breathing 20 cigarettes a day!? (While air pollution demands urgent action, the harm caused by cigarette smoke is 2 to 2.5 times greater, according to a Chinese study.) In the 1996 issue of Time Magazine, the president and CEO of Philip Morris was quoted saying that cigarettes are no more addictive than coffee or gummy bears.
This impact on teenagers by Big Tobacco propaganda is concerning. 8.5% of young adolescents (between 13 and 15 years) consume tobacco in some form in India. With stylish names, flashy packaging, fancy brand ambassadors, and fun flavours, the tobacco industry preys on the young to initiate tobacco use as well as continue it. A WHO report highlighted the addition of sweetening agents, flavorings, bronchodilators, and additives such as levulinic acid and menthol to tobacco products—measures intended to reduce the harshness of nicotine and create a cooling effect in the throat. These modifications in taste, smell, and sensory appeal, experts believe, hype the demand of these products among the youth.
Kicking the habit
The GATS 2 survey revealed that out of the total people who wanted to quit, 70% had to do it alone, and most couldn't sustain it beyond a month. We must also realize that cessation is not a one-off thing but a continuum—the counselling must always be ongoing and adaptive. Pranav Ish, a pulmonologist at VMMC and Safdarjung Hospitals said even 2-3 minutes of reinforcement has worked wonders in his patients. GATS 2, however, reveals a dismal picture when it comes to the attitude of healthcare providers: only 31.7% of healthcare providers advised their patients to quit in the last month, and 48.8% in the last year.
Aninda Debnath, assistant professor, Community Medicine, MAMC, Delhi, says that while a lot of programs related to tobacco cessation are in place, a critical look at their functioning and utilisation is important. The COTPA Act prohibits advertising of tobacco in any form; however, a study by Vital Strategies found 75 % of online surrogate marketing of tobacco on Meta platforms.
Vikrant Mohanty, HoD and Project Head, National Resource Centre for Oral Health and Tobacco Cessation, MAIDS, Delhi, said: 'While the government is doing its bit through cessation services at primary level, dedicated counsellors in NCD clinics, dentist training under NOHP, a comprehensive approach with integration of stakeholders at various levels is the need of the hour. The dropout from follow-up still remains huge, and faith in the treatment low.'
Also Read | Smokeless tobacco products contribute to over 50% of oral cancer cases in India, study finds
AI to the rescue
Traditional forms of counseling are, for one, not equitable—the social desirability bias kicks in when hospitals expect the patient to come back. Plus, affordability and accessibility to TCCs is an issue for most who come from lower to lower-middle classes and work in informal sectors or as daily wage workers. Researchers have found that the results of tobacco cessation have stagnated, or at times gone down, for people with social disadvantage. While mCessation in the form of encouraging text messages or telephonic counselling through NTQLS has been an innovative solution (as part of WHO's Be He@lthy, Be mobile), limited success has been observed. Some of the gaps in successful implementation of mHealth include voice recognition inaccuracies, network connectivity issues, poor digital literacy, shoddy interface, absence of personal connection, poor long-term engagement, and high attrition rates. Integrating mHealth with innovative solutions such as PSD (Persuasive Systems Design) or just-in-time-adaptive-intervention (JITAI) that deliver an intervention in moments of elevated need or receptivity has shown great promise.
This is where AI can give us a leg up. Mohanty adds that large language models can bridge the gap of delivery, provide personalized healthcare systematically, capture data, and use them in improving the outcomes.'
AI can be harnessed not only through chatbots but also indirectly to train healthcare professionals so they can assess, advise and follow-up with the patients rigorously. Dr. Debanath emphasised the importance of refresher training—a component often neglected—which can be made significantly more accessible and efficient with the help of AI.'
Monika Arora, Vice President of Research and Health Promotion at PHFI, believes, 'Chatbots and virtual assistants powered by AI can provide round-the-clock support, track and monitor tobacco use behavior, offer evidence-based information, and deliver personalized motivational messages. AI can also utilize predictive analytics to identify individuals at higher risk of relapse and tailor interventions accordingly.'
However, this can't happen in isolation. All the interviewees believed that AI should not be thought of as an alternative but as an adjunct to traditional strategies. Dr. Arora and others are working on an AI-based model under Project CARE, where the focus is on 'co-development with users and healthcare providers' who can come up with innovative and contextually relevant solutions.
Also Read | The tobacco epidemic in India
Digital literacy challenge
However, all is not rosy with mHealth and AI. While mobile penetration in the country is good, the lack of digital literacy might act as a massive deterrent. Debnath shared a personal anecdote: 'My mother has a smartphone, but she uses it only for calling and WhatsApp.' Moreover, in this age of digital revolution, when we are always bombarded with text messages and the ubiquitous 'ting' of notifications, the impact of one more message needs to be looked at with a fair bit of skepticism.
These newer innovations should be complemented with other time-tested strategies. Plain packaging, which was initiated by Australia for the first time in 2012—and was followed by a wave of countries—should be considered as the next step to challenge the growing empire of tobacco corporations. Stronger warnings, higher taxes, increasing the size of graphic warnings, banning e-cigarettes, and hiring brand ambassadors cam aid our efforts.
Emerging approaches such as adaptive counseling, designed to provide stepped care that addresses patients' unmet needs and parallels chronic disease management, can also be considered. Dr. Ish added: 'It feels rewarding that a patient who could earlier smoke three cigarettes had to contend with only one due to high costs.'
India has garnered international attention for its tobacco cessation program, but the sheer burden of tobacco warrants that we not only explore newer strategies while also ensuring rigorous implementation of the existing ones.
(Kinshuk Gupta is a writer, journalist, and public health physician. His debut book is Yeh Dil Hai Ki Chor Darwaja. kinshuksameer@gmail.com)
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