Project Summary: Background: India has 267 million users of smoked and smokeless tobacco, making cessation efforts critical for addressing tobacco-related cancers and diseases. An important opportunity comes from brief advice interventions to promote tobacco cessation. These interventions can be delivered in a few minutes by practitioners and typically include screening for tobacco use, brief counseling, and referral to services. However, these programs do not meet the needs of the Indian context at this time as they: a) typically come from high-resource, Western settings, b) emphasize the use of pharmacotherapy, and c) require highly credentialed staff. We focus here on task-shifting, or using less credentialed workers who are more readily available than highly credentialed professionals. We will support them through training and technology-based ongoing supports (using an “app” and a social media channel). Goal: We will adapt and evaluate the impact of a brief advice intervention for tobacco cessation to be delivered in dental clinics, tuberculosis clinics, and non-governmental primary health centers. This proposal leverages investigators' expertise with implementation science and behavioral interventions focused on cancer prevention and control; the Mumbai-based team's expertise in training practitioners to use brief advice programs; and the technology partner's expertise in developing apps to support health workers implement programs. Methods: This hybrid effectiveness-implementation study will test the impact of an adapted brief advice intervention on tobacco cessation outcomes and will also collect pilot data regarding implementation factors. Accordingly, the study draws on a tobacco cessation framework (5 A's) and an implementation science framework (the Exploration, Preparation, Implementation, and Sustainment framework). The study is organized around three aims. Aim 1 will include formative research to support adaptation of existing brief advice interventions. Aim 2 supports a randomized controlled trial to assess effectiveness of the adapted intervention and gather pilot implementation data. Aim 3 addresses the opportunity to engage trained practitioners in an ongoing manner through technology-based supports, with an emphasis on linking such engagement to program delivery. Innovations and impact: This study is innovative in that it focuses on scaleability at every step – from task shifting to selecting practitioners outside the primary healthcare system, to using technology to support practitioners. These features allow for a simple, scaleable brief advice intervention that can be used widely in low-resource settings in Mumbai as well as other low- and middle-income countries, which is key for impact. Findings from the study will support scalable tobacco cessation in India and will build the literature on adapting research evidence from high-income countries to lower- and middle-income countries.

Project Narrative This project is highly relevant to public health because it addresses the need for a resource- appropriate, scaleable tobacco cessation intervention for low-resource settings. There is limited knowledge about how best to translate effective interventions from high-resource settings to low-resource settings and how to use technology to support the ongoing training of busy practitioners. Upon completion, our study will deliver practice-focused strategies that can be adapted to other health issues and other low-resource settings.