Project Summary: Tobacco-related deaths are rising rapidly in low and middle-income countries (LMICs). In India alone, tobacco use accounts for over 1.2 million deaths each year. Reducing these deaths will require large-scale implementation of evidence-based interventions (EBIs) that promote tobacco use cessation. However, given the limited reach and logistical challenges of conducting in-person training to implement tobacco-control EBIs, new models are needed that can be implemented more broadly, flexibly and at low cost. Until such robust tobacco-control EBIs are implemented and scaled, tobacco-related mortality will continue to rise. Our long-term goal is to identify effective, low-resource strategies to promote broad-based implementation of tobacco-control EBIs in LMICs. This study builds on an intervention for schoolteachers, called the Tobacco Free Teachers, Tobacco Free Society (TFT-TFS) program, shown to be efficacious in increasing tobacco use cessation in a cluster-randomized trial. Teachers in India are an important channel for promoting tobacco control, given their roles as community leaders and role models. A critical next step in this research, which is our objective here, is to compare the implementation and effectiveness of the TFT-TFS program when delivered through in-person training verses a smartphone-based training model. Use of smartphones in educational settings is already pervasive in India offering a readily available, low-cost strategy for expanding training on the TFT-TFS program. By delivering TFT-TFS training through smartphones, the potential reach of the program can be multiplied over what can be achieved with in-person training. We will conduct a comparative effectiveness trial using a cluster-randomized design in which headmasters of schools in the Indian state of Madhya Pradesh will be randomly assigned to receive in-person training or training via smartphone for the TFT-TFS program. Once trained, headmasters in both groups will implement the TFT-TFS program within their schools. We will compare the training arms in terms of program implementation, effectiveness, cost, and reach. This Hybrid III study will be guided by the Consolidated Framework for Implementation Research and RE-AIM Framework; we will use mixed methods to analyze factors contributing to outcomes. Accordingly, our specific aims are to: (1) develop in-person and smartphone-based training models based on systematic assessment of contextual factors in Madhya Pradesh; (2) compare program implementation fidelity, effectiveness, and cost for the two training models; and (3) identify factors affecting program implementation after in-person vs. smartphone-based training using a mixed-methods design. This project is innovative by shifting the status quo from costly, time-intensive, in-person training to a smartphone-based training model to scale up tobacco control EBIs. The proposed research is significant because it introduces a new approach for reducing tobacco use and related deaths and demonstrates how training via smartphone can be applied to scaling other public health-related EBIs in resource-constrained areas.

Project Narrative The proposed project is relevant to public health because it introduces a robust new approach of using smartphone-based training to scale up tobacco control evidence-based interventions (EBIs). By delivering training through smartphones, the potential reach of the EBIs is multiplied over what can be achieved with in- person training. It is relevant to NCI's mission of addressing tobacco control and increasing the availability of low-cost, portable technologies for cancer control in low and middle-income countries.