Annie Liu Conducts a Project on Smoking Cessation in Delhi, India
According to a study published in BMC Med, smokeless tobacco is a major public health threat and in India, it is attributed to 75 percent of the global burden of disease. Annie Liu, a second-year M.P.H./M.A.I.A. candidate, spent one year in communities within Delhi, India and worked with the Public Health Foundation of India throughout the process. She conducted research on the social perceptions of smokeless tobacco and areca nut cessation.
“I chose tobacco because I wanted to work in a public health problem that was significant in India. Among all the different health problems, tobacco is one of the central ones. Smokeless tobacco, in specific, is a bigger killer than smoked tobacco,” Liu said.
Her research project was supported by the Center for the Advanced Study of India at the University of Pennsylvania, where she completed her undergraduate education. She was a recipient of the post-baccalaureate research fellowship that is typically awarded to alumni of the school.
“My project focused on the social meanings tied with using and quitting smokeless tobacco among women living in urban areas in Delhi. We went into communities in Delhi and wanted to get new perspectives,” Liu said. “We first did seven interviews just with people who use tobacco, then with people who were a part of non-governmental organizations, and leaders in the community. We interviewed vendors of smokeless tobacco as well.”
She also studied areca nut, as it is often used in combination with smokeless tobacco, as well as without. It is considered to be a health concern because it can be addictive, can cause immune and endocrine system disruption, as well as an increased risk for developing cancers and cardiovascular issues. It can also exacerbate type II diabetes.
While areca nut products can lead to many physiological effects, the products without tobacco are still perceived as harmless and beneficial to health.
Studies have also shown that smokeless tobacco cessation varies by geography, gender, age, and social status. Liu focused on women because studies have shown that they are less likely to think about quitting than male users are. They are also a lower proportion of them who attempt to quit when compared to males. Additionally, women have eight times higher relative risk for oral cancer and two to four times higher relative risk for cardiovascular disease.
Previous research on smokeless tobacco has been in communities within Mumbai in the South of India. Since every area is different, Liu also wanted to think about the specific local context when thinking about interventions. Within Delhi, there are multiple communities. While she was not able to visit all of them, she did make specific observations from the communities that she did visit.
In Delhi, smoking cessation interventions and treatment services are less available, according to Liu. While there is a national program that has a few centers, they can oftentimes be several hours away.
“People are working around their schedules and are tied with their work obligations. A lot of times, women especially, have to tend to their children, families and home life. So, it's very hard to visit these centers, especially if you have small children,” Liu said.
Before conducting the interviews, she and the team would go into the community to recruit participants, explain the research project, as well as share the date and time of the interview.
“We would all end up sitting on the ground in a circle. There were times when there were power cuts, but we were also surprisingly able to find offices with air conditioning. While we were interviewing women, they had their young children and babies with them. We had to be understanding towards that because otherwise, they wouldn’t have been able to attend,” Liu said.
Liu’s goal was to understand the quitting behavior of women, as well as the associated social meanings tied to cessation to develop gender-specific interventions to support increased cessation in the population. Currently, she is analyzing the qualitative data gathered from the interviews to publish preliminary results in October 2019.
Eventually, she hopes to publish a study based on the results, which will answer questions on whether women's cessation behavior is seen and talked about, such as when they quit, attempt to quit, and intend to quit. It will also include details on how cessation is understood among women who use smokeless tobacco or areca nut and the people in their lives, as well as the role that social pressures and other factors play in cessation behavior, and in the continued consumption of the products.
Written by Amanda Torres
Published on October 2, 2019
