Reducing tobacco use among low socio-economic status youth in Delhi, India: outcomes from project ACTIVITY, a cluster randomized trial

Abstract

To test the efficacy of an intervention to reduce tobacco use among youth (10-19 years old) in slum communities in Delhi, India. This community-based cluster-randomized trial included 14 slums composed of purposely built resettlement colonies and adjacent inhabitant-built Jhuggi Jhopris. Youth in the intervention received a 2 year multiple-component intervention: (a) youth and adult leader training; (b) peer-led interactive activities and outreach; (c) tobacco cessation camps; and (d) enforcement of India's Tobacco Control Law (smoke-free environments and youth access). Overall, no differences between the intervention and control conditions were observed over time; self-reported tobacco use declined in both groups. However, when stratified by type of residence, a significant decrease was observed among youth in the resettlement colonies in the intervention group for overall tobacco use (slope = -0.69) and cigarette and bidi smoking (slope = -0.66), compared to an increase in the control group (slope = 0.24 and 0.12, respectively) (P < 0.001). No differences in smokeless tobacco (SLT) use were observed for either group. Comprehensive community-based interventions that engage youth can be effective in reducing smoking among disadvantaged youth in India. More intensive interventions, like tax increases or large-scale media campaigns, appear warranted for the most marginalized in this context and for SLT products.

Fig. 1.

Conceptual model for Project ACTIVITY’s intervention strategies. The 2 year intervention embraced comprehensive community-based, low-cost, multiple strategies to promote awareness and skills around prevention and cessation of tobacco use among youth [8]. ACTIVITY adapts research evidence from developed countries that reveals that program and policy-based interventions can be successful in reducing the prevalence of tobacco use among youth [14].The intervention model was based on social cognitive theory [17], the researchers’ prior experience with comprehensive tobacco control interventions in India [11, 15, 18, 21], existing literature on tobacco control among youth globally, and qualitative research conducted at the beginning of the study that identified important cultural and contextual factors relevant to the program design and implementation [10]. Intervention strategies were employed to influence intra-personal and socio-environmental risk factors that were identified in our formative research as critical to reducing the prevalence of tobacco use.

Fig. 2.

Flow diagram for clusters and participants.