In the United States, the health hazards of tobacco use are well-known, and smoking cessation is widely promoted. However, in Asia, tobacco control is in its early stages and few cessation programs exist.
University of Arizona anthropologists Mark Nichter and Mimi Nichter are working to change this in India and Indonesia, two countries with some of the highest rates of tobacco use in the world.
With colleagues from centers of medical research in both countries, the Nichters were instrumental in initiating Project Quit Tobacco International in 2003, with funding from the Fogarty International Center at the National Institutes of Health.
They began with ethnographic research on tobacco use as a basis for developing culturally appropriate tobacco cessation activities in India and Indonesia, two countries where smoking is deeply embedded as cultural practice.
"We recognized as anthropologists that we could not simply take cessation programs developed in the U.S. and introduce them off-the-shelf in other countries," said Mimi Nichter, professor of anthropology, public health and family studies and human development.
Instead, the Nichters and their colleagues approached the issue of tobacco use from an anthropological perspective, concerned first with understanding the role of smoking in both cultures.
"We began by looking at smoking as a consumption event and the role of smoking in everyday life, recognizing that asking people to quit means more than just giving up nicotine," said Mark Nichter, Regents' Professor of Anthropology and professor of public health and family and community medicine.
"Smoking is a form of pleasure, a source of self-medication, and a shared experience that enables social interaction," he said. "Asking people to quit in the name of health in countries where people only associate smoking with lung cancer, and not scores of other health problems like TB, diabetes and heart problems, and where there is little appreciation for the harm of secondhand smoke was going to be challenging."
Project Quit Tobacco International focuses on three key areas. The first is medical education, and the Nichters have helped develop a tobacco curriculum in India and Indonesia that educates medical students on how tobacco use affects all parts of the body – not just lung health.
The comprehensive curriculum, which is fully integrated into students' four years of medical school, emphasizes that doctors must ask patients about their smoking and must inform them about the harm of smoking, not just for health in general but for their specific medical condition. The curriculum has been piloted in five medical colleges in each country and is freely available on the Project Quit Tobacco International website.
The project's second component involves developing tobacco cessation clinics that employ culturally sensitive approaches for counseling individuals about how to quit. Cessation training courses and videos modeling how to counsel different types of patients at different stages of readiness to quit have been introduced in both countries. Cessation clinics also have been set up specifically for patients with diabetes and TB, diseases gravely affected by smoking.
The third project component is a smoke-free homes initiative, a community-based movement to create non-smoking residences in order to reduce women's and children's exposure to secondhand smoke.
In both India and Indonesia, smoking is strongly tied to masculinity and is extremely common amongst men. About 70 percent of men in Indonesia and between 50 and 60 percent of men in India use tobacco. While smoking is very rare among women in both countries, the Nichters' research showed that about 70 percent of women, often along with their children, were frequently exposed to secondhand smoke in their homes.
And while women in both countries said they didn't want their husbands to smoke indoors, the vast majority felt powerless to ask their husbands to smoke outside the house.
"We found out that most women had complained to their husbands about it but said, 'They don't listen to us.' You tell men not to smoke and they smoke more; they don't want to be bossed around,'" Mark Nichter said.
This is what inspired the launch of the smoke-free homes initiative.
"We were trying to reframe smoking from a men's health problem to a family health problem that affects women and children," said Mimi Nichter. "So rather than demonizing smokers, we had to reframe the issue to be about men taking responsibility for the health of their family, which is an important cultural concern."
The Nichters have helped develop a variety of educational materials to promote the smoke-free home initiative and to teach the general public about the harm of secondhand smoke. They have worked with women's groups in both countries, bringing in local doctors to talk about the dangers of secondhand smoke.
"One of the things that we learned early on is that people don't respond real well to international statistics or even national statistics," Mark Nichter said. "If you talk about smoking in general being bad for your health, people don't pay much attention. They want information from doctors who they respect, and they want to know about the dangers of smoking to people like themselves, who doctors see in their practice."
The Nichters found that having community leaders sign contracts declaring their households as smoke-free zones led men to agree to comply with this new normative practice. In addition, providing people with stickers or signage, indicating a home or community's intent to be smoke-free, was an effective way of spreading the word and reminding men not to smoke.
"Women liked the fact that they don't even have to say 'no smoking' to men who visit their home; they can just point to a sticker," Mimi Nichter said.
While the initial idea of smoke-free homes was simply to keep men from smoking in their households, it has inspired some to quit altogether.
"Even though we weren't telling men to quit, some men did so once they weren't smoking in the house. They began smoking less and some of them did quit," Mimi Nichter said. "And there's a great deal of pride among those men who quit. They see quitting as a show of will power, not a loss of masculinity."
The Nichters' work is not without its challenges. India and Indonesia are among the countries with the highest rates of tobacco use in the world. Both countries grow their own tobacco and have their own brands of cigarettes, and Indonesia has some of the world's most aggressive cigarette ads, targeting young men and, more recently, women they hope will take up the habit.
But this hasn't discouraged the Nichters, who spend a couple of months each year working on the ground in India and Indonesia in addition to maintaining regular contact year-round with project teams in the two countries.
"The future of tobacco control is in the hands of our colleagues in India and Indonesia, but we feel good about helping build a strong foundation upon which to build a tobacco cessation community of practice in both countries," said Mark Nichter.
Since Project Quit Tobacco International's inception a decade ago, medical professionals, including doctors and health workers from many communities in both countries have received training in tobacco cessation and implementation of smoke-free home community interventions.
The smoke-free homes initiative continues to spread and was recently been adopted by the Ministry of Health in the Indian state of Kerala, where much of the project's work has been centered. The Nichters also hope that Project Quit Tobacco International might also serve as an inspiration for other medical schools, clinics and community-based tobacco cessation efforts globally.
"We have developed a website where anyone interested can go to see our educational materials, videos for training doctors on how to counsel patients for cessation, videos on the smoke free homes initiatives, and the medical school curriculum. We encourage others from around the globe to look at the materials and adapt them to their cultural context," Mark Nichter said.
"We emphasize that this is not a one-size-fits-all set of resources that you can just transplant to a different country," he added. "As engaged medical anthropologists, we want others to do the formative research necessary to come up with programs that make sense in their own cultural settings."