Kudos to Devon Noonan, associate professor, and her entire team for the submission of their NIH R21/R34 application entitled: “Evaluating the Feasibility and Efficacy of using WhatsApp Messaging and Online Social Support for Oral Tobacco Cessation in India." This proposal requests funding for a five-year period with a start date of July 1, 2021.

Oral smokeless tobacco (ST) use is prevalent in India — with 21.4% of the population (29.6% men, 12.8% women) reporting current ST use. This high rate of use increases the risk for tobacco related morbidity and mortality. Current cessation programs in India, like other low- and middle-income countries (LMICs) lack reach and accessibility for many. Given the phenomenal increase in the use of cell phones in India (88% of households have a cell phone) and other LMICs, one promising approach to increase the reach of ST cessation interventions is to use a mobile phone-based approach. A recent Cochrane review supports the use of mobile phone-based interventions for smoking cessation and recent work also supports the efficacy for ST cessation.

Thus, the overall objective of this study is to develop a culturally appropriate m-health intervention, The India Smokeless Tobacco Program (ISTOP) for ST cessation. This intervention will be informed by evidenced-based strategies and will include cessation support messaging that incorporates empirically-derived behavior change constructs. It will also feature a moderated online chat component to facilitate social support.

The intervention will be delivered via WhatsApp, a social media messaging app that offers both traditional features of a cell phone (e.g. text messaging) and features of social media (chat and video). India is currently the largest market in the world for WhatsApp, and currently, it reaches over 400 million people.

Our team has developed and evaluated both text-based and social support interventions in the U.S. for ST users that will form the core of the proposed intervention. For this combined R21/R33, we will conduct focus groups to inform the development of the ISTOP intervention. We will test the feasibility, acceptability, and preliminary efficacy of ISTOP compared to a usual care control (Smokeless Tobacco Cessation Booklet). If feasibility and acceptability benchmarks are met in the R21, we will transition to a fully powered randomized controlled trial in the R33 phase to test the efficacy of ISTOP and explore social support as a mediator of intervention effects.

Results of this study can be disseminated broadly and translated to the context of other LMICs to increase access to efficacious cessation interventions with the ultimate goal of decreasing cancer-related morbidity and mortality in smokeless tobacco users in LMICs.