title: System level approaches for mainstreaming tobacco control into existing health programs in India: Perspectives from the field.
abstract: BACKGROUND
  India is the second largest consumer of tobacco in the world, and varieties of both smoked and smokeless tobacco products are widely available. The national program for tobacco control is run like a vertical stand-alone program. There is a lack of understanding of existing opportunities and barriers within the health programs that influence the integration of tobacco control messages into them. The present formative research identifies such opportunities and barriers.
  
  
  METHODS
  We conducted a multi-step, mixed methodological study of primary care personnel and policy-makers in two Indian states of Andhra Pradesh and Gujarat. The primary purpose of our study was to investigate health worker and policy-maker perceptions on the integration of tobacco control intervention. We systematically collected data in three steps: In Step I, we conducted in-depth interviews (IDIs) and focus group discussions with primary care health personnel, Step II consists of a quantitative survey among health care providers (n = 1457) to test knowledge, attitudes and practices in tobacco control and Step III we conducted 75 IDIs with program heads and policy-makers to evaluate the relative congruence of their views on integration of the tobacco control program.
  
  
  RESULTS
  Majority of the health care providers recognized tobacco use as a major health problem. There was a general consensus for the need of training for effective dissemination of information from health care providers to patients. Almost 92% of the respondents opined that integration of tobacco control with other health programs will be highly effective to downscale the tobacco epidemic.
  
  
  CONCLUSIONS
  Our findings suggest the need for integration of tobacco control program into existing health programs. Integration of tobacco control strategies into the health care system within primary and secondary care will be more effective and counseling for tobacco cessation should be available for population at large.
authors.affiliation: Department of Non-Communicable Diseases, Public Health Foundation of India, New Delhi, India.
authors.forename: Rajmohan
authors.initials: R
authors.lastname: Panda
authors.affiliation: Department of Non-Communicable Diseases, Public Health Foundation of India, New Delhi, India.
authors.forename: Swati
authors.initials: S
authors.lastname: Srivastava
authors.affiliation: Department of Non-Communicable Diseases, Public Health Foundation of India, New Delhi, India.
authors.forename: Divya
authors.initials: D
authors.lastname: Persai
authors.affiliation: Department of Non-Communicable Diseases, MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa.
authors.forename: Emily
authors.initials: E
authors.lastname: Mendenhall
authors.affiliation: Department of Non-Communicable Diseases, Public Health Foundation of India, New Delhi, India.
authors.forename: Monika
authors.initials: M
authors.lastname: Arora
authors.affiliation: Department of Non-Communicable Diseases, Public Health Foundation of India, New Delhi, India.
authors.forename: Manu Raj
authors.initials: MR
authors.lastname: Mathur
keywords: Health care providers; health systems; integration; program managers; tobacco