Introduction
India also has one of the highest rates of oral cancer in the world, partly attributed to high prevalence of tobacco chewing.The World Health Organization predicts that tobacco deaths in India may exceed 1.5 million annually by 2020.[1] Tobacco-related mortality in India is among the highest in the world, with about 700,000 annual deaths attributable to smoking. Annual oral cancer incidence in the Indian subcontinent has been estimated to be as high as 10 per 100,000 among males and oral cancer rates are steadily increasing among young tobacco users.[2] Studies have documented the efforts taken by the physicians, doctors or even the dentists who could help patients to curb tobacco use in smoke or smokeless form.[3],[4],[5] Literature states that counselling in the form of group or individual helps the tobacco addicts to quit the habit of tobacco consumption.[6]

Individual counselling is a face-to-face encounter between a patient and a counsellor trained in assisting tobacco cessation.[7] The implementation of cessation programs in groups has been a popular method of delivering behavioural interventions. Behavioural interventions typically include such methods as coping and social skills training, contingency management, self control, and cognitive-behavioural interventions. The use of a group format for the delivery of a behavioural intervention appears to have two underlying rationale. One is that it offers opportunities to the patients to share their experiences and problems while other is that in group counselling, the patients might compete with the fellow patient to acquire better results than the budding partner. Literature also suggests that individual, group or even 5 minutes of brief counselling are effective ways to make an individual give up tobacco consumption habit. However, which one is more effective, still remains an unanswered question.[8]

Individual Counselling
The protocol for individual counselling should include four sessions for 15 minutes each in the first 3 months and 4 telephonic conversations carried out over a period of the next 3 months The follow up is at 3 and 6 months respectively. The protocol consist of 5 As (Ask, Advice, Assess, Assist and Arrange for follow up) and 5 Rs (Relevance, Risks, Rewards, Roadblocks and Relapse). During the individual counselling, the participants should be made aware of quitting, anticipation of triggers and challenges. In the first session (0-2 weeks), participants should be asked about their tobacco consumption habit, knowledge about the effects of tobacco on health, its relevance in their lives and whether they tried to quit before. The participants must record risks of tobacco and benefits of quitting tobacco in the two weeks. The participants are advised to quit by telling about the harmful effect on his health and the health of his family members in relation to health, social and financial condition.

In the second session (2-4 weeks), the dependence level of smoke and smokeless tobacco users is assessed using the modified Fagerstorm’s criteria.[3],[4] The participants are given a clear strong message to quit tobacco. Participants should be made aware about the rewards of quitting tobacco to them and their family members. They are also asked to check their dependence level at the end of every month and identify the reasons for the relapse.

In the third session (4-6 weeks), the participants must set up a quit date. They should be advised to write the cravings, uneasiness or difficulties they experienced from the time they quit till the end of every month. Reasons for the relapse should be noted from the booklet and solutions should be sought. The participants must realise the potential rewards from quitting tobacco like improved taste, improved smell, money saving habit, setting a good example for children, having healthier babies etc.

In the fourth session (6 weeks to 3 months), the participants must be assisted to find solutions to the problems from the manual. They should identify the road blocks and note the abstinence period from the time they had quit tobacco habit. The participants must seek encouragement from their family members, anticipate the triggers and identify the coping strategies. The participants must change their environment by throwing away matches, cigarettes, gutkha packets from their surroundings. The participants should report withdrawal symptoms like weight gain, lack of support etc.

In the next three months, phone calls should be made to the participants. In case if they failed to quit, the participants must be recalled by making calls and should be asked to repeat the protocol stated in the manual[1].

Group Counselling
In group counselling, the difference is the number of participants who interacts with the counselor. In group counselling method a minimum of 8 to 10 individuals must be present during the first three sessions. In the first session itself the participants must be asked to see videos depicting the harmful effects that tobacco products have on the body that forms a part of health education. The protocol or the sessions followed in the group counselling remains the same as in individual counselling, however the time spent is much more. Buddy selection is done in this group and each one in a pair must be asked to encourage his fellow partner to quit. The participants must speak about the initial efforts they might take to quit the habit of tobacco consumption in a group. In the group meetings the participants should discuss strategies to identify one’s use of tobacco consumption habit. They should be asked to share their views and experiences in a group with his buddy and help him to find a solution. They must discuss the road blocks which they face in a group and seek each and every ones opinion in a group and find the best possible solution.[1]

Conclusion
Different counselling strategies, recommendations and protocols are followed in healthcare establishments for the benefit of the patients. Medications and educational materials act as the adjunct for counselling methods. But providing practical counselling (individual or group) are the most recommended line of treatment for the patients. (Chat 1).

Flow Chart Of Counseling Sessions Through 6 Months Period

References
1.    M Rani, S Bonu, P Jha, S N Nguyen, L Jamjoum. Tobacco use in India: Prevalence and predictors of smoking and chewing in a national cross sectional household survey. Tobacco Control 2003; 12:1-8.
2.    Murthy P, Saddichha S. Tobacco cessation services in India: Recent developments and the need for expansion. Indian J Cancer 2010; 47: 69-74.
3.    A Randomized Trial Of Three Approaches to Smoking Cessation. McDowell K. Mothersill W. Rosser R. Hartman Can Fam Physician 1985; 31: 845-51.
4.    Gonseth S, Abarca M, Madrid C, Cornuz J. A pilot study combining individual-based smoking cessation counseling, pharmacotherapy, and dental hygiene intervention. BMC Public Health 2010; 10: 348.
5.    SL Tomar, CG Husten, MW Manley.Do dentists and physicians advise tobacco users to quit?J Am Dent Assoc 1996; 127: 259-65.
6.    Ministry of Health and Family Welfare. Government of India. Manual for Tobacco Cessation: Ministry of Health and Family Welfare; 2005.
7.    Lancaster T, Stead LF. Individual behavioral counseling for smoking cessation. Cochrane Database of Systematic Reviews 2005; 2:1-56.
8.    Stead LF, Lancaster T. Group behavior therapy programs for smoking cessation. Cochrane Database of Systematic Reviews 2005; 2:1-86.