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Table of Contents   
ORIGINAL RESEARCH  
Year : 2020  |  Volume : 31  |  Issue : 6  |  Page : 852-856
Evaluation of cessation services provided at a tobacco cessation clinic in a teaching dental hospital


1 Department of Public Health Dentistry, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, India
2 Association for Indian Coalition for Control of Iodine Deficiency Disorders (ICCIDD), New Delhi, India
3 School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia

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Date of Submission09-Jul-2019
Date of Decision04-Mar-2020
Date of Acceptance29-Sep-2020
Date of Web Publication22-Mar-2021
 

   Abstract 


Background: Tobacco cessation interventions provided in a dental office or hospital settings are beneficial in helping patients to quit tobacco. Regular monitoring of these interventions is required to assess their success rate and factors hindering its improvement. This study evaluated cessation services provided through a Tobacco Cessation Clinic (TCC) established in a government teaching dental hospital in Delhi, India. Materials and Methods: Patients visiting the TCC from April 2016 to March 2018 were contacted to participate in this study. All the willing participants were administered a structured questionnaire telephonically or in person. The questionnaire focused on gathering information on patients' current tobacco use status, feedback on intervention provided at TCC and reasons for missing TCC appointments. Bivariate and multivariate analysis was performed to assess the effect of socio-demographic factors, nicotine dependence and interventions at TCC on current tobacco use status of participants. Results: Of the 309 participants, 60 (19.4%) reported complete tobacco abstinence and 78 (22.3%) reduced consumption by more than half from their first visit to TCC. Most of the participants (81.5%) were satisfied with the tobacco cessation interventions provided at the TCC. Multivariate analysis shows that odds of quitting were higher in participants with low tobacco dependence (OR 3.03, CI 0.98,9.35) and those who were satisfied with counselling method at TCC (OR 8.8, CI 2.05, 38.35). Conclusion: Interventions provided at our TCC were found beneficial by the study participants to reduce tobacco consumption or achieve total tobacco abstinence. A timely reminder can be provided to increase patients' compliance.

Keywords: Smokeless tobacco, smoking tobacco, tobacco abstinence, tobacco use cessation

How to cite this article:
Mehta A, Ahmed S, Verma A, Kumar R. Evaluation of cessation services provided at a tobacco cessation clinic in a teaching dental hospital. Indian J Dent Res 2020;31:852-6

How to cite this URL:
Mehta A, Ahmed S, Verma A, Kumar R. Evaluation of cessation services provided at a tobacco cessation clinic in a teaching dental hospital. Indian J Dent Res [serial online] 2020 [cited 2021 May 9];31:852-6. Available from: https://www.ijdr.in/text.asp?2020/31/6/852/311661



   Introduction Top


Tobacco consumption, in its various forms, is a well-known risks factor for a range of chronic diseases including cardiovascular disease, cerebrovascular disease and several forms of cancer. It also predisposes the tobacco user to oro-dental afflictions such as periodontitis, halitosis, oral cancer, precancerous lesions and conditions.[1],[2] Worldwide, India ranks second in terms of tobacco consumption with 267 million tobacco users, to which more than one million deaths are attributed each year.[3],[4] Latest Global Adult Tobacco Survey (GATS,2017), India has reported that more than half of current smokers (55%) and smokeless tobacco users (50%) are planning or thinking of quitting tobacco.[3] These numbers suggest that there is an urgent need to provide effective and evidence-based tobacco cessation assistance to tobacco users in India. Tobacco cessation programmes in hospital and clinic settings have been found to be effective preventive measure in controlling tobacco addiction.[5] Professional tobacco cessation interventions delivered by health professionals are effective in increasing smoking cessation rates.[6],[7]

Dentists are in a unique position to identify tobacco use, provide timely tobacco cessation intervention due to the tell-tale signs of tobacco use on oro-dental structures such as leucoplakia, erythroplakia, oral sub-mucous fibrosis, stains, and smoker's palate. Smoking cessation interventions delivered by dental professionals have abstinence rates as high as 10-15%.[8] Evidence from Cochrane reviews also suggests that interventions delivered by oral health professionals can significantly increase the odds of tobacco abstinence (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.44 to 2.03).[9] Initiatives to improve tobacco abstinence rates by involving dental professionals are ongoing in India with many dental schools in India running Tobacco Cessation Clinic (TCC).[10] Health agencies such as World Health Organization had collaborated with the government of India to start TCCs in many health facilities around India and Indian Dental Association provides training to private dental practitioners in area of tobacco cessation.[11] Recently (2018), Dental Council of India made it mandatory for the dental schools to establish TCCs in all the dental schools in India with an aim to increase the role of dentists in providing tobacco cessation services.[12]

Implementation of preventive public health measures, including tobacco cessation programs requires regular monitoring and evaluation in order to gauge their effectiveness and introduce changes in them if required. Although TCCs have been established in dental settings, to the best of our knowledge, no research from India has reported evaluation of a tobacco cessation intervention delivered through these TCCs. We conducted a retrospective cohort study to assess the effectiveness of services provided at a TCC in a government-funded teaching dental hospital in Delhi, India.


   Methods Top


Study setting and sample: The sampling frame consisted of all the patients who received tobacco cessation intervention through a TCC in the Department of Public Health Dentistry of a government teaching dental hospital in Delhi, India from April 2016 to March 2018. All patients were contacted through phone and recalled to TCC in the month of October 2018. Patients who were not able to report physically to TCC were interviewed telephonically.

Patients who did not give consent to participate in the study and individuals who had received the intervention after March 2018 were excluded. The participants were divided into age groups, that is, less than 30 years and above 30 years of age in order to avoid collinearity with age of initiation of tobacco usage.[5]

Ethical clearance: Ethical clearance for conducting the study was obtained from institutional review board and ethical committee of the university (Proposal No. 5/12/156/JMI/IEC/2017). Written informed consent was obtained from those who reported in person and verbal consent was taken from those participants who chose to interview via telephone.

Intervention: The intervention at our TCC follows the intensive 5As approach.[13],[14] The first contact session is usually of 5-10 minutes. The faculty (AM, AV) at public health dentistry department records the basic demographic information, tobacco use status, and level of dependence using Fagerstorm test using a standardised questionnaire prescribed by National Tobacco Control Programme of India.[14] The patient is counselled and motivated to quit tobacco by informing them about ill effects of tobacco, available methods of quitting such as counselling, quit line numbers and NRT. A quit date is set after 2 weeks of counselling. Patients who are finding difficult to quit or had previous failed quit attempts were prescribed NRT in form of nicotine chewing gum. The gum is prescribed in 2 or 4 mg concentration depending upon quantity of tobacco consumed per day and tapering is started after 8 to 12 weeks.[14] Follow-up schedule for patients was 2, 4, 6 weeks and 3, 6 months. Frequency of tobacco consumption was recorded at each follow-up visit and message to quit tobacco was reinforced.

Data collection: Baseline data was extracted from the questionnaires filled at first visit of participant at TCC. Additional information was collected by a single examiner (SA) using a self-designed questionnaire that included questions on current tobacco status (continuing, abstinence, reduced), number of previous attempts, feedback on counselling, and reasons for not reporting to TCC. The questions for this questionnaire were adopted from similar studies conducted by Panda et al.[5] and Ho KS et al.[15] All the participants were surveyed either through phone or during their visit to TCC by a single investigator (SA). Overall two attempts were made to contact eligible participants telephonically at a gap of 1-week duration.

Data analysis: The data were analysed using Statistical Package for the Social Sciences Version 21.0 (IBM Corp., Armonk, NY, USA).[16] Chi-square tests were used to analyse the difference between sociodemographics characteristics, level of nicotine dependence, feedback on intervention at TCC (independent variables) and current tobacco use (dependent variable). Those independent variables which were showing statistically significant difference (P < 0.05) in bivariate analysis were included for multinomial regression analysis to find out their effect on current tobacco usage of study participants.


   Results Top


A total of 357 patients were eligible for this study, of which 309 (86.5%) provided consent for participation. [Table 1] shows baseline characteristics of the study participants. Most of the participants were males (n = 294, 95.2%), literate (n = 281, 91.9%), consuming tobacco in smoking form (n = 193, 62.4%), having low dependence to tobacco (n = 155, 50.2%) and were provided behavioural counselling without any NRT prescription (n = 260, 84.1%). Mean age of participants was 36.5 (SD 13.5) years with 43.7% (n = 135) under 30 years and rest 56.3% (n = 174) above 30 years of age. Mean age of initiation of tobacco usage was 22.9 (SD 9.4) years and was not a significant factor in tobacco abstinence among study participants (p > 0.05).
Table 1: Baseline characteristics of the study participants (n = 309)

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We divided the study participants into two groups based on their self-reported current status of tobacco usage, that is, abstinence and continuing tobacco group. Around 1/5th (n = 60, 19.4%) reported to have quit all forms of tobacco. There was a significant difference between the groups in relation to education level, feedback on counselling and level of tobacco dependence (P < 0.05). There was no statistical difference between the two groups with regards to type of intervention done at TCC, form of tobacco used, number of previous quit attempts as well as the mean age of initiation of tobacco habit [Table 2]. Reduction of more than 50% in tobacco consumption from the first visit to TCC was recorded among the remaining 249 participants who were still continuing with the tobacco use. Approx. 1/3rd (n = 78, 31.3%) of the participants reported a significant reduction in their tobacco consumption. [Graph 1] shows the reasons told by the participants for not keeping up the appointment. Around 1/3rd of the participants said they are busy with other work. Other participants told they went out of station; disliked treatment procedure in dental hospital; forgot appointment date; or were expecting dentist to remind them of the appointment date. Few participants (n = 20) felt that self-will is sufficient to abstinence tobacco hence they don't need professional counselling. Multinomial regression analysis showed that the participants with low dependence on tobacco (OR 3.03, CI 0.98, 9.3) and those who found counselling helpful (OR 8.87, CI 2.05, 38.3) had higher odds of quitting tobacco, although the differences between the concurrent groups were not statistically significant.

Table 2: Current tobacco use status of the study participants (n = 309)

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   Discussion Top


There are many TCCs running in medical and dental healthcare settings in India, but there is a need to develop a structured approach on collection, dissemination and evaluation of data generated from them.[11] The main reason for conducting this evaluation study is to assess the success rate and receive feedback from the participants regarding the tobacco cessation interventions provided at the TCC. The results of this study show that one in every five patients who visited our TCC achieved abstinence. Two reviews conducted using studies done in the USA and UK reported abstinence rates between 10% to 15%[8] and 2.5% to 18.8%, respectively.[17] The settings of included studies in both these reviews were TCC running in a dental office or dental hospital. These tobacco abstinence rates are slightly less than reported in our study (19.4%). TCCs established in a medical hospital or department had achieved even higher success rates as reported in Turkey[18] (40.4%) and Hong Kong[15] (35.1%). Patients visiting medical hospital TCC are usually suffering from tobacco-related morbidities and are more motivated to tobacco abstinence. Another reason for lower success rate (not related to type of health care setting) could be due to low prescription rate of NRT. Only 49 (15.9%) participants were prescribed NRT. It has been found that NRT in combination with counselling was more successful in helping patients in tobacco abstinence than behavioural counselling alone.[19]

Higher loss to follow-up can jeopardise the accuracy of results of any study. In our study, only 8.6% (n = 49) of the eligible participants were either not reachable or refused to participate in the study. This proportion seems to be acceptable as we found no significant difference between the follow-up and loss to follow-up groups for most of the demographic and tobacco dependence related variables.

Bivariate analysis of tobacco abstinence rates with various socio-demographic variables shows that higher education level, lower dependence to tobacco and positive feedback on counselling were significantly associated with higher quit rate whereas advancing age, marital status, age of tobacco initiation and number of previous quit attempts were not significant predictors of tobacco quitting rates. Level of tobacco dependency on tobacco was found to be a significant predictor for both tobacco abstinence and significantly reducing the quantity of tobacco. It was observed that more participants with low tobacco dependency (as determined by fagerstorm test score) were able to quit tobacco in our study. the patients with low fagerstorm test score are an excellent opportunity for healthcare professionals to help him/her achieve tobacco abstinence because they are less addicted to nicotine.[20] Many studies also have reported inverse relationship between quitting rates and fagerstorm score[15],[18],[21] whereas a study by Raherison C et al.[22] didn't report any such relation. Participants who have studied at least up to middle school education were able to quit tobacco than those studied up to primary school or were illiterate. Results are conflicting regarding role of education in predicting tobacco quitting rates as few studies found it to be a significant factor[23],[24] whereas others fail to find any such association.[15],[18] The mean age of starting with tobacco usage was 22.9 years in our study. The average age of initiation of tobacco usage in India is 18.8 years[3] which is even lesser than this study. This is a dangerous sign for the tobacco consumers because like any addiction substance the degree of nicotine dependence will increase with time.[24] Many study participants forgot their appointment or were expecting a reminder from TCC staff. Reinforcing the cessation messages and reminding the patients about appointments and important milestones in their journey towards tobacco cessation can be helpful and should be encouraged. Evidence suggests mobile phone based interventions have beneficial effect on increase smoking cessation rates.[25] Almost one-third of the study participants who are continuing with their tobacco addiction had reported to significantly reduce the quantity of tobacco consumed. This figure is encouraging and indirectly suggesting the positive effect of the interventions done at TCC on the study participants.

There were few limitations of this study such as tobacco abstinence was self-reported by the participants and was reported without objective measure of salivary cotinine or expired Carbon Monoxide. It is difficult to exclude selection bias in this study although we found no statistic difference between participants and non-participants. The results of this study are prone to information bias as interviewer was not blinded to the study objectives. Also, we did not obtain information on “intention to quit” from the participants. Studies have shown that intention to quit is an important factor associated with attempt to quit tobacco.[26]


   Conclusion Top


This study is a first attempt in India to evaluate effectiveness of a TCC running in a government dental hospital, with focus on both smoking and smokeless tobacco users. This study underlines the importance of providing cessation services to tobacco users in order to help them quit tobacco. We found significantly higher quit rates in study participants who found counselling helpful. A meta-analysis of 37 studies suggests that contact with a healthcare professional increases tobacco cessation frequency among the intervention group compared to the controls.[7] Tobacco cessation interventions are essential and main preventive strategy available for health care professionals to help its addict in quitting,[7] therefore, it's imperative for all the stakeholders to continuously evaluate the measures required for improving effectiveness of these interventions.

Financial support and sponsorship

This study was self-funded.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Dr. Abhishek Mehta
Department of Public Health Dentistry, Faculty of Dentistry, Jamia Millia Islamia, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_541_19

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