Abstract

Aims: The objective was to examine the predictors of readiness to quit tobacco among oral potentially malignant disorder (OPMD) and oral cancer (OC) patients in dental health care setting. Settings and Design: Two hundred and seven patients diagnosed with OC or OPMDs comprising 153 males and 54 females, with mean age being 52.2 years, with varying levels of addiction formed the study group. Subjects and Methods: Readiness to quit tobacco as measured by the ladder of change and the single-item readiness question was significantly correlated with measures of perceived risk. Statistical Analysis Used and Results: Pearson’s correlations showed that readiness to quit tobacco was significantly correlated with the participant’s perception of his or her health compared with other tobacco users of the same age (P < 0.005). Readiness to quit was positively correlated with the degree to which participants felt that their oral condition is related to their tobacco use (P < 0.001), how much their general health is affected by tobacco use (P < 0.01), and how much quitting tobacco could influence their health positively (P < 0.001). Post hoc analyses showed that readiness to quit was also significantly and negatively correlated with nicotine addiction (P < 0.001) and decisional balance scores (P < 0.01). Conclusions: There is an urgent need for tobacco risk assessment, intervention, and education with this population of patients, and hence, health professionals can play a significant role in motivating and assisting to quit.

Introduction

Oral cancer (OC) ranks in the top three of all cancers in India, which accounts for over 30% of cancers reported in the country. India has one of the highest rates of OC in the world.[1] As per the recent estimates by India’s National Cancer Registry Program, 1.45 million cases would occur in 2016 with 0.74 million deaths in India. This is expected to rise to 1.73 million cases and 0.88 million deaths by 2020.[2] Tobacco use continues to succeed as the most significant cancer risk as it alone accounts for millions of cancer deaths annually becoming a global health priority. India’s tobacco problem is very complex, with large use of a variety of smoking forms and an array of smokeless tobacco (ST) products that are used either alone or concurrently with other products.[3] The habit of chewing betel nut leaves rolled with lime and tobacco, a mixture known as paan, is thought to be the chief cause of OC in India. It has been well established that essentially all OC is preceded by visible clinical changes in the oral mucosa, usually in the form of white or red lesions, oral potentially malignant disorders (OPMDs), a two-step process of cancer development.[4] [5] Prevention and early detection of such OPMDs have the potential of not only decreasing the incidence but also improving the survival rates of those who develop OC. Unfortunately, nearly half of the patients with oral squamous cell carcinoma worldwide are diagnosed at advanced stages (III, IV), with 5-year survival rates ranging from 20% to 50% depending on the tumor site.[6]

Considering the known risk factors, OC appears to be to a certain amount, a preventable disease. Thus, early diagnosis, management, and providing tobacco cessation interventions are the need of the hour for better prognosis and also to reduce the morbidity and mortality from the disease. Hence, categorizing the candidates receiving treatment, particularly for conditions or symptoms that may plausibly be related with tobacco use, and proactively providing tobacco cessation interventions in the health settings may motivate an individual to change his or her health behavior. In light of this, the objective of this paper is to examine the psychological and behavioral factors among patients with OPMDs and OC relevant to tobacco cessation and the interrelationships between these constructs.

Subjects and Methods

This study was conducted in the oral medicine department of a dental college and hospital. The study is approved by the Institutional Review Board. A total of 207 outpatient department patients seen over a period of 5 years between 2013 and 2017, aged 21 years or older, current regular tobacco user using either smoking or ST with the use of five or more cigarettes/chewing tobacco sachets per day for the past 3 years, diagnosed clinically and histopathologically as either OC and/or OPMDs (leukoplakia, erythroplakia, submucous fibrosis [SMF]) were included in the study. Never/former tobacco users were excluded from the study. After explaining the nature of the study, participants were administered informed consent and then were asked to complete the survey instrument containing all assessment items. At baseline, the participants completed questions regarding demographic variables, medical utilization in the past year (number of doctor visits and hospitalizations, medications used), tobacco history, and current tobacco behaviors and attitudes. Nicotine dependence was measured using the Fagerstrom Test for Nicotine Dependence (FTND), a 6-item measure of nicotine dependence with potential scores ranging from 0 to 10. Scores above 6 on the FTND are suggestive of high nicotine dependence.

Motivation to quit tobacco was assessed using the contemplation ladder and a single item that asked participants to rate on a 1–10 scale how ready/willing they were to quit tobacco (“readiness”). Decision-making was measured using the Smoking Decisional Balance Scale, which comprises 10 items examining the participant’s perception of the benefits (pros) and costs (cons) of tobacco use. Symptoms of depression were assessed using the Hospital Anxiety and Depression Scale (HADS). Confidence was assessed using a single question that asked participants “if you decided to quit tobacco, how confident are you that you could quit?” Participants marked their answers on a 1–3 scale, with 1 being “not confident” and 3 being “very confident.” Perceived risk from tobacco use was measured by three items that asked the participant to specify on a 5-point scale: (1) how they perceived their own health compared with other tobacco users; (2) the degree to which tobacco use was affecting their health; and (3) how much quitting might improve their health. An additional risk perception item asked whether they believed that their oral condition was related in any way to their tobacco use (yes/no).

Statistical analyses

Pearson’s correlations were used to test the association between continuous variables. One-way analysis of variances and Chi-square analyses were used to examine the differences between groups. A multivariate regression analysis was conducted to examine the predictors of readiness to quit tobacco.

Results

Of the 306 patients screened, only 207 agreed to be a part of the study. Of them, 153 were males (73.9%) and 54 were females (26%). The average patients’ age was 52.2 (standard deviation [SD] = 9.2) years. 27 (13%) were diagnosed with OC and 180 (86.9%) with OPMDs (leukoplakia, erythroplakia, SMF, and lichen planus). Nine of the OC patients reported hospitalization in the past year and spent an average of 9 days (range: 1–20) in the hospital for OC treatment. The HADS score was 16.0 (SD = 8.3), significantly higher among women (16.8, SD = 8.4) as compared to men (14.3, SD = 7.9: P < 0.05).

One hundred and eight participants used smoking tobacco (cigarettes, bidis) and 99 of them used ST (gutka, panmasala, etc.). 63% (130) of the participants lived with a tobacco user at their homes. The level of addiction on FTND scale for smokers showed that 13.2% had low level of addiction, 38.8% medium level of addiction, and 47.9% high level of addiction. Among ST users (FTND-ST), 6.1% had low level of addiction, 36.4% had medium level of addiction, and 57.5% had high level of addiction. The level of addiction was highest among bidi users as compared to cigarette users and higher among commercial ST product users as compared to traditional paan users (betel leaf, areca nut, and lime with or without tobacco). Pearson’s correlations showed positive associations between nicotine dependence and frequency and duration of tobacco use (r = 0.69; P < 0.001), HADS scores (r = 0.16; P < 0.05), and decisional balance (r = 0.21; P < 0.01).

Sixty-three percent of the participants had made one or more quit attempts lasting for at least 2 days in the past year. On an average, participants had made 3.6 (SD = 5.4) quit attempts and 18% had long-term tobacco abstinence of 12 months or longer. None of them received any professional tobacco intervention in their quit attempt. 5.4% reported to have used nicotine chewing gums (nicotine replacement therapy) during previous quit attempt. Smoking Decisional Balance Scale results showed an average score of 14.4 (SD = 3.4) on the pros and 10.8 (SD = 2.2) on the cons subscales. Average scores on the contemplation ladder were 8.1 (SD = 3.4), indicating a high level of motivation to change [Table 1]. 45% were willing to quit in the following 30 days, and 22.5% within the next 6 months; however, 32.5% had no plans to quit tobacco. Scores on the single-item readiness question also showed high level of motivation to quit (mean = 8.8 on 10-point scale; SD = 5.6). Pearson’s correlations showed a significant, positive association between the contemplation ladder and readiness scales (P < 0.001). Analysis of the single-item confidence measure showed a mean score of 7.0 (1–10 scale; SD = 3.7), with 45% of participants endorsing scores of 8–10 (highly confident) and 36% endorsing a score of 5 or lower.

Table 1 Motivation and plans to quit tobacco as measured by the contemplation ladder

33.4% said that their health was almost the same or better than other tobacco users of their age and 66.6% felt that they had some tobacco-related illness. 63% thought that their oral condition was related to their tobacco use and 37% thought that tobacco was not at all responsible for their oral condition or their overall health. Likewise, when asked how much quitting tobacco could help improve their health, 57.6% thought that it would benefit them immensely [Table 2]. Readiness to quit tobacco as measured by the ladder of change and the single-item readiness question was significantly correlated with measures of perceived risk. Pearson’s correlations showed that readiness to quit tobacco was significantly correlated with the participant’s perception of his or her health compared with other tobacco users of the same age (P < 0.005). Those who thought that their health was “same or better” than others had an average readiness score of 4.0 (SD = 2.4), while those who stated their health was “much worse” comparatively had average readiness score of 6.9 (SD = 3.6). Readiness to quit was positively correlated with the degree to which participants felt that their oral condition is related to their tobacco use (P < 0.001), how much their general health is affected by tobacco use (P < 0.01), and how much quitting tobacco influence their health positively (P < 0.001). Similarly, higher mean readiness scores (mean = 6.9, SD = 4.3) were observed among those who positively documented (“yes”) to the question asking whether they had symptoms of a tobacco-related disease that was initiated or worsened by tobacco use as compared with other participants (mean = 6.0, SD = 3.9; P < 0.001).

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