|Year : 2022 | Volume
| Issue : 4 | Page : 388-392
Assessment of nicotine dependence among cigarette smokers seeking oral health care using fagerström test for nicotine dependence: A cross-sectional study
Nalini Parimi1, Nalini Bikkina2, Vikram Simha Bommireddy3, Morampudi Tejaswi4, Sirija Edupalli5, V Srujana Krishna Adapa6
1 Department of Public Health Dentistry, St. Joseph Dental College, Eluru, Andhra Pradesh, India
2 Department of Humanities and Social Sciences, GITAM School of Gandhian Studies, Visakhapatnam, Andhra Pradesh, India
3 Department of Public Health Dentistry, Sibar Institute of Dental Sciences, Takkellapadu, Andhra Pradesh, India
4 Private Dental Practitioner, Dr. Smiles Dental Clinic, Eluru, Andhra Pradesh, India
5 Department of Dentistry, Andhra Hospitals, Eluru, Andhra Pradesh, India
6 Private Dental Practitioner, Care Dental Clinic, Hanuman Junction, Telangana, India
|Date of Submission||15-Jan-2022|
|Date of Decision||12-Sep-2022|
|Date of Acceptance||23-Sep-2022|
|Date of Web Publication||19-Dec-2022|
Department of Public Health Dentistry, St. Joseph Dental College, Duggirala, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: In the quest of articulating customized tobacco cessation strategies, evaluation of the level of nicotine dependence among participants is quintessential. Objective: This study was conducted to assess the levels of nicotine dependence and its association with age and socioeconomic status among patients seeking oral health care at a teaching dental institution in coastal Andhra Pradesh. Materials and Methods: This cross-sectional study was done among 199 participants with the habit of cigarette smoking who participated in the study. Nicotine dependence scores were assessed using Fagerström Test for Nicotine Dependence (FTND). IBM SPSS version 20 software was used for data analysis. The Chi-square tests and Kruskal–Wallis analyses of variance were done to analyze the study data. P ≤0.05 was considered statistically significant. Results: The mean FTND score was 4.52 ± 2.1. Significant differences in the mean nicotine dependence score were found between different age groups (P < 0.001) and participants belonging to different socioeconomic strata (P < 0.001). While a positive correlation was observed between age and FTND score, an inverse relation was noted between FTND score and socioeconomic status with participants from lower socioeconomic status demonstrating higher FTND scores. The majority of the participants reported smoking <10 cigarettes per day. Conclusion: The study participants demonstrated moderate nicotine dependence. The assessment of nicotine dependence scores as a preliminary step in tobacco cessation counseling is essential to effectively articulate customized cessation strategies.
Keywords: Fagerström scale, nicotine dependence, smokers
|How to cite this article:|
Parimi N, Bikkina N, Bommireddy VS, Tejaswi M, Edupalli S, Adapa V S. Assessment of nicotine dependence among cigarette smokers seeking oral health care using fagerström test for nicotine dependence: A cross-sectional study. J Indian Assoc Public Health Dent 2022;20:388-92
|How to cite this URL:|
Parimi N, Bikkina N, Bommireddy VS, Tejaswi M, Edupalli S, Adapa V S. Assessment of nicotine dependence among cigarette smokers seeking oral health care using fagerström test for nicotine dependence: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2022 [cited 2023 Feb 9];20:388-92. Available from: https://www.jiaphd.org/text.asp?2022/20/4/388/364016
| Introduction|| |
Tobacco consumption emerged as one of the most common and deleterious habits in recent decades. The global statistics reveal the ubiquitous nature of tobacco use. In India, the habit of tobacco consumption is very prevalent with 28.6% of all adults consuming tobacco in one form or the other. The contribution of tobacco toward a country's disease burden and the range of negative health outcomes tobacco could be responsible for led to the identification of tobacco consumption as a global epidemic. In the Indian context, a lot of efforts have been directed toward making people aware of the ill effects of tobacco. The Indian government has been making consistent efforts to bring down the growing consumption of tobacco which include the Cigarette Act 1975 and Cigarettes and Other Tobacco Products Act, 2003. In 2007, National Tobacco Control Programme was launched and the National Tobacco Control Cell was constituted which organizes at the national, state, and district levels.
Although oral health-care professionals are well informed about the scope of the dental profession in identifying tobacco users and offering tobacco cessation counseling, it is seldom considered an integral part of the provision of oral health care. However, strategies such as cognitive-behavioral therapy at the dental office are evolving to be an effective means of achieving tobacco cessation among patients., These strategies not only provide the tobacco users with information about the quit process but also attempt to identify reasonable ways to identify motivational cues from previous quit attempts of the participants and draft customized strategies to counter the circumstances that preclude cessation of tobacco use. However, in the quest of articulating customized tobacco cessation strategies, evaluation of the level of nicotine dependence among participants is quintessential. The evaluation of nicotine dependence can be done in a multitude of ways which include the Diagnostic and Statistical Manual-IV substance dependence structured interviews, Fagerström Tolerance Questionnaire which is an eight-item scale, and the Fagerström Test for Nicotine Dependence (FTND) which is a six-item scale. There is a paucity of literature on the evaluation of nicotine dependence as a preliminary step in the provision of tobacco cessation counseling. With this background, the objective of this study was to evaluate nicotine dependence among cigarette-smoking dental patients using FTND.
| Materials and Methods|| |
This cross-sectional study was conducted in a teaching dental institution in coastal Andhra Pradesh. The study was conducted from January 2017 to December 2017. Ethical approval for the study (SJDC/CEC/2015-2016) was obtained from the Institutional Ethical Committee of St. Joseph Dental College, Eluru, on December 22, 2015. Prior permission was obtained from the administrative authorities of the institution before the conduct of the study. The sample size for the study was determined to be 199 using G* power 126.96.36.199 software, (Kiel, Germany: Kiel University) (Test family: t-tests; Test: Means – difference from constant (one sample case); Tails: Two-tailed; α error probability – 0.05; power – 0.8; effect size – 0.2). One hundred and ninety-nine cigarette smokers were recruited for the study. All the participants were self-reported current cigarette smokers (participants who reported smoking at least 100 cigarettes during their lifetime and currently smoking) with no tobacco chewing habits. Informed consent was signed by all the study participants and the data collection was anonymous.
FTND is a six-item scale. Four items in the scale are dichotomous in nature, whereas the other two items are multichotomous. The scale score ranges between 0 and 10 with higher scores indicative of high nicotine dependence. The test was administered to all the study participants by a single trained interviewer. Details relating to age, gender, education, occupation of the head of the family, and monthly family income were also obtained from the study participants. Socioeconomic status was assessed using the modified Kuppuswamy scale. Data collection for each participant lasted for 3 min on average. The collected data were later intended to be used to articulate customized cessation strategies for individual participants in the tobacco cessation clinic of the institution. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) version 22 software (IBM SPSS, IBM, Armonk, NY, USA). Descriptive statistics, Chi-square tests, and Kruskal–Wallis analyses of variance were done to analyze the study data.
| Results|| |
The mean age of the study participants was 42.89 ± 17.97 years and all the participants were males. [Table 1] presents the age group-wise distribution of the participants' responses to each of the six items in the FTND. It was observed that participants who were 65 years and older prefer to smoke within 5 min after waking up in the morning at a comparatively higher frequency than the younger age groups. Although it was observed that the difficulty to refrain from smoking at forbidden places increased with increasing age, this difference between age groups was not statistically significant. The first cigarette in the morning was reported to be the most difficult one to give up by participants belonging to all the age groups considered in this study except ≤24 years. Most of the participants reported smoking 10 or lesser number of cigarettes per day. Among participants who were older than 64 years of age, 48.5% smoked 11–20 cigarettes per day. With increasing age, there was a clear transition from smoking cigarettes during the rest of the day to predominantly smoking in the 1st h after waking up in the morning. The majority of the participants reported that they would not smoke if they were so ill that they were on bed for most of the day.
|Table 1: Age group-wise distribution of item responses in the Fagerstrom test for nicotine dependence|
Click here to view
The mean nicotine dependence score of the study sample was 4.52 ± 2.1. [Table 2] shows the differences in mean nicotine dependence scores based on the age group of the study participants. The highest mean scores were observed among participants aged 65 years and older. When the nicotine dependence scores were compared between participants belonging to different socioeconomic strata, a decreasing trend was observed from lower socioeconomic status to upper-middle socioeconomic status [Table 3].
|Table 3: Differences in nicotine dependence scores based on socioeconomic status|
Click here to view
| Discussion|| |
The mean nicotine dependence score observed in this study reveals that there was moderate nicotine dependency among the study participants. To the best of our knowledge, this is the first study to preliminarily assess nicotine dependence scores in the quest of providing tobacco cessation counseling in the tobacco cessation clinics set up in teaching dental institutions as directed by the Ministry of Health and Family Welfare (MOHFW) and the Dental Council of India (DCI). Cigarette smoking is responsible for chronic diseases like lung cancer that tend to manifest in the later part of life besides compromising the quality of life owing to the other adverse effects on health in the short run. While the immediate impact of cigarette smoking on health is not life-threatening, the chronic conditions developed as a result of the habit can be fatal.,,
The mean age of the participants in this study was comparable to the mean age reported in the studies conducted by Farooq et al. and Evins et al. All the study participants were males which is similar to other tobacco-related studies conducted by Farooq et al., Park et al., and Hill et al. While moderate nicotine dependency was identified in the present study, another study conducted by Goyal et al. among participants attending dental outreach programs reported low nicotine dependency. Similarly, a study conducted by Chhabra et al. among patients attending a teaching dental institution reported low tobacco dependency. The mean FTND scores similar to those observed in this study were reported by Webb et al. and Malhi et al. Nearly, 64% of the study participants reported smoking <10 cigarettes per day in this study, which is in contrast with the study conducted by Raja et al., where only 10% of the study participants smoked <10 cigarettes per day and another study conducted by Farooq et al., where 75% of the participants reported smoking <10 cigarettes per day.
Participants from lower socioeconomic status were found to have higher FTND scores in the present study which is similar to the findings reported by Chen et al. and Siahpush et al. However, contrasting findings were observed in the study conducted by Ayo-Yusuf and Omole among adult smokers in South Africa. The possible reasons for higher dependence among participants from lower socioeconomic strata are low self-efficacy among participants and lack of intention to quit the habit which could be due to the stress arising from their social and financial disadvantages. A significant increase in FTND scores was observed with increasing age in this study. Li et al. reported increased dependence scores among middle-aged adults (45–64 years) compared to younger adults and older people. While the exact mechanism for increasing trend in nicotine dependence with increasing age is not completely discernible, it is postulated that desensitization of nicotine cholinergic receptors as a result of prolonged nicotine exposure with increasing age could be one of the primary reasons for this phenomenon. Furthermore, it is hypothesized that younger individuals are not as vulnerable as their older counterparts in responding to the psychological cues of the urge to smoke. The limitations of the present study include restrictions on cigarette smoking. Nevertheless, the study results demonstrate that there is moderate tobacco dependency among cigarette smoking participants availing oral health care at dental institutions. Future studies can focus on obtaining data relating to dependency on smokeless tobacco in tandem with cigarette smoking.
| Conclusion|| |
The findings of this study provide an insight into the fact that there is moderate nicotine dependence among cigarette smokers availing care at oral health facilities, which is high among lower socioeconomic strata and older age groups. Therefore, the establishment of tobacco cessation centers in teaching dental institutions as directed by MOHFW and DCI, and making committed efforts toward drafting and delivering customized tobacco cessation strategies could be very effective.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Singh A, Ladusingh L. Prevalence and determinants of tobacco use in India: Evidence from recent global adult tobacco survey data. PLoS One 2014;9:e114073.
Hoffman SJ, Mammone J, Rogers Van Katwyk S, Sritharan L, Tran M, Al-Khateeb S, et al.
Cigarette consumption estimates for 71 countries from 1970 to 2015: Systematic collection of comparable data to facilitate quasi-experimental evaluations of national and global tobacco control interventions. BMJ 2019;365:l2231.
WHO. Report on the Global Tobacco Epidemic, 2019. Geneva: World Health Organization; 2019.
Kaur J. National tobacco control programme – A critical review and steps forward. Health Millions 2012;38:8-16.
Rajput S, Gadiyar A, Kumar A, Kamat AK, Gaunkar R, Jain A. Tobacco cessation counseling: Are dentists doing enough? J Indian Assoc Public Health Dent 2020;18:60-5. [Full text]
World Health Organization. Toolkit for oral health professionals to deliver brief tobacco interventions in primary care. Geneva: World Health Organization; 2017.
Selvamary AL, Aswath Narayanan MB, Doss J, Ramesh Kumar SG. Effectiveness of cognitive behavior therapy in tobacco cessation at a dental setting: A hospital-based randomized controlled trial. J Indian Assoc Public Health Dent 2016;14:370-6. [Full text]
Lancaster T, Stead LF. Individual behavioural counseling for smoking cessation. Cochrane Database Syst Rev. 2005;(2):CD001292. Update in: Cochrane Database Syst Rev 2017;3:CD001292.
Kandel DB, Hu MC, Yamaguchi K. Sequencing of DSM-IV criteria of nicotine dependence. Addiction 2009;104:1393-402.
Fagerström KO. Measuring degree of physical dependence to tobacco smoking with reference to individualization of treatment. Addict Behav 1978;3:235-41.
Heatherton TF, Kozlowski LT, Frecker RC, Fagerström KO. The fagerström test for nicotine dependence: A revision of the Fagerström tolerance questionnaire. Br J Addict 1991;86:1119-27.
Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 2007;39:175-91.
Wani RT. Socioeconomic status scales-modified Kuppuswamy and Udai Pareekh's scale updated for 2019. J Family Med Prim Care 2019;8:1846-9.
] [Full text]
Committee on the Public Health Implications of Raising the Minimum Age for Purchasing Tobacco Products; Board on Population Health and Public Health Practice; Institute of Medicine; Bonnie RJ, Stratton K, Kwan LY, editors. Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. Washington (DC): National Academies Press (US); 2015. The Effects of Tobacco Use on Health. Available from: https://www.ncbi.nlm.nih.gov/books/NBK310413/
. [Last accessed on 2021 Jan 21].
Centers for Disease Control and Prevention (US); National Center for Chronic Disease Prevention and Health Promotion (US); Office on Smoking and Health (US). How Tobacco Smoke Causes Disease: The Biology and Behavioral Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta (GA): Centers for Disease Control and Prevention (US); 2010.
HHS (Department of Health and Human Services). The Health Consequences of Smoking-50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014.
Farooq MU, Puranik MP, Uma SR. Effectiveness of cognitive-behavioral therapy compared with basic health education for tobacco cessation among smokers: A randomized controlled trial. J Indian Assoc Public Health Dent 2020;18:25-30. [Full text]
Evins AE, Mays VK, Rigotti NA, Tisdale T, Cather C, Goff DC. A pilot trial of bupropion added to cognitive behavioral therapy for smoking cessation in schizophrenia. Nicotine Tob Res 2001;3:397-403.
Park CB, Choi JS, Park SM, Lee JY, Jung HY, Seol JM, et al.
Comparison of the effectiveness of virtual cue exposure therapy and cognitive behavioral therapy for nicotine dependence. Cyberpsychol Behav Soc Netw 2014;17:262-7.
Hill KP, Toto LH, Lukas SE, Weiss RD, Trksak GH, Rodolico JM, et al.
Cognitive behavioral therapy and the nicotine transdermal patch for dual nicotine and cannabis dependence: A pilot study. Am J Addict 2013;22:233-8.
Goyal J, Menon I, Singh RP, Gupta R, Sharma A, Bhagia P. Prevalence of periodontal status among nicotine dependent individuals of 35-44 years attending community dental camps in Ghaziabad district, Uttar Pradesh. J Family Med Prim Care 2019;8:2456-62.
] [Full text]
Chhabra C, Chhabra KG, Bishnoi S, Singh J, Sahu V, Lohra A, et al.
Exploring the predictors of quitting tobacco usage among patients attending a private dental institution – A survey from Jodhpur, India. Oral Health Dent Manag 2014;13:815-20.
Webb MS, de Ybarra DR, Baker EA, Reis IM, Carey MP. Cognitivebehavioral therapy to promote smoking cessation among African American smokers: A randomized clinical trial. J Consult Clin Psychol 2010;78:24-33.
Malhi R, Patthi B, Singla A, Dhama K, Niraj LK, Ali I. Breaking the hurdle with three tobacco cessation interventions in your life: A randomized controlled trial. J Indian Assoc Public Health Dent 2018;16:103-8. [Full text]
Raja M, Saha S, Mohd S, Narang R, Reddy LV, Kumari M. Cognitive behavioural therapy versus basic health education for tobacco cessation among tobacco users: A randomized clinical trail. J Clin Diagn Res 2014;8:C47-9.
Chen A, Machiorlatti M, Krebs NM, Muscat JE. Socioeconomic differences in nicotine exposure and dependence in adult daily smokers. BMC Public Health 2019;19:375.
Siahpush M, McNeill A, Borland R, Fong GT. Socioeconomic variations in nicotine dependence, self-efficacy, and intention to quit across four countries: Findings from the international tobacco control (ITC) four country survey. Tob Control 2006;15 Suppl 3:i71-5.
Ayo-Yusuf OA, Omole OB. Nicotine dependence, socioeconomic status, lifestyle behaviours and lifetime quit attempts among adult smokers in South Africa. S Afr Med J 2020;110:796-801.
Li H, Zhou Y, Li S, Wang Q, Pan L, Yang X, et al.
The relationship between nicotine dependence and age among current smokers. Iran J Public Health 2015;44:495-500.
Benowitz NL. Nicotine addiction. N Engl J Med 2010;362:2295-303.
Tsai YW, Wen YW, Tsai CR, Tsai TI. Peer pressure, psychological distress and the urge to smoke. Int J Environ Res Public Health 2009;6:1799-811.
[Table 1], [Table 2], [Table 3]