Are Nigerian oral health workers overlooking opportunities to promote interventions for tobacco smoking cessation?

Abstract

INTRODUCTION Since dentists are strategically positioned to promote tobacco abstinence and cessation, we assessed their commitment through their patients’ dental history in one of the busiest tertiary dental clinics in Nigeria, and also aimed to assess factors associated with screening for tobacco use. METHODS This retrospective and descriptive study utilized the dental records of patients (aged 12–80 years) at the oral diagnosis unit of the Lagos State University Teaching Hospital (LSUTH), Nigeria, from 2017–2018. Descriptive statistics were used to quantify variables such as age, gender, history of tobacco use, while the outcome variable was provision of cessation assistance through referral to the preventive dentistry cessation clinic. Data were analyzed by χ2 tests, t-test, and regression analysis. The significant level for statistical analysis was set at 5% (p≤0.05). RESULTS A total of 15786 new patients, mean age 49.3±12.8 years, were reviewed. Only 4104 (26%) of the patients had their tobacco use history documented; of these, 656 (16%) indicated past or current tobacco use; only 120 (18.3%) of these were referred for cessation counseling in the preventive dentistry unit. Males (n=611; 93.1%) had a higher proportion of past or present tobacco use. Patients presenting with oral ulcers (OR=1.94) and jaw tumors (OR=2.45) were significantly more likely to be screened for tobacco use. CONCLUSIONS Less than 0.01% of new patients were provided with tobacco use cessation advice, and opportunities for screening were essentially unexploited implying an urgent need to incorporate tobacco cessation interventions as part of standard clerking sheets for patients. INTRODUCTION Tobacco consumption occurs in many forms such as cigarettes, pipes, cigars, cigarillos, bidis, kreteks, smokeless tobacco (chew, snuff, and dissolvable strips, sticks, or lozenges), and through a hookah or waterpipe. The most common and referenced version of tobacco use is smoking. According to the U.S. Food and Drug Administration (FDA), the categories of smoked tobacco products are cigars, hookah, pipe tobacco, roll-your-own tobacco, electronic nicotine delivery systems and cigarettes. A cigarette is a thin cylinder of finely cut tobacco rolled in paper for smoking with chemical additives and a filter. There are 93 known harmful and potentially harmful chemicals in cigarettes including nicotine, cadmium, lead, acetaldehyde, ammonia, and benzene, and more than 7000 chemicals in cigarette smoke itself1. Close to 80% of the world’s 1 billion smokers live in lowto middle-income countries, like Nigeria2. Due to poor regulatory framework and weak governing systems, easy distribution of tobacco products, the initiation and maintenence of tobacco use is widely prevalent in Nigeria. Currently, about 1 in every 5 Nigerians smokes3, with high prevalence of consumption, as high as 50% among highrisk occupations like truck drivers4. Over 20 billion sticks of cigarettes are consumed annually in the country3. The World Health Organization (WHO) estimates that tobacco kills nearly 7 million people annually while 100 million tobacco related deaths were recorded over the course of the 20th century5. Tobacco is the leading preventable cause of mortality globally, contributing to cancer, cardiac disease, stroke, chronic lung diseases and other non-communicable Research Paper| Population Medicine Popul. Med. 2021;3(February):6 https://doi.org/10.18332/popmed/132292 2 diseases6. Furthermore, the consumption of tobacco products also has a negative impact on oral health; tobacco smoking is a significant etiological factor in periodontal diseases, deficits in postoperative oral healing and recovery, and plays a role in the failure of dental implants7. These diseases not only affect disability adjusted life years (DALYs), but also lead to a significant economic burden on societies8,9. One of the six measures developed to advance tobacco control is to ‘offer help to quit tobacco use’10 in the WHO Framework Convention for Tobacco Control, which is ratified by 177 countries worldwide. Substantial evidence shows that smoking cessation reduces mortality from tobaccorelated diseases and improves health11. However, smoking is a powerful addiction and despite numerous quit attempts, many individuals who smoke frequently fail to stop smoking12. Smoking cessation programs are therefore necessary to provide the support required for smokers to quit13. An analysis of 17 trials investigating physicians’ advice as an intervention concluded that even brief advice was effective in increasing the odds ratio for quitting smoking (1.74)14. National health organizations and organized dentistry have long advocated for practitioners to take a more active role in tobacco interventions with their patients13,15. Carr and Ebbert16 have reported that abstinence rates may increase among tobacco users as a result of behavioral interventions with an oral examination component provided by dentists and their auxiliaries in clinics or community settings. Dental healthcare providers are a great resource to aid in tobacco cessation. The patient–dentist relationship is unique; the dentist has the opportunity to meet his/her patient over many visits, which provides the opportunity to initiate and reinforce tobacco cessation practices. Dentists are experienced and knowledgeable in diagnosing oral disease4, particularly the adverse oral health effects of tobacco smoking, which on many occasions are present as potentially malignant or malignant lesions. Dentists can provide cessation assistance to their patients by identifying the oral signs of tobacco use, informing patients of these and assessing their willingness to quit smoking. They can also refer patients who desire to quit for smoking cessation services. It is estimated that about 50% of patients visit their dentist at least once a year17. In many countries, dentistry may be a potential setting for several aspects of clinical public health interventions because of their regular recall system of patients, presenting opportunity for promoting life style changes. In a recent Nigerian study, about half of the patients visiting the teaching hospital attended the dental clinic, a very high proportion18. Thus, the dental office visit provides a unique opportunity for dental professionals to point out the detrimental effects of tobacco and to discuss and assist in quitting. Cessation assistance within the dental clinic can be defined as referring patients for cessation counseling in the preventive dentistry unit. Since dentists are strategically positioned to promote tobacco abstinence and cessation of tobacco use, we aimed to review patients’ dental records in one of the busiest tertiary dental clinics in Nigeria to determine if tobacco use was documented and referral services for tobacco cessation were made. METHODS This retrospective and descriptive study utilized the dental records and case histories of patients (aged 12–80 years) seen at the oral diagnosis unit of the Lagos State University Teaching Hospital, Nigeria, over 2 years. The study was done at the dental center of the Lagos State University Teaching Hospital (LASUTH), which is the clinical division of Faculty of Dentistry, Lagos State University College of Medicine. Ethical approval for the study was obtained from the Health Research and Ethics Committee of the Lagos State University Teaching Hospital, Ikeja. The study was implemented in line with the Declarations of Helsinki and the confidentiality of all the participants was assured by the researchers. An official written request, which was approved, was also obtained from the medical records department of the Hospital. Written informed consent was not taken since the data were retrieved anonymously from the patients’ records and confidentiality was guaranteed by omitting personal identifiers. The inclusion criteria were male and female subjects presenting for the first time to the dental center. The exclusion criteria included case files with incomplete information with respect to age and gender and missing diagnosis or treatment plan. The principal investigator and a second researcher were responsible for data collection using 40 randomly selected dental records of patients at the oral diagnosis unit of the dental center which were not included in the final analysis. Inter-examiner reliability for both examiners was 0.90, whereas the intra-examiner reliability was 0.92 and 0.87 for the two examiners, respectively. The dental records of the patients were subsequently retrieved by the dental record officers after they obtained the written permission from the medical records department. The principal investigator used a proforma to record the date of birth, gender, the presenting complaint and diagnosis made by the attending dentist, documentation of tobacco use history and treatment plan, including referral of the patient to the Preventive Dentistry unit for smoking cessation. The chart review procedure was replicated by the other examiner and the records were compared for reproducibility and consistency. Other sociodemographic parameters such as socioeconomic status, religion, and occupation were not included during the assessment of the patients’ dental records. Statistical analysis Data were entered and analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 20 (IBM, Armonk, New York). Descriptive statistics were used to quantify variables such as age, gender, history of tobacco use and referral to the preventive dentistry cessation clinic. Descriptive statistics included the mean age, sex distribution, Research Paper| Population Medicine Popul. Med. 2021;3(February):6 https://doi.org/10.18332/popmed/132292 3 and smoking status of the survey respondents. Data were analyzed by χ2 tests, t-test, and linear regression analysis. The confidence and significant levels for statistical analysis were set at 95% and 5%