Indian Journal of Dental Research

: 2012  |  Volume : 23  |  Issue : 1  |  Page : 123-

Tobacco cessation in India: A contemporary issue in public health dentistry

Ramya Kalyanpur1, K Pushpanjali2, KVV Prasad1, Kumar Gaurav Chhabra1,  
1 Department of Public Health Dentistry, S. D. M. College of Dental Sciences and Hospital, Dharwad, India
2 Department of Public Health Dentistry, M. S. Ramaiah Dental College and Hospital, Bangalore, India

Correspondence Address:
Ramya Kalyanpur
Department of Public Health Dentistry, S. D. M. College of Dental Sciences and Hospital, Dharwad


In India, tobacco use is incredibly linked to poverty and accounts for the high public health costs of treating tobacco-related diseases. Dental public health programs aid in detecting the tobacco-related periodontal diseases, oral cancers, etc., where the majority belongs to the submerged portion of iceberg, which otherwise leads to substantial morbidity and mortality. Moreover, public health dentists plays a key role in identifying both clinical and subclinical cases and aid in tobacco use cessation through various modes of health education and counseling. Therefore, the community-based measures are deemed to be the most cost-effective tool for tobacco cessation.

How to cite this article:
Kalyanpur R, Pushpanjali K, Prasad K, Chhabra KG. Tobacco cessation in India: A contemporary issue in public health dentistry.Indian J Dent Res 2012;23:123-123

How to cite this URL:
Kalyanpur R, Pushpanjali K, Prasad K, Chhabra KG. Tobacco cessation in India: A contemporary issue in public health dentistry. Indian J Dent Res [serial online] 2012 [cited 2022 Jun 25 ];23:123-123
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Full Text

Tobacco use is one among the five greatest risk factors for mortality, and also the single most preventable cause of death. [1],[2],[3],[4] In developing countries like india, the disease burden, health care costs as well as other fiscal losses resulting from premature deaths attributable to tobacco consumption are increasing rapidly. World Health Organization (who) estimates in 2004 projected 58.8 million deaths to occur globally, of which 5.4 million are attributed to tobacco use. As of 2002, 70% of the deaths are in developing countries. It is predicted that 1.5-1.9 billion people will be smokers in 2025. [2],[3]

India is the second largest consumer of tobacco in the world. The prevalence of all types of tobacco use among men has been reported to be high in most parts of the country (generally exceeding 50%). [5] Further, a national level survey on tobacco use in India has reported that 16.2% are current smokers and 20.5% are tobacco chewers. This survey also showed that beedi is the most popular form of tobacco smoking, followed by cigarette smoking; similarly, pan with tobacco is the major chewing form of tobacco. [6] This has attributed to the dramatic increase in tobacco-associated oral problems like oral precancerous lesions and conditions such as leukoplakia, erythroplakia, oral submucus fibrosis, periodontal diseases, tooth loss and cancers of oro-pharyngeal region. [3],[7],[8]

Studies have shown that India has the highest rate of oral cancer in the world. Annually almost 7% of all cancer deaths in males and 4% in females are due to tobacco-related oral cancers. [8],[9] Moreover, it is estimated that 56,000 new cases of tobacco-related oral cancers occur every year, which would lead to more than 100,000 individuals suffering from the disease in the population in any given year. Nearly 95-100% of tobacco users develop periodontal diseases which have a diminishing effect on oral health. As a result, tobacco-related oral manifestations have a negative impact on oral health and quality of life. [1],[9],[10]

Conservative cost of treating selected tobacco-related cancers, oral problems, heart and lung disease amounted to ×30,833 crores in 2002-2003. Tobacco users are also less productive due to increased sickness, and those who die prematurely deprive their families of the much-needed income. Many of the Indian communities have a negative attitude toward tobacco control and are ignorant about the health and economic impacts of tobacco use. Thus, "tobacco epidemic" has emerged as one of the major public health problems in India. This has urged the WHO to initiate the tobacco cessation activities in India. [3],[8],[9],[10],[11]

Tobacco cessation (quitting) is a relatively new area in tobacco control in India. It is considered to be the most cost-effective intervention as compared to other tobacco control programs. [7],[8],[10],[11] In the year 2002, WHO in collaboration with Government of India has identified 13 tobacco cessation centers and they were operationalized on 31 st of May, 2002, on the occasion of "World No Tobacco Day," with a multidisciplinary approach. In connection to this approach, the role of public health dentist has been strongly emphasized in assisting the tobacco users to quit and has become a contemporary issue in the field of public health dentistry in achieving "Tobacco Free Oral Environment." [12],[13],[14]

 Tobacco Cessation and Public Health Dentist

As health professionals, the role of public health dentist is constantly expanding and can be as far reaching as a professional's imagination, sense of responsibility and efforts. This is attributed to their expertise in dental and oral matter; they are highly respected, trusted and influential community leaders in any society. Their voices are heard across a vast range of social, economic and political arenas. Thus, they constitute a "teachable moment" to the community and can perform a unique role in tobacco use cessation activities. [1],[8],[10]

Iceberg Phenomenon of Tobacco-Related Oral Diseases

The disease in a community can be compared with an iceberg. The floating tip of the iceberg is what the physician sees in the community, that is formed by the clinical cases. The big submerged part of iceberg represents the hidden mass of disease, which is formed by inapparent, pre-symptomatic and undiagnosed cases and carriers in the community. Water line represents the demarcation between apparent and inapparent disease. [15]

Much of the evidence focuses on the cases which represent the tip of the iceberg. At this stage, most of the oral lesions are diagnosed at a very late stage, when not only the treatment becomes more expensive, but also the morbidity and mortality increase. A similar picture is represented for tobacco-related cases.

As a part of community outreach programs, public health dentist gets a prospect to identify the cases which are not only in the tip of iceberg but also in the submerged portion of iceberg, i.e., tobacco-related oral lesions, smokers, attitude toward tobacco use and the risk groups. Thus, a public dentist gets a wide opportunity to sensitize the people and prepare tobacco users for cessation. Counseling is the one of the methods approached for tobacco cessation. [7],[14],[16]

However, most of the public health dentists are unfamiliar with counseling techniques for tobacco cessation. They may be unsure about the success of cessation efforts. Further, experience in other countries has shown that the advice of a dentist helps to motivate patients, encourage them to quit and improve their chances of quitting. Thus, a public health dentist can assist in tobacco use cessation programs which can help the individual to lead a socially and economically productive life. [8],[16]

Role of the public health dentist has been highlighted at two levels: [3],[8]

Individual levelCommunity

Individual level

This is approached at chair side, where the public health dentists see the harmful effects of tobacco use and they spend more time with the patient than other physicians. They should use this time to counsel the patient by promoting the oral health and healthy lifestyles. This can be achieved through few minutes of focused talk during oral examination and make the patient aware and conscious of the harmful effects of tobacco use. Thus, every interaction of public health dentist with their patients at every visit can lead to a significant change in patient's attitude and behavior toward tobacco cessation. [3],[8]

Guide to counseling for tobacco cessation (quitting)

For those willing to quit

The 5 "A" method

1) Ask - about tobacco use at every visit, 2) Advise - non-users to never use tobacco and users to quit, 3) Assess - the patient's readiness to quit and the level of dependence, 4) Assist - with quitting, 5) Arrange - follow-up visits. [3],[4],[8],[10],[16],[17],[18],[19]For those not willing to quit

The 5 "R" method

Ask and\or advise the patient about: 1) Relevance of quitting, 2) Risks of continuing tobacco use, 3) Rewards of quitting, 4) Roadblocks to quitting, 5) Repeat these at every visit. [3],[4],[8],[10],[16],[17],[18],[19]

Tailoring messages to the patient's stage of change

It is well known that quitting is a process rather than an event which not only requires individual efforts but also necessities extreme co-ordination from all the sectors to achieve greater success rates. However, the intervention aimed at tailoring messages to the patient's stage of change can help the tobacco user move forward on the road to permanent abstinence [Table 1]. [4],[10],[12],[13],[16],[19],[20] Thus, adopting such tailoring message into the field of dentistry and public health dentistry, in particular, can be one of the most effective behavioral interventional therapies.{Table 1}

In the community

A public health dentist can make an immense contribution in tobacco use cessation at the community level by various ways such as the following: by acting as a role model by not using tobacco or By quitting successfully, performing individual or group meetings periodically about the importance of tobacco use cessation, developing and implementing school intervention models for tobacco cessation, displaying educational material during the out-reach programs or in the urban and rural health centers where most of the population visit to seek health care, also writing articles about benefits of tobacco control policies, participating in talk shows, linking with NGOs to spread health awareness, bringing into limelight the success stories of tobacco use cessation which can help in enlightening the community perception about tobacco use, encouraging the farmers for alternative crop initiatives which should be done in consultation and co-ordination with the horticulture department. [1],[3],[8],[16]

Apart from providing health education to the public regarding the harmful effects of tobacco on oral health and general health through pamphlets, role play, mass media, etc. they also help in the following: 1) referring the tobacco users to counseling centers and do the follow-up, 2) identifying the high-risk groups like young adults and pregnant women and supporting them to stop tobacco use, 3) helping in monitoring the action against smoking and other forms of tobacco use at a local level in order to promote implementation through community participation, 4) periodic surveillance and 5) conducting research for developing the newer methods for tobacco control. [1],[10],[16]

Thus, public health dentist should be strongly motivated for the cause of tobacco cessation; only then, the efforts toward cessation will be fruitful. This can be achieved through systematic training on tobacco and its health hazards, identification and clinical diagnosis of tobacco-related lesions and tailored method for tobacco use cessation and knowledge about referral of cases to the appropriate centers. This training should be directed to the undergraduate and postgraduate dental public health students, and the staff members, with an interdisciplinary approach.

 Benefits of Intervention for Cessation of Tobacco Use

Studies have shown that patient prefer tobacco cessation activities at an individual level where dentists listen to them and advise them honestly. Just 3-5 minutes of focused talk during the examination is enough to make the patients aware and conscious of the tobacco use. [4],[5],[8],[10],[12],[16],[20],[21] Further, the tobacco use cessation measures taken by public health dentists are not likely to convert more than 1 or 2% of patients who use tobacco per year, but in the long run the efforts of a public health dentist to promote tobacco use cessation can have an appreciable impact. [1]

 Barriers for Tobacco Cessation

Despite the imperative role of public health dentist in tobacco cessation, there are certain barriers averting their tasks on tobacco cessation. This can be due to the following reasons:

There is no remarkable internal motivation among the tobacco users due to their deprived socioeconomic conditions, stress, and other allied reasons. This mainly hampers the community participation in tobacco cessation. [22]The majority of societal members strongly resist tobacco cessation since they believe smoking is a macho habit.Most of the dental professionals do not have sufficient skill, time and desire for participation in tobacco cessation activities. [4],[10],[18],[21],[23]

In India where there is a predominant influence of socio-cultural practices on tobacco use, it becomes the most challenging task for the public health dentist to assist in its cessation. [22]Major difficulty in tobacco cessation is the behavioral aspect of tobacco use. This can be overcome through proper reinforcement of behavior intervention procedures.Further, tobacco is considered to be one of the cash crops for farmers and advising them for an alternative crop is the one of the major confront for all the sectors including the public health dentist. [22]

Thus, as a part of community-based program, a public health dentist plays an essential role in the control of tobacco epidemic through participation in various tobacco use cessation programs by identifying cases and providing health education and proper referrals. This can help in reducing the morbidity and mortality caused due to tobacco use.


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