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POPH90227 Public Health in Practice

Topic “Effectiveness of Smokeless Tobacco Cessation Interventions on Reducing Oral Cancer.”

Student ID: 1025738

Name: Hidayatullah Khan

Assignment 2

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Introduction:

Consumers of Smokeless Tobacco (SLT) are at higher risk of oral cancer (Wyss et al., 2016).

SLT has been observed to have 28 carcinogenic materials, which are associated with different

kinds of cancers (Awan et al., 2018). To curb the epidemic of Oral cancers, the World Health

Organization has proposed several SLT cessation interventions (WHO, 2012). Also, different

countries have their own approach to these SLT cessation interventions in order to minimize the

risk of Oral cancers (Khan et al., 2014). Subsequently, in this literature review, we will aim to

consolidate the publications which are reporting effective smokeless tobacco cessation

interventions. The first Assignment mentioned the background and the association of smokeless

tobacco (SLT) with oral cancer. Also, it provided the justification and methodology of the

literature review, which is being conducted in this paper. Furthermore, the most effective SLT

cessation interventions will be identified in this literature review, and those interventions will be

provided to health professionals as a recommendation. This will help us in filling the gap

information which is currently observed when it comes to SLT cessation, as there are very few

cessation interventions studies regarding SLT usage which is observed to be more effective than

others (Ebbert et al., 2015). The identified effective SLT cessation interventions will help health

professionals in gaining knowledge about the effectiveness of the SLT cessation intervention,

which they can implement to help decrease SLT consumption and thus decreasing the risk of oral

cancer.

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Literature Review:

A ten-year cohort study in India (Gupta et al., 1992), has utilized health education intervention to

decrease the use of SLT. The authors of this cohort observational study have found that

education programs have significantly reduced the risk of oral cancers, as more SLT

consumption has been reduced due to education programs. The participants of the cohort study

were divided into two groups, the intervention, and the control group, the intervention group

receiving a highly dedicated education program while the control group received a minimum

amount of education against SLT usage. This resulted in a greater decrease rate of leukoplakia

indicating a lower risk of oral cancer among the intervention group as compared to the control

group (Mohammed & Fairozekhan, 2017). This study (Gupta et al., 1992), proved the

practicality of the use of education as an intervention against the risk of oral cancer. It is crucial

to note that, the comparison of intervention is not between the intervention and no intervention,

but rather between dedicated education programs and minimal intervention through providing

minimal education or information. Moreover, the authors of this study also mentioned in the

findings that, women were more likely to stop the usage of SLT as compared to men after

participating in education programs (Gupta et al., 1992). This can be due to the factor that,

cultural usage of smoking products in India by women is not well accepted (Lahoti & Dixit,

2021). Hence, cultural factors are also needed to bring into account as different regions or

countries have different cultures which can affect the way interventions are perceived. Moreover,

the first follow-up was conducted for the intervention and control group three years after the

baseline survey (Gupta et al., 1992). The follow-up showed that the incidence of oral leukoplakia

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fell to 40 percent in the intervention group as compared to 10 percent in the control group.

Overall, we can conclude from this study in India that, the risk of oral cancer was majorly

reduced due to the stoppage of SLT usage among participants, which was a direct consequence

of dedicated SLT education programs (Asthana et al., 2019).

Another cohort study in the United States of America by (Stevens et al., 1995) has found that

utilization of dental setting as a tool for applying SLT cessation interventions provided by the

dental hygienist or the dentist during dental care, prove to be beneficial. This is because the

healthcare environment is seen as a better setting, to begin with, while implementing SLT

cessation interventions (Jitnarin et al., 2021). The credibility of health care providers in giving

cessation advice to the patients at health settings is trusted highly, as the patients are vulnerable

and sensitive towards their health (Jitnarin et al., 2021). It is important to note that, the

participants in this intervention group were mostly young males aged fifteen years and older

(Stevens et al., 1995). The limitation of this study was that none of the females reported usage of

SLT, therefore only males were included in the intervention group. Moreover, participants

during the initial survey who reported not using SLT were provided usual care during their

dental visit, and nothing was recorded in their medical history as compared to participants who

mentioned usage of SLT were placed in intervention group and status of their usage of SLT was

mentioned in their medical file, so that during dental visits they receive the SLT cessation

interventions and be contacted for follow-ups in future. The intervention included a routine oral

examination with special attention to the part of the mouth in which tobacco was kept and an

explanation of the health risks of using smokeless tobacco. After receiving unequivocal advice to

stop using tobacco, each patient viewed a 9-minute videotape, received a self-help manual, and

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was briefly counseled by the dental hygienist. After follow-ups at third- and twelve-months time,

the intervention increased the proportion of participants who quit the usage of SLT by about one-

half (12.5% vs 18.4%, P < .05) (Stevens et al., 1995). These findings show that the efficacy of

SLT cessation at a dental office for the general population of smokeless tobacco users is

effective as compared to usual care provided during dental visits. Subsequently, a broader

perspective has been adopted by (Nethan et al., 2020), the authors of this study reviewed

nineteen systematic studies based on behavioral SLT interventions comprising 24498

individuals. These studies were from both developed and developing countries with participants

ranging from aged 14 to 82 years old. Therefore, the results were different as expected and

substantial heterogeneity was observed (I2 > 50%). The authors of this study (Nethan et al.,

2020) found that, behavioral interventions were effective in SLT cessation intervention in adults

(RR = 1.63, 95% CI = 1.32 to 1.94) both in the developed (RR = 1.39, 95% CI = 1.16 to 1.63)

and developing (RR = 2.79, 95% CI = 2.32 to 3.25) countries. However, the behavioral SLT

cessation was not as effective for the youth as it was for adults. A lack of evidence for

effectiveness of behavioral interventions in SLT cessation for youth was noted both in developed

(RR = 1.39, 95% CI = 0.58 to 2.21) and developing (RR = 0.87, 95% CI = 0.68 to 1.07). It is

crucial to mention that the quality of the reporting of the included studies was determined

through the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE).

Moreover, the differences in the above findings can be explained in the terms of various SLT

products consumed in different parts of the world, for instance chewing tobacco, snuff, snus is

mostly consumed in developed countries and betel quid, mawa, and gutkha are consumed in

developing countries (Shaik & Maddu, 2019). Also, another reason for the variation of results

may be due to the lack in the implementation of the World Health Organization measures in

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curbing the use of SLT, including those linking with Article 14 regarding reduction strategies

concerning SLT cessation (Mehrotra et al., 2019). Furthermore, the limitations of this study are

that only three countries Sweden, the United States of America, and India) have recorded studies

on the role of behavioral interventions in SLT cessation, with six months follow-up, as many

high SLT consuming countries have no evidence of follow-up or are less than six months in

following -up participants (Nethan et al., 2020). Lastly, from the meta-analysis of this study

(Nethan et al., 2020), we can say that behavioral SLT interventions for the general adult

population in America, Sweden, and India are an effective way to reduce SLT consumption,

which is indicated by the quality of evidence provided. Hence, it is safe to say that behavioral

intervention can be an effective technique for SLT reduction in low-economic places to

maximize the effect and increase reach of interventions for catering to SLT users. This could be

accomplished by using the cost-effective SLT cessation strategies implemented in the developed

countries, which can be customized for use in developing countries to make them feasible.

Another study of thirty-four randomized controlled trials (RCT) was reviewed by (Ebbert et al.,

2015). The main objective of this review was to assess the effects of behavioral and

pharmacologic interventions for the treatment of SLT use with a follow-up time of at least six

months. Overall, 16,000 participants were included in thirty-four randomized trials. Out of these

thirty-four studies, sixteen studies were related to pharmacotherapies with 3722 participants.

Also, seventeen trials with 12,394 participants were tested for behavioral interventions. After the

meta-analyses of the studies, the authors of this study (Ebbert et al., 2015), found that behavioral

interventions showed a significant effect on the SLT abstinence rates. Even though, two trials of

varenicline with 507 participants (Ebbert et al., 2011; Fagerström et al., 2010) increased SLT

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abstinence rates at six months compared to placebo (RR 1.34, 95% CI 1.08 to 1.68. But, the

other pharmacotherapies such as bupropion (Dale et al., 2007; Dale et al., 2002), Nicotine

replacement therapy (NRT), nicotine patch, or nicotine gum did not increase tobacco abstinence

rates (Danaher et al., 2015; Ebbert et al., 2013; Ebbert et al., 2011; Stotts et al., 2003). Hence, we

can conclude that behavioral support studies were more helpful in increasing SLT abstinence

rates compared to pharmacotherapies.

In the same vein, studies on SLT usage among the general population are growing slowly and

gradually, but the prevalence of SLT users who are from the military background is found to be

almost twice as compared to the SLT users found in the general population (Severson et al.,

2009). This could be due to the use of SLT which has been increasing while smoking has been

decreasing over the same period. Thus, this change can be the result of severe restrictions on

smoking and the provision of tobacco cessation programs that target cessation of smoking rather

than of SLT among military individuals (Severson et al., 2009). Therefore, to shed light on this

issue, a study on SLT cessation intervention for SLT users among the military personnel of the

United States of America was reviewed by (Severson et al., 2009). The purpose of this RCT

study was to evaluate the SLT cessation intervention in military personnel. Total military

personnel of 785 participated in the RCT trial from across 24 military dental clinics. The authors

of this study found through chi-square analyses that, the behavioral SLT cessation interventions

such as counseling calls and self-help materials about quitting SLT were found to be effective as

compared to the usual care provided in dental clinics. Thus, we can depict from this study

(Severson et al., 2009) that, minimal SLT behavioral treatment can drastically decrease SLT use

in military personnel and has the prospective for huge applicability in a different context. Also, If

SLT users are identified in dental visits and routinely referred to SLT cessation interventions

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such as telephone counseling, or provision of self-help material, then it is expected that this

could have a significant effect on the health and wellbeing of military personnel. Subsequently,

one of the strengths of this study is that it is the largest studies of SLT cessation involving

military individuals. Moreover, with minimal effort of implementing SLT cessation, it records

great SLT quit rates.

Recommendations for Health workers:

The above literature review showed a variety of Smokeless Tobacco cessation interventions,

strategies, and appropriate settings for implementing SLT cessations. Hence, it can be concluded

that, for different regions, different SLT cessation interventions apply. However, overall

behavioral interventions provided by health professionals are deemed to be most effective in all

regions as compared to other interventions such as pharmacotherapy or nicotine replacement

strategies. The recommendations for health professionals are that SLT behavioral cessation

interventions should be implemented in all health settings of a country, especially those having a

high burden of SLT consumption, as behavioral interventions have been found to have maximum

benefit in SLT cessation as compared to other SLT cessation interventions (Ebbert et al., 2015;

Jitnarin et al., 2021; Lahoti & Dixit, 2021). Also, health care providers, specifically oral health

workers are recommended to utilize the WHO toolkit (WHO, 2017) as a part of their routine to

implement quick tobacco cessation interventions. These include the implementation of 5A’s

model i.e., Ask, advice, Assess, Assist and Arrange as well as 5R’s model i.e., Relevance, Risk,

Reward, Roadblocks, and Repetition (WHO, 2017). Furthermore, health workers should

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communicate the potential adverse health effects of the SLT as they are seen as reliable sources

and as they can indicate on the health effects of SLT this can impact to nudge the higher policy

changes and determine the local policies as well (Sutcliffe, 2012). Also, different regions or

countries have different cultural values, hence, to maximize the effectiveness of the

interventions, the SLT cessation should only be specific for that particular country rather than

apply to the whole world as there are differences between the developed and developing

countries. Subsequently, the social challenges of SLT users may also be one of the determinants

due to which the SLT dependence occurs therefore, asking the patients in a socially acceptable

and sensitive manner about the social challenges may help to create health care plan according to

the needs of the patient and the entire healthcare team can take these challenges into

consideration while conducting their sessions with such patients (Williams et al., 2016). Apart

from this, health care providers can also be useful in referring and identifying any underlying

issue that can be a cause of the dependence on the SLT substances, hence it is necessary for

healthcare workers to connect the patients with resources inside and outside of the healthcare

system. Furthermore, patients experience surveys can lead to creating better clinical practices to

determine which SLT cessation interventions are working and to which patients are more

responsive (Ali et al., 2008). By creating a relationship between health workers and community

members, multiple effective initiatives (e.g., ant tobacco education program, group counseling

session, cultural activities, can be taken against the reduction of SLT use, thus reducing oral

cancer incidences among the community. In the above-mentioned literature review, we also see

that the same interventions are more effective in one region and are less effective in the other.

Therefore, every country should have its own guidelines to reduce SLT cessation.

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Conclusion:

In summation, this literature review on the Effectiveness of Smokeless Tobacco Cessation

Interventions on Reducing Oral Cancer describes several effective methods to stop the usage of

SLT, thus reducing the risk of oral cancers. Due to the effective SLT cessation interventions, the

cost of oral cancers and other smoke-related diseases in a country will decrease in the long run.

Initially, the treatment and prevention of SLT users are capital intensive indeed, but also

beneficial in the long run for the prosperity of a country. Subsequently, to handle the situation

and using resources in a meaningful way, prevention strategies should be focused on rather than

treating SLT users. Throughout the above critical analysis of the literature, it has been evident

that SLT users are more prone to develop oral cancers as compared to individuals who do not

consume any tobacco products. Furthermore, preventative measures such as behavioral

interventions were seen to be more effective according to the literature review. An important

finding to emerge in this study is that each behavioral intervention will have a different effect on

each country depending on social and cultural factors. Hence, more research is needed country-

wise with the consideration of different social and cultural factors for the selected country to

minimize SLT usage. Although studies have been conducted by many authors, the problem of

SLT usage among different income statuses or differences between rural and urban SLT users is

still insufficiently explored. Therefore, there should be detailed research on the epidemiological

studies, different risk factors, risk assessment scales, and understanding of SLT usage in various

age groups of individuals to know more about the complexity of SLT usage and how to reduce

its consumption will be fruitful. SLT cessation intervention-based research needs encouragement

globally, especially in the low-income group countries which are deficient in tobacco cessation

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support. Lastly, it is concluded that behavioral interventions have been proven to be an

efficacious and feasible modality for SLT cessation intervention in all settings.

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