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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 2  |  Issue : 3  |  Page : 74-79

Comparative evaluation of cognitive behavioral therapy and regular health education in reducing nicotine dependence among cigarette smokers: A randomized controlled trial


1 Department of Orthodontics, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India
2 Department of Prosthodontics, Sree Sai Dental College and Research Institute, Srikakulam, Andhra Pradesh, India
3 Department of Orthodontics, Konaseema Institute of Dental Sciences, Amalapuram, Andhra Pradesh, India
4 General Dental Practitioner, Smile Dental Clinic, Guntur, Andhra Pradesh, India
5 Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
6 General Dental Practitioner, Nidhi's Dental Care, Vijayawada, Andhra Pradesh, India

Date of Submission06-Apr-2021
Date of Decision04-May-2021
Date of Acceptance17-May-2021
Date of Web Publication29-Sep-2021

Correspondence Address:
Dr. Pavan Kumar Chiluvuri
Department of Orthodontics, Konaseema Institute of Dental Sciences, Amalapuram - 533 201, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jopcs.jopcs_10_21

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  Abstract 


Introduction: It is important to introspect if the methods used in tobacco cessation counseling are effective in achieving abstinence and reducing nicotine dependence among tobacco users. The objective of this study was to evaluate the effectiveness of cognitive behavioral therapy (CBT) at tobacco cessation clinics in a teaching dental institution in reducing nicotine dependence among dental patients with the habit of cigarette smoking in comparison to regular health education to quit tobacco. Materials and Methods: This prospective, randomized controlled trial was conducted in a teaching dental institution in the state of Andhra Pradesh. 160 self-reported current cigarette smokers with no tobacco chewing habits participated in the study. 80 each were assigned to the intervention group and control group where CBT for cessation of cigarette smoking and regular health education to quit smoking were provided, respectively. Data relating to frequency of cigarette smoking and nicotine dependence scores using Fagerstrom nicotine dependence scale were collected at baseline. Both the groups were followed up for 4 months in two-monthly intervals. IBM SPSS version 20 software was used for data analysis. Results: While there was no significant difference in the mean nicotine dependence score between the study groups at baseline, a statistically significant difference was observed between the groups at follow up visits. Repeated measures analysis of variance revealed significant reduction in nicotine dependence scores with time in the intervention group (P = 0.004), whereas the differences in the control group between different study time points were not significant (P = 0.39). It was also observed that the frequency of cigarette smoking reduced significantly between the baseline and follow-up visits in the intervention group (Cochran's Q-test; P = 0.028). Conclusion: The findings of this study provide an insight into the fact that CBT as tobacco cessation counseling technique is effective in reducing nicotine dependence among subjects seeking oral health care.

Keywords: Dental Council of India, Fagerstrom scale, nicotine dependence


How to cite this article:
Datla PK, Mukarla NP, Chiluvuri PK, Naidu SS, Darisi R, Priya KT, Kapalavayi A. Comparative evaluation of cognitive behavioral therapy and regular health education in reducing nicotine dependence among cigarette smokers: A randomized controlled trial. J Prim Care Spec 2021;2:74-9

How to cite this URL:
Datla PK, Mukarla NP, Chiluvuri PK, Naidu SS, Darisi R, Priya KT, Kapalavayi A. Comparative evaluation of cognitive behavioral therapy and regular health education in reducing nicotine dependence among cigarette smokers: A randomized controlled trial. J Prim Care Spec [serial online] 2021 [cited 2021 Oct 27];2:74-9. Available from: http://www.jpcs.com/text.asp?2021/2/3/74/327051




  Introduction Top


Tobacco consumption emerged as one of the most common and most deleterious habits in the recent decades.[1] The global statistics reveal the ubiquitous nature of tobacco use.[2] In India, the habit of tobacco consumption is very prevalent with nearly 30% of all adults consuming tobacco in one form or the other.[3] 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.[4] In the Indian context, lot of efforts have been directed toward making people aware of the ill effects of tobacco. The Indian government launched National Tobacco Control Programme in 2007 to bring down the growing consumption of tobacco, and constituted the National Tobacco Control Cell, organizing at the national, state, and district levels.[5]

Although oral health-care professionals are well informed about the scope dental profession has in identifying tobacco users and offering tobacco cessation counseling, it is seldom considered as an integral part of the provision of oral health care.[6],[7],[8] However, cognitive behavioral therapy (CBT) at the dental office is evolving to be an effective means of achieving tobacco cessation among patients.[9],[10] CBT attempts to modify and rearticulate the thought processes and enables learning of new behaviors all of which are conducive for successfully quitting tobacco.[9] Besides providing information about the quit process, CBT also attempts to identify the reasonable ways to achieve modifications in the thinking process, identify motivational cues from previous quit attempts, should there be any, develop aversion toward tobacco use, and draft customized strategies to counter the circumstances that preclude cessation of tobacco use.[10] On the other hand, regular health education at oral health-care facilities emphasizes on the ill effects of tobacco cessation and encourages participants to quit tobacco, meaning that the primary objective in regular health education is the provision of information.

With this background, the objective of this study was to evaluate the effectiveness of CBT in reducing nicotine dependence among dental patients who are cigarette smokers in comparison to regular health education to quit cigarette smoking.


  Materials and Methods Top


This prospective, randomized controlled trial was conducted in a teaching dental institution in the state of Andhra Pradesh. The study was conducted from February, 2019 to September, 2019. Ethical approval for the study was obtained from the Institutional Review Board (IRB) (09-19-IRB-KIDS) of the corresponding institution. Administrative authorities of the participating institution were approached and prior permissions were obtained before the conduct of the study. Sample size for the study was determined using G*power 3.1.9.2 software (G*power 3.1: University of Dusseldorf, Germany) (α error probability – 0.05; power – 0.8; effect size – 0.5; allocation ratio – 1). Sample size was determined to be 128 (64 in each group); 160 cigarette smokers were recruited in the study to accommodate for an anticipated loss to follow up of 20%. All the 160 participants were self-reported current smokers with no tobacco chewing habits. Informed consent was signed by all the study participants before administration of the intervention. Randomization sequence was generated using Microsoft excel 2016 and participants were assigned to either of the study groups following the sequence.

A single investigator trained in CBT for tobacco cessation counseling conducted one-to-one counseling for the participants in the CBT arm. The subjects in the CBT arm discussed significant barriers for quitting tobacco and were provided with solutions to overcome the barriers together with measures to improve self-efficacy. The primary focus in all the CBT sessions was to modify the thought processes of the participants so as to perceive risk, offer support and necessary training to quit cigarette smoking and to deal with potential relapse. CBT sessions were conducted at baseline, and follow-up visits after the collection of the study data. The counseling session lasted for 23.4 ± 4.6 min on an average. In the control arm, conventional chair side advice was given to participants to refrain from tobacco use along with information on the ill-effects of tobacco. In both the groups, nicotine dependence scores were calculated at baseline using Fagerstrom nicotine dependence scale.[11] Age, frequency of tobacco use, and chief complaint for which the subject sought oral health care were the background variables considered in this study. Both the groups were followed up for 4 months in two-monthly intervals, where the Fagerstrom nicotine dependence scores were documented. During the two follow-up visits, subjects in the CBT arm were interviewed with regard to changes in smoking behaviors and the benefits of tobacco cessation were reinforced along with provision of oral health care as necessary. The participants in the control group received the information and advice similar to what they received at baseline. [Figure 1] shows the CONSORT flow diagram of the study. Statistical analysis was done using IBM SPSS version 20 software (IBM SPSS, IBM, Armonk, NY, USA). The final sample constituted 69 in the intervention group and 73 in the control group. Descriptive statistics, independent samples t-test, one-way analysis of variance (ANOVA) with Tukey's post hoc analysis, repeated measures ANOVA with Mann–Whitney post hoc tests, and Cochran's Q-test were employed in data analysis.
Figure 1: Study flowchart

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  Results Top


The mean age of the study participants was 51.32 ± 7.9 years in the CBT arm and 49.6 ± 6.1 years in the control group. All the study participants were males. [Table 1] shows the distribution of study subjects based on age, frequency of smoking at baseline dichotomized based on the cut-off of 5 cigarettes per day, and the chief complaint for which they sought oral health care. The mean nicotine dependence score of the study subjects in the intervention group at baseline was 4.77 ± 2.1, which is comparable to the dependence score of 4.41 ± 1.89 in the control group (independent samples t-test; P = 0.26). [Table 2] shows the item wise descriptive statistics of the responses to Fagerstrom scale by participants in the intervention and control groups at baseline. While there was no significant difference in the mean nicotine dependence score between the study groups at baseline, a statistically significant difference was observed between the groups at follow up visit [Table 3]. [Figure 2] shows within-group comparisons of mean nicotine dependence scores and number of cigarettes smoked per day from baseline to follow-up visits. Repeated measures ANOVA revealed significant difference with time in the intervention group (P = 0.004), whereas the differences in the control group between different study time points were not significant (P = 0.39). A stratified analysis of change in mean Fagerstrom scale scores in the intervention group based on age group and frequency of smoking was presented in [Table 4]. Frequency of tobacco usage was identified as an effect modifier in the association between tobacco cessation counseling and decline in nicotine dependence. No significant differences were observed across different age strata. It was also observed that the frequency of cigarette smoking reduced significantly between the baseline and follow-up visits in the intervention group (Cochran's Q-test; P = 0.028), while the difference was not statistically significant in the control group (Cochran's Q-test; P = 0.37).
Table 1: Descriptive statistics of the background characteristics at baseline

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Table 2: Item wise descriptive statistics of the responses to Fagerstrom Scale at baseline

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Table 3: Comparison of mean nicotine dependence scores between the study groups at baseline, 2 months, and 4 months follow-up

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Table 4: Stratified analysis of mean change in nicotine dependence scores from baseline to 4 months follow-up in the intervention group

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Figure 2: Changes in the mean nicotine dependence score within each of the study groups with change in time

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  Discussion Top


Cigarette smoking is responsible for chronic diseases such as lung cancer that tend to manifest in the later part of life besides compromising the quality of life owing to 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. However, the immediate ill effects of cigarette smoking on health are important in the public health purview as these effects mechanistically contribute to the manifestation of chronic diseases in the later years of life.[12] The severity of exposure plays a crucial role in determination of the potential harm caused by cigarette smoking as the complex mixture of high doses of toxicants in cigarettes lead to a multitude of adverse health conditions when inhaled repeatedly for prolonged periods of time.[13] More immediately, the habit can lead to diminishing of health status which is evident from the poor self-rated health among the smokers, biomarkers of physiologic disadvantage, and vulnerability to develop acute respiratory illnesses. The long-term impact of cigarette smoking includes a range of conditions integral of coronary heart disease, chronic obstructive pulmonary disease and so on.[14] Owing to this notorious impact of cigarette smoking on health, it is imperative for health-care professionals from diverse disciplines to make sustained efforts to reduce the habit of tobacco consumption in the communities they serve.

Tobacco cessation counseling has been proven to be effective in enabling people to quit tobacco. In the present study, CBT tailored to individual contexts which was provided on a one-to-one basis was found to be more productive in reducing or reversing the habit of cigarette smoking compared to regular health education that emphasized on mere provision of information. In CBT, the discussions vary depending on the patient's context taking into consideration his/her problems in quitting cigarettes and finding ways to overcome the problems in an empirically substantiated manner.[15] Another fundamental advantage of CBT is its focus on breaking down problems to present them as small parts and the emphasis on existing concerns without placing undue attention on the concerns in the past. There are numerous studies in literature which reported the effectiveness of various educational interventions on tobacco cessation.[16],[17],[18],[19],[20],[21] The findings of this study were similar to those reported in the literature, with subjects from the CBT arm demonstrating reducing frequency of cigarette smoking and lower mean Fagerstrom scale scores compared to the control group.

The mean age of the participants in this study was comparable to the mean age reported in the studies conducted by Farooq et al.[18] and Evins et al.[22] All the study participants were males which is similar to other studies on tobacco cessation counseling conducted by Farooq et al.,[18] Park et al.,[20] Hill et al.[23] This is one of the first attempts to consider the chief complaint at initial visit to possibly play a role in subject's interest and attention to tobacco cessation counseling, especially in light of the fact that the study participants were care seekers at oral health-care facilities. Chief complaints at the initial visit may act as an effect modifier in the association between the intervention and the outcome of nicotine dependence. However, no significant differences in the chief complaints of subjects were observed between participants from the intervention and control arm.

Nearly 40% 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.,[19] where only 10% of the study participants smoked <10 cigarettes per day and another study conducted by Farooq et al.,[18] where 75% of the subjects reported smoking <10 cigarettes per day. A significant difference was observed between participants who reported <5 cigarettes/day and ≥5 cigarettes/day at baseline in the mean change of nicotine dependence score from baseline to 4 months follow-up. This signifies the fact that magnitude of indulgence in the habit does have a role in determining the adherence of the participants to the instructions given and the ability to successfully quit the habit of cigarette smoking. The baseline nicotine dependence score in this study across groups was 4.59 which is comparable to the reports published by Webb et al.,[21] and Malhi et al.[24] There were significant differences in the mean nicotine dependence scores between the intervention and control groups at both the follow-up visits in this study, which is comparable to the results reported by Schnoll et al.,[16] Sykes and Marks,[17] Evins et al.[22] However, no differences in the mean nicotine dependence scores were observed in the control group from baseline to follow-up, which is contrary to the observations made by Raja et al.[19] Despite the existing empirical evidence which supports the provision of tobacco cessation counseling at dental settings to be effective in achieving the desired outcomes, the perceptions of oral health-care professionals toward such provision remains an area of concern.[25] Dentists and primary care physicians assume an important role in increasing the tobacco quit incidence. This notion is further reinforced by the inextricable link between oral and general health with oral health being designated as a necessary part of primary care.[26] According to literature, oral health professionals who are invested into providing an effective cessation program could achieve an annual quit rate of up to 15%.[27] In light of these observations and also keeping in view the negative influence of tobacco on the health related quality of life of people, provision of tobacco cessation counseling at dental settings contribute toward public health and primary health care. In order to more effectively achieve the desired outcomes, there is a need to train oral health-care professionals in pharmacological aspects of tobacco cessation counseling as well.[28]

The limitations of the present study include restriction to cigarette smoking and reliance on self-reported behaviors in determining the effectiveness of the intervention. Nevertheless, the study results demonstrate significantly superior nature of CBT when compared to regular health education in cessation of cigarette smoking. Future studies can focus on obtaining serum/urinary/salivary cotinine levels to eliminate the possibility of response bias for social desirability.


  Conclusion Top


The directives given by the Ministry of Health and Family Welfare in association with Dental council of India to set up TCC at every teaching dental institution is laudable and demonstrates the commitment at policy level toward bringing down tobacco consumption in the country. The findings of this study provide an insight into the fact that CBT is effective in the provision of tobacco cessation counseling. Therefore, formal training sessions for dental students in CBT render the cessation counseling more effective in light of the existing empirical evidence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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