Study design
A questionnaire based cross sectional study was conducted from June 2018 to April 2019 among people aged more than 18 years who visited outreach programs of the Department of Public Health Dentistry, CODS, BPKIHS - Dharan, Nepal including dental camps. This study adhered to STROBE guidelines. BPKIHS is an autonomous Health Sciences University which is located at eastern part of Nepal in province one. It is the only Government University with tertiary care in eastern part of Nepal. It has extended its continued health services through teaching district concept to primary health care centers, district hospitals and zonal Hospitals in different parts of the region. Study was conducted during regular outreach programs of Department of Public Health Dentistry including dental camps.
Setting and participants of the study
Data collection was done in five districts out of 14 districts in state number one and one district from state number two using convenience sampling technique. Outreach programs were conducted once a week in one of the centers. Dental camps were organized once a month in support with local authorities for the needy people. All the people who had fulfilled the eligibility criteria and had given written informed consent were included in this study. Outreach programs of the department of public health dentistry included two primary health care center, one family health care center, two health post and the dental camps in 13 various sites. Out of these centers three were located in urban areas, two were located in rural areas. Dental camps meanwhile were organized in rural areas.
Eligibility criteria
People aged more than 18 years who had visited outreach programs of the Department of Public Health Dentistry, BPKIHS-Dharan, Nepal including dental camps were included in this study. People with medical or psychiatric condition who were unable to respond to the questions were excluded.
Ethical approval
Ethical approval was obtained from the Institutional Review Committee, B.P.Koirala Institute of Health Sciences, Dharan, Nepal (Ref. No: 398/074/075-IRC and Code No: IRC/1191/017). Signed informed consent was obtained from each participant.
Study size
The sample size was calculated by taking the prevalence of tobacco use in Nepal (30.8%) [13]; considering 95% CI, 5% absolute precision and 15% non-response rate, calculated sample size was 378. Sample size was calculated using following formula [(Zα/2)2pq/L2]. As convenience method of sampling was used, the number from each center was not predetermined. Sample collection was done till the sample size was reached.
Demographic characteristics
Demographic variables consisting of age, sex, occupation, marital status, education (illiterate, primary level, middle class level, secondary level, high school level and graduate or postgraduate) income of the family and socioeconomic status (SES) was calculated using Kuppuswamy scale and classified as per the modifications done in the year 2009 (Ghosh and Ghosh, 2009) using current consumer price index for the year 2017. The current consumer price index was obtained online from Nepal Rastra Bank website (Nepal RB 2017) and the conversion factor was calculated (Conversion factor = Consumer Price Index 2017 divided by Consumer Price Index of 1976). The computed conversion factor was 26.7 (114.8/4.3). For simplicity, SES was categorized into upper (26–29), middle (11–25) and lower (≤5–10) class.
Other variables used in this study were:
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1.
Do you drink alcohol? (yes or no).
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2.
Do any other members in your family smoke/tobacco chew? (yes or no).
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3.
At what age do you started smoking/chewing tobacco?
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4.
Total duration of smoking/tobacco chewing in years.
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5.
Ever tried to quit smoking/tobacco chewing in last 1 year: yes/no.
The following forms of tobacco use were recorded for tobacco prevalence. Smoking: manufactured cigarettes, cigar, bidis and pipe. Tobacco chewing: khaini, gutka, loose-leaf of tobacco, and gul.
Nicotine dependence
A standard questionnaire proforma of Fagerstrom Test for Nicotine Dependence (FTND Revised Version) for smoking given by Heatherton et al. [14] and smokeless form of tobacco given by Ebbert et al. [15] was translated and validated in Nepali language through standard WHO guidelines. During back translation, the meanings of some questions were modified, so the questions were modified keeping the same scoring criteria (Appendix 1). This modified standard translated and validated questionnaire in Nepali language was administered to each participant by face-to-face interview by the single investigator. Each Smoking and smokeless tobacco questionnaire consisted of 6 questions, carrying score/point based on the answer given. The score ranged from 0 to 10. Based on the calculated score dependency was categorized as highly dependent (7–10), moderately dependent (4–6) and minimally dependent (< 4). Further it was categorized into nicotine dependency (highly and moderately dependent) and no nicotine dependency (minimally dependent).
The higher the Fagerström score, the more intense was the patient’s physical dependence on nicotine. Higher scores indicated that treatment of withdrawal symptoms, usually with nicotine replacement therapy, will be an important factor in the patient’s plan of care.
Operational definitions
a. Current smokers: People who reported smoking at least 100 cigarettes during their lifetime and who, at the time they participated in a survey, reported smoking every day or some days. Current smokeless tobacco product users: Chewing tobacco at least once during their lifetime and, at the time of the survey, using every day or some days. b. Nontobacco users: Never used tobacco. c. Ex-tobacco user: Stopped more than 1 month prior to the examination.
All the subjects were advised for smoking/tobacco cessation and tobacco cessation counselling was given to every one after administration of questionnaire. Behavioral cognitive therapy was given involving 5 “A” and 5 “R” technique.
Statistical analysis
After completion of the survey, data obtained was entered in Microsoft Excel Sheet version 2007 and analyzed using the Statistical Package for Social Sciences (SPSS version 11.5). Descriptive statistics including the mean, median, percentage, standard deviations and interquartile range were computed. FTND score was categorized as high, moderate and minimal dependent. Further it was categorized as nicotine dependent (high and moderate) and nicotine not dependent (minimal dependent) for analysis of association. Chi-square test and Fisher’s exact tests were used to compare the proportion difference between categorical variables where needed. Relationship between FTND score and different study variables (gender, mean age of initiation and total duration of tobacco use, SES, marital status, occupation, alcohol use, number of cigarettes smoked per day, number of packets/cans of smokeless tobacco chewed/day and family member smoking/chewing tobacco) were computed for odds ratio. Univariate and binary logistic regression analyses were performed to find the association between the different variables and FTND score and nicotine dependence and their odds ratios (OR) were calculated.