Non-compliant packaging and illicit smokeless tobacco in Bangladesh, India and Pakistan: findings of a pack analysis

INTRODUCTION

Illicit smokeless tobacco (ST) trade has seldom been documented despite ST use in at least 127 countries across the world. Based on non-compliance with packaging regulations, we report the proportion of illicit ST products from samples on sale in Bangladesh, India and Pakistan where 85% of global ST users reside.

METHODS

We purchased unique ST products from tobacco sellers in two purposively selected administrative areas (division/district) in each of the three countries. The criteria to determine illicit ST products were based on country-specific legal requirements for ST packaging and labelling. These requirements included: 'market retail price disclosure', 'sale statement disclosure', 'pictorial health warning (PHW) pertinence', 'appropriate textual health warning' and 'using misleading descriptors (MDs)'. Non-compliance with even one of the legal requirements was considered to render the ST product illicit.

RESULTS

Almost all ST products bought in Bangladesh and India were non-compliant with the local packaging requirements and hence potentially illicit, all products in Pakistan lacked desirable features. The most common feature missing was health warnings: 84% packs in Bangladesh, 93% in India, and 100% in Pakistan either did not have PHW or their sizes were too small. In Bangladesh, 61% packs carried MDs. In India and Pakistan, the proportions of such packs were 32% and 42%, respectively.

CONCLUSIONS

Weak and poorly enforced ST control policies may be slowing the progress of tobacco control in South Asia. Standardised regulations are required for packaging and labelling ST. Improving compliance and reducing sale of cheap illicit products may require business licensing and market surveillance.

Behavioural support and nicotine replacement therapy for smokeless tobacco cessation: protocol for a pilot randomised-controlled multi-country trial

BACKGROUND

Smokeless tobacco (ST) is consumed globally by more than 350 million people, with approximately 85% of all users based in South and Southeast Asia. In this region, ST products are cheap and easily accessible. Evidence-based interventions to people quit ST use are lacking. This study aims to test the feasibility of conducting a future definitive trial of ST cessation, using a culturally adapted behavioural intervention, and/or nicotine replacement therapy (NRT) in three South Asian countries.

METHODS

We will conduct a factorial design, randomised-controlled pilot trial in Bangladesh, India and Pakistan. Daily ST users will be recruited from primary health care settings in Dhaka, Noida and Karachi. Participants will be individually randomised to receive intervention A (4 or 6 mg NRT chewing gum for 8-weeks), intervention B (BISCA: face-to-face behavioural support for ST cessation), a combination of interventions A and B or usual care (Very Brief Advice - VBA). The participants will provide demographic and ST use related data at baseline, and at 6, 12 and 26 weeks of follow-up. Salivary cotinine samples will be collected at baseline and 26 weeks. The analyses will undertake an assessment of the feasibility of recruitment, randomisation, data collection and participant retention, as well as the feasibility of intervention delivery. We will also identify potential cessation outcomes to inform the main trial, understand the implementation, context and mechanisms of impact through a process evaluation and, thirdly, establish health resource use and impact on the quality of life through health economic data.

DISCUSSION

The widespread and continued use of ST products in South Asia is consistent with a high rate of associated diseases and negative impact on the quality of life. The identification of feasible, effective and cost-effective interventions for ST is necessary to inform national and regional efforts to reduce ST use at the population level. The findings of this pilot trial will inform the development of larger trials for ST cessation among South Asian users, with relevance to wider regions and populations having high rates of ST use.

TRIAL REGISTRATION

ISRCTN identifier 65109397.

Smokeless Tobacco Initiation, Use, and Cessation in South Asia: A Qualitative Assessment

Introduction

Smokeless tobacco (ST) is a significant South Asian public health problem. This paper reports a qualitative study of a sample of South Asian ST users.

Methods

Interviews, using a piloted topic guide, with 33 consenting, urban dwelling adult ST users explored their ST initiation, continued use, and cessation attempts. Framework data analysis was used to analyze country specific data before a thematic cross-country synthesis was completed.

Results

Participants reported long-term ST use and high dependency. All reported strong cessation motivation and multiple failed attempts because of ease of purchasing ST, tobacco dependency, and lack of institutional support.

Conclusions

Interventions to support cessation attempts among consumers of South Asian ST products should address the multiple challenges of developing an integrated ST policy, including cessation services.

Implications

This study provides detailed understanding of the barriers and drivers to ST initiation, use, and cessation for users in Bangladesh, India, and Pakistan. It is the first study to directly compare these three countries. The insight was then used to adapt an existing behavioral support intervention for ST cessation for testing in these countries.

Smokeless tobacco products, supply chain and retailers' practices in England: a multimethods study to inform policy

BACKGROUND

In England, many people of South Asian origin consume smokeless tobacco (ST). ST use can lead to oral cancer, which is disproportionately high in South Asians. Our aims were to assess the compliance of ST product retailers with statutory regulations and to explore the supply chain of ST.

METHODS

We undertook a multimethods study between August 2017 and July 2019 in five English boroughs with a high proportion of ethnic South Asians. We purchased ST products and conducted field surveys with ST retailers at point of sale. Qualitative interviews were conducted with ST retailers and suppliers. ST packs were assessed for regulatory compliance, while quantitative and qualitative data triangulated information on retailers' practices and the ST supply chain.

RESULTS

We collected 41 unique ST products, which included dry snuff, naswar, gutka, chewing tobacco and zarda. ST products were not registered, and demonstrated low compliance with health warning (14.6%) and packaging (56.1%) requirements. ST availability in surveyed boroughs was high (38.2%-69.7%); dry snuff, naswar and zarda were most commonly available. ST retailers demonstrated limited knowledge of regulations, and one-third were found to advertise ST at point of sale. Qualitative insights revealed illicit supply and distribution networks, as well as ST production in discreet locations.

CONCLUSION

ST products are widely available in England, yet non-compliant with statutory regulations. In order to safeguard consumers, in particular ethnic South Asians, stronger efforts are needed to regulate the supply chain of ST at both national and international levels.

The Epidemiology of Tobacco Use among Khat Users: A Systematic Review

Khat, an "amphetamine-like green leaf," may influence the consumption of tobacco. This study reviews the epidemiology of tobacco use among khat users. Electronic database searches using appropriate keywords/terms were conducted to identify observational studies of khat use. Assessment of quality and risk of bias of all included studies was conducted, and the results were synthesised descriptively. Nine eligible cross-sectional studies were identified. All assessed self-reported tobacco among khat users and were carried out in Africa and the Middle East. Eight reported cigarettes and one reported waterpipes as the mode of use. Methods of tobacco use prevalence assessment varied. Prevalence of "current" tobacco use among students and university teachers ranged from 29 to 37%; "lifetime" tobacco use in university teachers was 58% and "undefined" tobacco use in nonspecific adults and students ranged from 17 to 78%. Daily tobacco use among adults was reported as 17% whilst simultaneous tobacco and khat use was reported as between 14 and 30% in students. In conclusion, tobacco prevalence among khat users appears significant. Findings should be interpreted cautiously due to self-reported tobacco use, diversity in questions assessing tobacco use, and type of tobacco consumption. Future research should address the methodological shortcomings identified in this review before appropriate policy interventions can be developed.

Short-Term Smoking Cessation in English Resident Adults of Bangladeshi Origin: A Service Review

INTRODUCTION

Cigarette smoking in English residents of Bangladeshi origin, particularly men, exceeds national estimates. Cessation outcomes and potential predictors of successful cigarette smoking cessation in this group await identification.

METHODS

This service review reports cessation outcomes and predictors of success for 324 adult English resident Bangladeshi origin smokers recruited into a project providing a specialist tobacco cessation service. Interview measures included sociodemographics, tobacco use and dependence. Cessation data (self-reported and validated) at 4 weeks was also collected. Cessation rate and predictors of successful cessation, modeled using multiple logistic regressions, are reported.

RESULTS

Clients' mean age was 45.59 (SD = 13.83) years. Thirty-three (10%) were females. Mean level of small area deprivation was 56.98 (SD = 5.37). Initial mean expired air carbon monoxide score was 11.66 parts per million (SD = 7.17). Thirty-eight per cent used combination nicotine replacement therapy (NRT) with behavioral support. Sixty-nine percent reported successful smoking cessation after 4 weeks, validated with carbon monoxide (mean =1.23 parts per million, SD = 1.32). Predictors of successful cessation were use of combined NRT with behavioral support (OR = 1.82, 95% CI = 1.07, 3.09), and community recruitment (OR = 1.85, 95% CI = 1.07, 3.22).

CONCLUSIONS

English adult smokers of Bangladeshi origin resident in a highly disadvantaged locality, accessing community outreach services to help them quit and using NRT have validated short-term success rates greater than that locality's general population who access National Health Service Stop Smoking Services to quit.

Khat dependence syndrome: a cross sectional preliminary evaluation amongst UK-resident Yemeni khat chewers

ETHNOPHARMACOLOGICAL RELEVANCE

Khat is a natural psychostimulant that has pharmacological effects similar to that of amphetamine. The behaviour of khat chewing is embedded within a cultural context. Meanwhile khat chewing is associated with psychological and physiologically burden, as a 'dependence producing' substance.

AIMS OF THE STUDY

To assess the applicability of the construct of substance dependence syndrome (DSM-IV, 1994) to khat chewing and to examine psychosocial and behavioural correlates of this syndrome including tobacco use.

MATERIALS AND METHODS

A sample of 204 khat chewers was recruited during random visits to khat sale outlets. A face to face interview that assessed socio-demographic, psychosocial dependence, substance dependence syndrome and behavioural characteristics was conducted. Descriptive, exploratory psychometric and multivariate analyses were employed.

RESULTS

Approximately a third (31%) of khat chewers reported symptoms consistent with dependence syndrome including increased khat chewing (13%) and cessation attempts (19%) while 17% reported withdrawal symptoms including depression (61%), increase in appetite (74%) and interrupted sleep (58%). Thirty-eight percent reported continued khat chewing despite impacts on their health. Psychometric assessment of the DSM-IV criteria for khat chewing dependence identified two factors; factor 1 consisted of bio-behavioural items and factor 2 withdrawal items, accounting for 67% of the variance and Cronbach's alpha coefficient at 0.78. In multivariate logistic regression modelling, there was an association between intensity of psychological khat dependence (SDS-Khat) and nicotine dependence with the likelihood of exhibiting khat chewing dependence syndrome (p=0.0005, OR=1.51, 95%CI=1.33-1.71; p=0.043, OR=2.87, 95%CI=1.03-7.98, respectively).

CONCLUSIONS

The substance dependence syndrome criteria are applicable to khat chewing and associated with increased intensity of nicotine and psychological khat dependence. The applicability of khat dependence syndrome and exploration of its dimensions and associated factors should be extended in future research. Concurrent validation of these findings using specific objective measures for self-report khat chewing is also recommended.

Smokeless tobacco cessation in South Asian communities: a multi-centre prospective cohort study

AIM

To evaluate smokeless tobacco cessation in communities of South Asian origin.

DESIGN

Multi-centre prospective cohort study.

SETTING

Three tobacco cessation services offering specialist smokeless tobacco cessation outreach clinic support to South Asians (Bangladeshi, Indian and Pakistani) resident in England.

PARTICIPANTS

A total of 239 South Asian participants seeking to stop smokeless tobacco use between November 2010 and December 2011.

MEASUREMENTS

Socio-demographics, tobacco use and dependence, self-reported abstinence at 4 weeks and satisfaction measures.

FINDINGS

Participants' mean age was 45 [standard deviation (SD) = 13] years, were predominantly female (76%), of Bangladeshi origin (74%), either home carers (53%) or not working (29%). Sixty-three per cent were recruited from community locations, 21% through a clinical contact and 16% through friends and family. Mean daily number of smokeless tobacco intakes was 10 (SD = 7) and the mean dependence score was 4.5 (SD = 1.9). Sixty-three per cent of participants achieved continuous abstinence 4 weeks after quitting. Using nicotine replacement therapy (NRT) versus not using it [OR = 3.47, 95% confidence interval (CI): 1.25, 9.62] and below median (≤ 8) daily smokeless tobacco intakes (OR = 1.91, 95% CI: 1.07, 3.40) predicted successful abstinence.

CONCLUSION

South Asian smokeless tobacco users resident in England accessing services to help them stop appear to have short-term success rates comparable with smokers attending stop-smoking services, with higher success rates being reported by those using nicotine replacement therapy.

Oral pain before and after smokeless tobacco cessation in U.K.-resident Bangladeshi women: cross-sectional analyses

INTRODUCTION

Paan quid with tobacco (PQT) use is common in South Asian populations. Oral pain following a PQT cessation attempt is commonly reported. Factors determining this await full exploration.

METHODS

This prospective study of PQT chewers used a prepiloted interview and clinical examination. Oral pain, socioeconomic position, oral status, health service use, tobacco use and dependency, and psychological distress measures were collected from U.K.-resident Bangladeshi women before and after their quit attempts. Analysis included descriptive and analytic modeling of oral pain determinants, using multiple logistic regressions and a significance value p ≤ .05.

RESULTS

A total of 150 females (mean age 51.2 [SD = 13.7, range = 24-84] years) completed the study. Baseline oral pain prevalence was 39% and 73% at follow-up. Completed education level predicted baseline oral pain (OR = 3.43, 95% CI [1.66, 7.11], p = .001). Follow-up oral pain was predicted by completed education level (OR = 3.74, 95% CI [1.43, 9.79], p = .007), anxiety (OR = 3.52, 95% CI [1.23, 10.07], p = .019), choosing behavioral support alone in the cessation attempt (OR = 3.12, 95% CI [1.26, 8.70], p = .015), failure to stop tobacco chewing during the cessation attempt (OR = 4.16, 95% CI [1.44, 12.04], p = .009), and tooth wear (attrition) (OR = 5.71, 95% CI [1.84, 17.79], p = .003). Lower dependency level (OR = 0.79, 95% CI [0.64, 0.97], p = .023) was protective.

CONCLUSION

Dental care access, nicotine replacement therapy, and anxiety management should be incorporated into cessation service delivery protocols to manage oral pain onset and facilitate successful cessation.

Predictors of successful short-term tobacco cessation in UK resident female Bangladeshi tobacco chewers

AIM

  To identify predictors of short-term smokeless tobacco cessation in Bangladeshi women resident in the United Kingdom.

DESIGN

  Prospective cohort study.

SETTING

  A tobacco cessation service offering culturally tailored smokeless tobacco cessation support.

PARTICIPANTS

  A total of 419 Bangladeshi women chewing paan with tobacco.

MEASUREMENTS

  Demographics, tobacco use and dependence and cessation attempt process and outcomes.

FINDINGS

  Client mean age was 48.92 [95% confidence interval (CI) 47.5, 50.34] years and the mean area social deprivation score was 3.65 (95% CI 3.33, 3.97). Mean daily smokeless tobacco intakes, as paan, was 9.96 (95% CI 9.22, 10.7); 69.8% were recruited from primary care, 78.8% received behavioural support and nicotine replacement therapy (NRT) and the remainder behavioural support alone. Self-reported 4-week continuous abstinence was 58.3%, predicted by NRT use [odds ratio (OR) = 4.93, 95% CI 2.02, 12.00], community recruitment (OR = 1.84, 95% CI 1.01, 3.35) and relatively lower social deprivation (IMD) score (OR = 1.98, 95% CI 1.18, 3.33).

CONCLUSION

  Bangladeshi women in the UK attending clinics to help cessation of paan with tobacco appear to be more likely to be successful in the short term if they use nicotine replacement therapy, are recruited via the community and have relatively lower levels of social deprivation.

Factors associated with dental and medical care attendance in UK resident Yemeni khat chewers: a cross sectional study

Background

The chewing of khat leaf with tobacco smoking amongst Yemenis, Somalis and Ethiopians is reported to impact oral and general health. The health status and particularly dental and medical care attendance of UK-khat chewers has not received attention. This study aimed to explore health status and dental and medical attendance and its associated factors in UK permanently resident Yemeni khat chewers.

Methods

A cross- sectional study with a purposively selected sample of 204 khat chewers was conducted. Data were collected through face to face interviews. Data analysis included descriptive, Chi-square tests and binary logistic regressions.

Results

The mean age for this study sample was 44.84 (SD = ±19.70) years and 35% were employed. Forty five percent reported symptomatic medical attendance for self reported health conditions in the last two weeks whilst 44% had symptomatic dental attendance. Higher khat chewing dependency levels associated positively with both symptomatic dental and medical attendance (p = 0.004, OR = 1.14, 95%CI = 1.04-1.25; p = 0.003; OR = 1.16, 95%CI = 1.05-1.29, respectively). Higher social participation levels associated negatively with symptomatic dental attendance (p = 0.034, OR = 0.98, 95%CI = 0.96-0.99) whilst increase in age and self-reported health conditions associated positively with symptomatic medical attendance (p = 0.030, OR = 1.03, 95%CI = 1.01-1.06; p = 0.001, OR = 4.51, 95%CI = 2.02-10.08, respectively).

Conclusions

In this study of khat chewers, a significant proportion reported symptomatic dental and medical attendance. Demographic, psychosocial and self reported general health conditions were associated significantly with dental and medical attendance. Strategies to improve the dental and medical care attendance amongst this group should focus on these and other unexplored underlying factors.

Validation of self-reported khat chewing amongst khat chewers: an exploratory study

ETHNOPHARMACOLOGICAL RELEVANCE

Khat chewing amongst the UK communities originating from Yemen and the East African coast is suggested to create dependency through its main stimulant components (cathinone, norephedrine and norpseudoephedrine) on the central nervous system.

AIMS OF THE STUDY

To validate self-reported khat chewing behaviours by measuring levels of cathinone, norephedrine and norpseudoephedrine in saliva and to explore their associations with self-reported khat chewing dependency.

MATERIALS AND METHODS

Face-to-face interviews were conducted amongst 30 male UK-resident khat chewers. Saliva samples were collected from each participant and high-performance liquid chromatography (HPLC) employed to extract and quantify the levels of the biomarkers.

RESULTS

The mean (SD) for cathinone and the composite norephedrine and norpseudoephedrine levels were 33.93 (±39.20) and 29.28 (±26.32)μg/mL respectively. These biomarkers were significantly associated (p≤0.05) with khat chewing dependency.

CONCLUSIONS

Validation of self-reported khat chewing is possible. Khat chewing dependency correlates significantly with biomarker levels in saliva. Replication is required.

Validity and reliability of a Severity of Dependence Scale for khat (SDS-khat)

AIMS OF THE STUDY

(1) To assess psychological khat dependence and (2) to assess the validity and reliability of the Severity Dependence Scale (Gossop et al., 1995) amended for khat use (SDS-khat), in a sample of UK-resident male adult Yemeni khat chewers.

MATERIALS AND METHODS

A cross-sectional study using a face to face structured interview schedule was conducted amongst purposively sampled UK-resident adult Yemeni male khat chewers, aged 18 years and above, selected during random visits to places of khat sale. A factor analysis with principal components extraction was conducted to explore the construct validity of the proposed SDS-khat. Reliability of the proposed scale was assessed using test-retest and internal reliability tests. The concurrent validity of the proposed SDS-khat was assessed in relation to individual measures and a composite index of khat chewing behaviours using univariate analyses.

RESULTS

Two hundred and four Yemeni male adult khat chewers were interviewed. The mean score of the proposed SDS-khat was 5.52 (SD ±4.03). Forty nine percent of respondents (95% CI=43-55%) with ≤5 scores were more likely not psychologically dependent. A single factor, uni-dimensional solution identifying the five items making up the scale accounted for 52.33% of variance. The internal reliability was good (Cronbach's alpha coefficient=0.76) and the test retest intraclass correlation coefficient (ICC) was 0.93 (95% CI=0.80-0.97). Many individual aspects of the khat chewing were significantly related to the scale. Assessment of the proposed SDS-khat's concurrent validity with individual items of khat chewing identified several significant relationships (p≤0.05) whilst the composite index of khat behaviour also identified a significant relationship (OR=14.40, 95% CI=6.71-30.89). The proposed SDS-khat also correlated with self-reported reasons for khat chewing (p≤0.001, OR=3.54; 95% CI=1.80-6.96).

CONCLUSIONS

In this sample of Yemeni khat chewers the SDS-khat is recommended as a valid and reliable research tool for measuring psychological dependence upon khat. Further validation in other samples is indicated.

Bangladeshi dental students' knowledge, attitudes and behaviour regarding tobacco control and oral cancer

Bangladesh's oral cancer incidence is high. Dentists can participate in tobacco control. The aim of this study is to explore tobacco use, tobacco control attitudes and oral cancer knowledge among Bangladeshi dental undergraduates. This cross-sectional study used the Global Health Professional Students Survey and the Humphris Oral Cancer Knowledge Scale. One hundred eighty six questionnaires were analysed, a 79% response rate. Tobacco use, oral cancer knowledge, attitudes towards tobacco control and the dentist's role in tobacco cessation varied significantly between colleges and by gender. Oral cancer knowledge and positive tobacco control attitudes did not influence tobacco use. There is a global problem in preparing dental students for a holistic, integrated approach to oral cancer prevention.

Male prisoner tobacco use and oral cancer knowledge: a case study of a local prison in India

There is a high prevalence of tobacco consumption among prisoners. This study aimed to establish tobacco use, to explore and assess oral cancer awareness and to identify associations between oral cancer awareness and tobacco use in a sample of male prisoners in a local Indian prison.

METHODOLOGY

A systematically selected random sample of male prisoners participated and a structured interview schedule was used, generated from two different sets of validated standardised questionnaires: the WHO STEPS instrument for NCD (Non Communicable Diseases) Risk Factors to assess tobacco consumption and the modified Humphris Oral Cancer Knowledge Scale to assess oral cancer knowledge.

RESULTS

Participation rate was 100%. Prevalence of tobacco consumption, mainly smoked, amongst prisoners was 68.5% (95% CI 63, 73%) The mean oral cancer knowledge score amongst prisoners was 13.28 (95% CI 12.9, 13.6). Statistically significant associations (P < 0.05) were found between oral cancer knowledge and age of participants, years of education and starting age of tobacco use. No association was found between oral cancer knowledge and tobacco consumption.

CONCLUSIONS

Tobacco use was high. Knowledge did not appear to impact on this behaviour, indicating the need for effective smoking interventions in this sample.

Validation of a dental pain screening questionnaire in a semi-urban hospital setting in South India

AIMS

To assess the validity of modified DePaQ items in correctly classifying dental pain patients into three groups of common dental conditions when compared against clinically-determined classification; generate a model of classification equations from a sub-population of the sample; and assess the validity of the model in predicting group membership of new dental pain cases.

METHODS

Consecutive adult hospital dental patients aged 18 years and older attending with a dental pain complaint were diagnosed by a dentist. Before treatment commenced a self-complete questionnaire was completed. The examining dentist was blinded to the questionnaire responses. The sample was randomly split into two groups (RS1 and RS2). Discriminant analysis was carried out on RS1 to develop a model for classifying new dental pain cases into three groups. This model was used to classify dental pain cases in RS2.

RESULTS

Of the 311 questionnaires distributed, 306 (98.4%) were returned. Of the 205 Group 1 cases diagnosed clinically 186 (90.7%) were correctly predicted as belonging to that group by M-DePaQ. For 54 clinically diagnosed Group 2 cases 44 (81.5%) were correctly predicted, and for 32 Group 3 cases, 26 (81.3%) were correctly predicted. The model of classification equations derived from RS1 were capable of correctly classifying 85%, 82% and 79% of clinically-derived classification for Group 1, 2 and 3 respectively.

CONCLUSIONS

This study has demonstrated that the M-DePaQ is valid in classifying dental pain patients into three groups of common dental conditions. Classification equations generated from a sub-group of the sample provided a valid statistical model for classifying dental pain cases from the same setting.

Oral cancer screening in the Bangladeshi community of Tower Hamlets: a social model

Background:

UK oral cancer incidence has risen by 22% in the last 10 years. Oral cancer is often detected at a late stage when treatment is debilitating and the chances of survival are poor. Certain black and minority ethnic groups are at elevated risk of oral cancer due to the prevalence of risk factor behaviours. We describe the background to, the development of and outcomes of an oral cancer screening activity appropriate to the needs of members of a disadvantaged community at high risk of oral cancer, carried out between 2006 and 2008 in Tower Hamlets, East London.

Methods:

In all, 1320 people participated during 34 days of screening, divided into two phases (Phase I (2006/2007): n=485, Phase II (2008): n=835). Modifications to the delivery process were implemented for Phase II in an attempt to recruit more high-risk individuals and to improve screening specificity.

Results:

In total, 75 people were urgently referred for further investigation (Phase I: n=20, Phase II: n= 55). Nine were diagnosed with dysplastic lesions (Phase I: n=3, Phase II: n=6) and a further eight showed potentially malignant disorders without dysplasia (Phase I: n=1, Phase II: n=7). Screening participants with low levels of completed education (OR: 6.94, 95% CI: 1.66, 28.98) and who chewed paan with tobacco (OR: 8.01, 95% CI: 3.54, 18.08) were more likely to be referred for further investigation.

Conclusion:

The project offers insights for the further development of oral cancer screening interventions for disadvantaged communities.

Activities related to the occurrence of traumatic dental injuries in 15- to 18-year-olds

OBJECTIVE

To assess the activities related to the occurrence of traumatic dental injuries (TDI) in order to establish the relationship between gender, socio-economic status (SES) and major TDI related events, using classification and examination procedures suitable for epidemiological purposes, in a sample of 15- to 18-year-old students in Taiwan.

METHODS

A random sample of 6312 15- to 18-year-old senior high school students in southern Taiwan was selected. Each was examined with standard clinical procedures and a questionnaire.

RESULTS

The prevalence of TDI was 19.9%. The major TDI related events included sports and leisure activities (30.8%), eating (20.5%), falls (19.4%), traffic accidents (10.2%) and collisions (7.1%). Within TDI victims, sports and leisure related TDI were more prevalent among males (P = 0.001, OR = 1.640, 95% CI = 1.225, 2.195) and high SES adolescents (P = 0.014, OR = 1.991, 95% CI = 1.149, 3.449). The occurrence of non-accidental TDI was not related to age, gender and SES (P > or = 0.643).

CONCLUSION

Traumatic dental injuries have become an important issue in public health and dentistry. Prevention and treatment of TDI should be emphasised to the public, the health professional and the policy maker. Future investigations into the relationship between TDI related events and their determinants are indicated.

Dental pain and care-seeking in 11-14-yr-old adolescents in a low-income country

The purpose of this article was to document the 1-month dental pain prevalence in 11-14-yr-old subjects attending Grade Six of middle schools in Peshawar, Pakistan, and to explore the effect of dental pain and the impact on daily living on dental care-seeking. A self-completed questionnaire survey of all 13 middle schools in University Town, Peshawar, Pakistan, was carried out in April 2007. Questionnaire items on dental pain were adapted from the dental pain screening questionnaire (DePaQ) and items on the impact on daily living were adapted from the child-oral impact on daily performance (OIDP-Child) questionnaire. Regression analysis was carried out to determine the relative usefulness of predictors for care-seeking. The prevalence of dental pain was estimated to be 30.4%, and care-seeking in those reporting pain was estimated to be 64%. Care-seeking was associated with 'pain felt in one tooth', 'painful tooth felt loose', 'difficulties sleeping', and 'difficulties playing', which accounted for 35% of the explained variance. The findings substantiate dental pain as an important dental public health concern in Pakistan and support the hypothesis that assessment of dental pain characteristics can add to the accuracy of dental need estimation.

Impact of the curriculum on Chinese dental students' tobacco control attitudes and beliefs: a case study in Harbin, China

Smoking is a major public health problem in China. Dentists can participate in tobacco control activity.

AIM

To report the curriculum impact on dental students' tobacco control attitudes and beliefs in Harbin Dental School, Harbin, China.

METHODS

A descriptive cross sectional study using the Global Health Professionals Survey self-complete questionnaire, assessing respondents': tobacco use prevalence, second-hand smoke exposure, knowledge and attitudes regarding tobacco control, smoking and cessation, and the content of the dental school's curriculum and training on tobacco effects and patient counselling. Third, 4th and 5th year undergraduates and postgraduate students participated in December 2005.

RESULTS

The response rate was 96%. Current smoking prevalence was 4% whilst 74% reported exposure to second hand smoke in the previous week. There was variable recall of aspects of teaching, 12% reporting receiving formal smoking cessation training. Respondents were extremely positive in their professional behaviour beliefs but less about population based tobacco control. There was no relationship between curriculum recall and positive beliefs and attitudes about tobacco control.

CONCLUSIONS

In this sample of Chinese dental students a low current smoking prevalence and high levels of exposure to second hand smoke were reported. Varying levels of recall of tobacco control aspects of the dental curriculum existed. Positive tobacco control attitudes and beliefs were reported, but this did not necessarily correlate with aspects of the curriculum content.

Family structure is associated with oral pain in 12-year-old Greek schoolchildren

OBJECTIVE

To determine the prevalence, associated correlates and impact of oral pain in 12-year-old schoolchildren in Stayroypoli, Greece.

DESIGN AND METHOD

Cross-sectional survey of all schoolchildren attending the last year of government primary schools using self-administered questionnaires. Approval was granted by the Greek Ministry of Education and Religion. Cooperation was obtained from the schools. Children whose parents did not refuse their participation were invited to complete a questionnaire. Oral pain prevalence was estimated and association with sociodemographic/economic factors tested. Associations between pain experience and impact on daily activities were examined.

RESULTS

Of the 296 children registered, 225 (76.0%) were present on the days data were collected. Usable questionnaires were completed by 187 children (83.1%). Oral pain in the previous 4 weeks, reported by 70 (37.4%), was more likely to affect children living with one parent/other people (OR 3.0, 95% CI = 1.2-7.4, P = 0.013) and those who brushed less than twice a day (OR 2.8, 1.5-5.2, P = 0.001). Impact on daily activities was reported by 64 children (91.4%). The most commonly stated impacts were eating (40.0%), cleaning teeth (25.7%) and sleeping (18.6%).

CONCLUSIONS

Oral pain prevalence was high in 12-year-old schoolchildren in Stayroypoli, is associated with family structure, and impacts substantially on daily activities.

Tobacco control policy initiatives and UK resident Bangladeshi male smokers: community-based, qualitative study

OBJECTIVE

To reflect on recent proposed tobacco control initiatives in the socio-cultural context of the smoking behaviours of UK resident Bangladeshi men.

DESIGN

Cross-sectional study using focus groups and one-to-one interviews conducted in English and Sylheti. Eighty-one men, aged 18-64 years, were recruited from the Bangladeshi community of Tower Hamlets, London, during 2002. Participants were purposively selected to reflect their age, place of birth and tobacco-use status. The discussions were tape-recorded and subsequently transcribed. The transcripts were analysed using 'framework' principles. Three of the current themes for tobacco control -- smoke-free workplace environments, access to alternative sources of tobacco, and use and availability of nicotine replacement therapy -- were used to organise the data.

RESULTS

Smoking initiation and use was confirmed as linked to gender, age, religion and tradition. Continued smoking was supported by anxieties about harassment in younger respondents, the migration experience of older respondents, and the unskilled employment opportunities available in the restaurant trade. These employment opportunities, whilst providing social support, did not support smoking regulations, in contrast to the practices observed in the general employment market. Levels of knowledge about the health risks of smoking varied by age. Three cheaper alternative tobacco types were readily accessible for use: contraband, roll-ups and traditional chewing tobacco in paan (chewing tobacco mixed with areca nut rolled in a betel leaf). Despite the latter's associations with use by women, younger respondents described the transition to chewing tobacco in paan as a smoking cessation aid instead of nicotine replacement therapy. There was confusion about the purpose, availability and efficacy of nicotine replacement therapy. Respondents reported isolation and marginalisation from current tobacco control initiatives, including much NHS Stop Smoking Service provision.

CONCLUSION

The socio-cultural context of the smoking behaviours of this group of Bangladeshi men was linked to a reported isolation and exclusion from current tobacco control initiatives. These initiatives should be inclusive and address the reported needs of this community. The findings have implications for service development. Addressing these findings will help to inform the implementation of relevant public health policy initiatives for tobacco control to meet the needs of this community.

Emotional intelligence and perceived stress in dental undergraduates: a multinational survey

This multinational survey investigated the relationship between emotional intelligence (EI) and perceived stress (PS) in seven countries. First-year dental undergraduates attending a dental school in England, Greece, Romania, South Africa, Australia, and the United States and three schools in Malaysia were invited to complete a set of questionnaires on age, gender, academic background, satisfaction with career choice, EI, and PS. Of 860 questionnaires distributed, 596 were fully completed--a response rate of 69.3 percent. Mean EI score was 123.8 (95 percent CI 122.7-124.9), and mean PS score was 19.1 (95 percent CI 18.6-19.7). Significant differences in EI and PS scores were detected between different countries. Females (p<0.05), younger students (p<0.001), those without a previous higher education qualification (p<0.001), and those not satisfied with their decision to study dentistry (p<0.001) were more likely to report PS when compared to their counterparts. A significant inverse relationship (coefficient=-0.29, p=0.001) between EI and PS was detected. Independent significant predictors of PS identified were gender (beta=0.22, t=5.71, p=0.001), previous higher education qualification (beta=-0.14, t=-2.42, p=0.010), satisfaction with decision to study dentistry (beta=-0.20, t=-5.11, p=0.001), and EI (beta=-0.24, t=-6.09, p=0.001), with the latter being relatively the most important predictor. In conclusion, the inverse relationship between EI and PS has been confirmed in this heterogeneous sample representing diverse sociocultural and academic contexts of dental undergraduates.

Improving access to dental care in East London's ethnic minority groups: community based, qualitative study

There are few studies of access to dental care in ethnic minority groups which have compared their findings with those reported by the general adult population. Furthermore, studies have focused on either the younger or older members of these communities.

AIM

This study aimed to identify barriers to the uptake of primary dental care in East London, to identify any variation in responses from the general adult population and to report ideas to improve access to primary dental care expressed by the participants.

METHODS

A qualitative study using community based participatory methods was adopted. Data were generated through purposefully sampled focus groups and analysed using a grounded approach.

SETTING

East London (UK), 2001.

PARTICIPANTS

68 volunteers aged 18-40 years, from the Bangladeshi, Indian, Black Caribbean communities and general adult population.

RESULTS

Three inter-related themes were found to influence views on access: the structure of primary dental care, cost and anxiety. There was little evidence of differences in barriers to access based on ethnicity alone, reflecting the role of factors such as social class. Adult volunteers with young families enabled a wider perspective on barriers to access to be achieved, particularly with respect to the impact of the cost of dental care on family budgets. Proposals for reducing the barriers to accessing primary dental care were identified. These addressed a perceived need to extend services through outreach activity, develop communication skills within primary dental care practice and liaise with other primary health care services.

CONCLUSION

This focus group study has confirmed the existence within East London's ethnic minority groups of barriers to accessing primary dental care reported within the general population for some time. That these responses are alike may be accounted for by the common levels of social disadvantage experienced. The rapid appraisal process enabled the identification of proposals to reduce access barriers. These are being implemented and their effectiveness in reducing barriers to accessing primary dental care remains to be established.

Khat chewing amongst UK resident male Yemeni adults: an exploratory study

AIM

This cross sectional study recruited adult male Yemeni residents in Sheffield and Birmingham, UK, to assess their use of khat.

METHODS

Structured interviews were conducted in both areas during weekly khat chewing sessions. The data collected included socio-demographic characteristics, khat use, dependency on khat, psychological functioning of chewers (GHQ-12) and nicotine dependency. Patterns of khat use, dependency and psychological functioning were correlated with age and self-reported oral problems.

RESULTS

75 khat chewing volunteers (mean age 40.75 years) were interviewed. Average age of starting khat chewing was 17 years. The weekly amount chewed ranged from 0.25-3.0 khat bundles. Older respondents were more likely to be frequent chewers (p<0.025). 39% were assessed as dependent on khat, which correlated with frequency of use (p<0.041) and being in debt (p<0.046). Khat chewing correlated with nicotine dependence (p< 0.014). Self-reported oral problems correlated with both nicotine (p<0.04) and khat dependence (p<0.001). 93% reported that khat chewing promoted excessive smoking and 12% that this practice had initiated their tobacco use.

CONCLUSIONS

Khat chewing creates dependency and correlates with tobacco smoking and nicotine dependence. Further research should investigate the correlations between khat and nicotine dependence. Development of a specific measure of khat dependence is recommended.

Development and validation of a dental pain-screening questionnaire

Dental pain, estimated to affect 12-40% of community-dwelling adults, is a symptom of a wide range of clinical conditions. A population screening instrument is needed to study their prevalence. This project aimed to develop a questionnaire for classifying a sample of dental pain patients into three groups of common dental pain conditions, i.e. Group 1 (Acute periapical periodontitis and Irreversible pulpitis), Group 2 (Reversible pulpitis and Dentine hypersensitivity) and Group 3 (Pericoronitis). Initial items were generated through a literature review, individual unstructured patient interviews and consultation with experts. Items generated were administered to a sample of dental pain patients for self-completion. Responses were subjected to a series of factor and discriminant analyses to identify questions capable of differentiating the sample into three groups, originally categorized by clinical diagnosis, with high classification rates. The selected items were administered to a further sample of dental pain patients to test for its sensitivity and specificity in classifying the sample into three groups against the gold standard of clinical diagnosis. The final 16-item Dental Pain Questionnaire (DePaQ) was capable of correctly classifying 89.7% of dental pain cases initially categorized by clinical diagnoses. The sensitivity of the questionnaire was 0.80-Group z1, 0.85-Group 2 and 0.59-Group 3. Specificity was 0.83-Group A1, 0.89-Group A2 and 0.90-Group 3. The DePaQ, which can easily be administered by non-clinical personnel, may be used to collect epidemiological data on common dental pain conditions, assess dental needs for a specified population, and triage of patients seeking treatment for dental pain.

Why and how to get patients to stop smoking

Despite the fact that smoking cigarettes harms oral and systemic health, there is little current evidence of successful primary dental care involvement in smoking cessation. This paper aims to present the arguments for developing the role of primary dental care in smoking cessation and reviews the current literature on how this can be achieved in practice. It is argued that it is timely to incorporate this rapidly developing evidence base on what works in smoking cessation into primary dental care activity.

Emotional intelligence and stress coping in dental undergraduates--a qualitative study

OBJECTIVE

To explore how dental undergraduates with different levels of emotional intelligence (EI) cope with stress.

DESIGN

Qualitative unstructured depth interviews.

SETTING

A dental teaching hospital in the UK, 2002.

SUBJECTS AND METHODS

Subjects selected from the undergraduate population of a 5-year dental degree course. A questionnaire survey was carried out to determine the EI scores of the subjects. In each year of study, subjects were divided into low and high EI groups at the median score. From each EI group in each year, one male and one female subject were recruited.

DATA COLLECTION

Unstructured face-to-face interviews.

DATA ANALYSIS

Transcribing, sifting, indexing and charting data according to key themes.

RESULTS

10 males and 10 females with low and high EI, representing all 5 years of study were interviewed. The experience of stress, expressed in emotional terms, ranged from anger and frustration to hatred. Four sets of coping strategies, adopted at varying degrees according to EI, were identified. High EI students were more likely to adopt reflection and appraisal, social and interpersonal, and organisation and time-management skills. Low EI students were more likely to engage in health-damaging behaviours.

CONCLUSIONS

Future research needs to establish whether the enhancement of EI in dental students would lead to improved stress-coping, and better physical and psychological health.

The prevalence and causes of maxillofacial fractures in patients attending Accident and Emergency Departments in Recife-Brazil

AIM

This study aimed to investigate the epidemiological characteristics of maxillofacial fractures among patients admitted to the Accident and Emergency Departments of three major hospitals in Recife, Brazil.

MATERIAL AND METHODS

A prospective design. The data were collected from each hospital over 3 months. A timetable was developed which randomly allocated visits to the three hospitals, six times a week for 6 hours a day. Data on socio-demographic variables, presence of bone fractures and/or maxillofacial fractures, type of injuries, aetiological factors, and place of occurrence were recorded.

RESULTS

The final sample size was 5,644 patients. The prevalence of any bone fractures was 32.1% and for maxillofacial fractures 4.1%. Multiple logistic regression analysis showed that maxillofacial fractures were related to age, sex and level of education but not to employment status. Violence was the main cause of maxillofacial fractures, and the most frequent place of occurrence was the street.

CONCLUSIONS

Maxillofacial fractures represented 12.6% of all bone fractures, males and less educated subjects were more likely to be affected than their females and more educated counterparts, and violence was the most common cause.

Oral Health of Bangladeshi Women Tobacco-with-paan Users and Self-reported Oral Pain Following Tobacco Cessation

OBJECTIVES

The study objectives were to assess the oral health status of a sample of UK resident Bangladeshi women tobacco-in-paan users and its relationship to participant age and number of daily paan, to determine the prevalence of oral pain at baseline and at the one-week postcessation follow-up, and to explore the relationship between oral health status and changes in self-reported oral pain at baseline and at the one-week postcessation follow-up.

METHODS

Interviews were conducted in Sylheti using fully structured questionnaires and an oral examination was carried out. A quit date was set and nicotine replacement therapy patches (Nicorette 15 mg, Pfizer) were supplied. Age, number of daily paan, and oral pain characteristics, including intensity, frequency, any provoking factors, and associated symptoms were recorded. Oral mucosal lesions (OMLs) and numbers of teeth decayed, missing, filled, and those with recession, abrasion, loss of attachment (LOA), and tooth wear were charted.

RESULTS

Fifty-two women took part. The mean age was 42.8 years and number of daily paan with tobacco was 13. Compared to those aged 18-39 years, those aged 40 years and older had poorer oral health. Older adults were significantly more likely to have higher numbers of teeth with recession, abrasion, and LOA greater than 3.5 mm. They were significantly more likely to have an OML at baseline. The prevalence of self-reported oral pain was 26.9 percent at baseline and 51.9 percent at one-week follow-up. Presence of an OML at baseline was a significant predictor of reports of oral pain at the one-week follow-up. Results of stepwise multiple regression analysis confirmed this finding (OR = 3.66; 95% CI = 1.06, 12.621; P = .04).

CONCLUSIONS

Reports of oral pain at follow-up during a tobacco cessation program correlate with the presence of OMLs at baseline. Further investigation of this relationship is needed. Access to appropriate dental care, as an aid to successful tobacco cessation, is indicated.

Children's dental health: British expatriate residents in Tokyo, Japan

AIM

To identify in expatriate British parents resident in Tokyo, Japan, their levels of dental health knowledge, patterns of dental health behaviour, and caries status of their children compared to Japanese children.

METHODS

223 parents with children at one school were asked to complete a structured questionnaire. Data were collected on: parental knowledge and behaviours with respect to caries prevention, and sweet consumption of the children. The caries status of the children was established by a clinical examination, using standard criteria.

RESULTS

The questionnaire response rate was 66.8%. The mean age of the children was 7.6 years (range 3-11 years). The responses related to 51 British, 21 Japanese, and 20 children who had British and Japanese mixed parents. 33% of British and none of Japanese children had sweet foods frequently. Fluoridated toothpaste was used by 67% of British and 10% of Japanese children. British parents knew about dental caries more than Japanese. 13% of British and 38% of Japanese children were found in the higher caries experience group.

CONCLUSION

Parental access to information in the UK and to fluoridated toothpaste in Japan could have helped to prevent dental caries in these expatriate British children.

Emotional intelligence and perceived stress in dental undergraduates

This study investigated the relationship between emotional intelligence (EI) and perceived stress (PS) in dental undergraduates. All dental undergraduates attending a UK dental school were invited to complete a questionnaire on age, gender, year of study, EI, and PS. Two hundred and thirteen students (48 percent male) participated, a response rate of 70 percent. The mean score for EI was 117.54 (S.D. 14.90) and PS was 17.73 (S.D. 6.49). Factor analysis confirmed four factors previously identified in the literature as comprising emotional intelligence: optimism/mood regulation, utilization of emotions, appraisal of emotions, and social skills. T-tests indicated that females had significantly higher EI scores than males. Mean PS scores were significantly higher for students aged over twenty-one years compared with those aged twenty-one years or less (p < 0.001), female compared to male students (p < 0.05), and those in higher years compared to those in lower years of study (p < 0.001). Correlational analysis showed an inverse relationship between EI and PS. Multiple regression analysis identified year of study, optimism/mood regulation, and gender as independent, significant predictors of PS. In conclusion, low EI scorers report more PS. Future research should investigate the relationships of EI and PS with impact on lifestyle behaviors, academic and clinical performance, and health outcomes.

The use of PBL to facilitate the development of professional attributes in second year dental students

OBJECTIVES

To investigate dental students' perception as to whether PBL can facilitate the development of professional attributes.

DESIGN

A cross-sectional survey of second year dental undergraduates in a UK dental school.

METHOD

At the end of a PBL module, all students were asked to complete a fully structured questionnaire. Data were collected on socio-demographics, aspects of the PBL experience and the extent to which students perceived that PBL had facilitated the development of professional attributes.

RESULTS

The response rate was 96%. The frequency distributions of the PBL experience and development of professional attributes were skewed to the positive. Non-white students, compared to white students, rated significantly more highly the extent to which they thought PBL had facilitated the development of professional attributes. Differences between male and female students, and mature and less mature students were not significant. Students who rated the PBL experience positively were significantly more likely to rate highly the extent to which they thought PBL had facilitated the development of professional attributes.

CONCLUSIONS

The factors that affect the relationship between ethnicity and development of professional attributes need further research. To enhance the development of professional attributes, teachers of PBL need to ensure that students find the learning experience worthwhile and stimulating.

Tobacco cessation, oral pain, and psychological distress in Bangladeshi women

This study reports the experience of oral pain and psychological distress following tobacco cessation in Bangladeshi women. A cross-sectional survey was carried out in which telephone interviews were conducted in the Sylheti language by two female Bangladeshi researchers using structured questionnaires. Study participants were 58 Bangladeshi women, aged 22-60 years, who had recently given up chewing paan-with-tobacco. The General Health Questionnaire (GHQ-12) was used to measure psychological distress. A questionnaire on pain description, location, duration, onset, and intensity also was administered. Logistic regression analysis was carried out to explore the relationships between psychological distress and age, chewing characteristics, and the oral pain experience. The response rate was 100%. Of the sample, 22% reported having pain for 2 days and 28% for at least 1 week, 65% reported that the pain started by itself, 69% reported the intensity as mild or discomforting, and 52% experienced psychological distress. Significant predictors for high psychological distress were number of daily paan (odds ratio, OR=1.13), current tooth problem (OR=4.60), pounding pain (OR=6.50), pain onset (OR=3.21), and pain intensity (OR=5.57). The prevalence of oral pain reported for Bangladeshi women following an attempt at chewing tobacco cessation is high. Characteristics of this outcome suggest the pain is of dental origin. These characteristics are correlated to psychological distress. The success of chewing tobacco cessation initiatives in the population may be influenced by oral pain and psychological distress. Further research is needed to explore the etiological factors associated with oral pain in this group of tobacco users.