Pan-American prevalence of smokeless tobacco use and association with oral potentially malignant disorders and head and neck cancer: a systematic review and meta-analysis

OBJECTIVES

To determine the prevalence of smokeless tobacco (SLT) use and its association with oral potentially malignant disorders (OPMDs) and head and neck cancer (HNC) in the Pan-American Health Organization (PAHO) region.

STUDY DESIGN

A literature search was conducted across 9 databases and other sources. The eligibility criteria were pediatric (0-18 years old) and adult (19 years and older) populations consuming any type of SLT. Meta-analysis was performed to determine the prevalence of SLT and the association between its use and OPMDs/HNC in the PAHO region; the Grading of Recommendations Assessment, Development, and Evaluation tool was used to verify the certainty of evidence.

RESULTS

Fifty-nine studies from 6 PAHO countries were included, of which 51 were also subjected to quantitative analysis. The pooled SLT prevalence of use was 15% (95%CI: 11.93-18.69) overall, 17% (95%CI: 13.25-22.65) in adults, and 11% (95%CI: 8.54-14.78) in the pediatric population. The highest reported SLT prevalence of use was 33.4% (95%CI: 27.17-39.93) in Venezuela. HNC was positively associated with SLT use (OR = 1.98, 95%CI: 1.54-2.55), with a moderate certainty of evidence. Among OPMDs, only leukoplakia reported a positive association with SLT use (OR = 8.38; 95%CI: 1.05-67.25). However, the quality of the evidence was very low.

CONCLUSION

A high consumption of SLT use, chewing tobacco and snuff, is reported among the adult population residing in the PAHO region with a positive association with the development of oral leukoplakia and HNC.

Impact of the COVID-19 pandemic on an online cancer screening training programme for healthcare providers in the public sector in India: learnings from a hub and spoke model perspective

Introduction

This article elicits our experiences and strategic approaches to ensure the sustainability of the online capacity-building programmes for healthcare providers (HCPs) in comprehensive cancer screening through the 'Hub and Spoke' model during the coronavirus disease (COVID-19) pandemic.

Methods

During the first wave of COVID-19, training for three cohorts of medical officers (MO) (Batch-A) was ongoing (May-December 2020). The Indian health system abruptly shifted focus towards containing the COVID-19 spread, leading to new challenges in conducting training courses. A new five-step strategic approach for cohort MO-14 (Batch-B) was adopted to spread awareness about the importance of cancer screening and the roles and responsibilities of HCPs in the implementation and conduct of practical sessions in their states in collaboration with their respective state governments. We also adopted social media - WhatsApp for official communication.

Results

Enrolling Batch-B following the new strategic approach reduced refusals by 25% and dropouts by 36% compared to Batch-A. Course compliance and completion was a significant 96% in Batch-B.

Conclusion

The COVID-19 pandemic opened a window of opportunity to understand the need for vital changes to improve the quality of our hybrid cancer screening training. Inclusion of the state government in planning and implementing the changes, awareness among HCPs about the importance of training and responsible acceptance of cancer screening, district-wise approach, use of social media in sharing course materials and conducting in-person training in the respective state have demonstrated significant impact on the quality of the training and in scaling-up of cancer screening. Prolonged mentorship, robust Internet connectivity for providers and training on handling gadgets and online video communication would profoundly benefit remote training programmes.A well-devised backup system is essential for training programmes during unforeseen eventualities such as the COVID pandemic.

Asking physicians how best to implement cervical cancer prevention services in India: A qualitative study from Mysore

Cervical cancer is the second most common cancer among Indian women. Screening is an effective prevention strategy, but achieving high screening rates depend upon identifying barriers at multiple levels of healthcare delivery. There is limited research on understanding the perspectives of providers who deliver cancer prevention services. The objective of this study was to explore physician perspectives on cervical cancer prevention, barriers to effective implementation, and strategies to overcome these barriers in India. Guided by the "Multilevel influences on the Cancer Care Continuum" theoretical framework, we conducted semi-structured interviews with physicians in Mysore, India. From November 2015- January 2016, we interviewed 15 (50.0%) primary care physicians, seven (23.3%) obstetrician/gynecologists, six (20.0%) oncologists, and two (6.7%) pathologists. We analyzed interview transcripts in Dedoose using a grounded theory approach. Approximately two-thirds (n = 19, 63.3%) of the participants worked in the public sector. Only seven (23.3%) physicians provided cervical cancer screening, none of them primary care physicians. Physicians discussed the need for community-level, culturally-tailored education to improve health literacy and reduce stigma surrounding cancer and gynecologic health. They described limited organizational capacity in the public sector to provide cancer prevention services, and emphasized the need for further training before they could perform cervical cancer screening. Physicians recommend an integrated strategy for cervical cancer prevention at multiple levels of uptake and delivery with specific efforts focused on culturally-tailored stigma-reducing education, community-level approaches utilizing India's community health workers, and providing physician training and continuing education in cancer prevention.

How well do covariates perform when adjusting for sampling bias in online COVID-19 research? Insights from multiverse analyses

COVID-19 research has relied heavily on convenience-based samples, which-though often necessary-are susceptible to important sampling biases. We begin with a theoretical overview and introduction to the dynamics that underlie sampling bias. We then empirically examine sampling bias in online COVID-19 surveys and evaluate the degree to which common statistical adjustments for demographic covariates successfully attenuate such bias. This registered study analysed responses to identical questions from three convenience and three largely representative samples (total N = 13,731) collected online in Canada within the International COVID-19 Awareness and Responses Evaluation Study ( www.icarestudy.com ). We compared samples on 11 behavioural and psychological outcomes (e.g., adherence to COVID-19 prevention measures, vaccine intentions) across three time points and employed multiverse-style analyses to examine how 512 combinations of demographic covariates (e.g., sex, age, education, income, ethnicity) impacted sampling discrepancies on these outcomes. Significant discrepancies emerged between samples on 73% of outcomes. Participants in the convenience samples held more positive thoughts towards and engaged in more COVID-19 prevention behaviours. Covariates attenuated sampling differences in only 55% of cases and increased differences in 45%. No covariate performed reliably well. Our results suggest that online convenience samples may display more positive dispositions towards COVID-19 prevention behaviours being studied than would samples drawn using more representative means. Adjusting results for demographic covariates frequently increased rather than decreased bias, suggesting that researchers should be cautious when interpreting adjusted findings. Using multiverse-style analyses as extended sensitivity analyses is recommended.

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.

Tobacco use as a well-recognized cause of severe COVID-19 manifestations

INTRODUCTION

The Coronavirus disease (COVID-19) infection is caused by the novel Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) primarily affecting the lungs. All tobacco-related illnesses including asthma, chronic obstructive pulmonary disease (COPD), and coronary artery disease are known to reduce the lung capacity and impair the immune system of the body and can greatly influence the ability to fight the novel coronavirus. The purpose of this state-of-the-art literature review is to summarize the evidence of the association of tobacco use with the severity of the COVID-19 manifestations.

METHOD

Articles describing the association of tobacco use with the severity of COVID-19 manifestations were searched on PubMed, MEDLINE, and Google. This review covers the relevant studies on the subject published from January 1, 2020 to September 10, 2020.

RESULTS

Tobacco use in all forms, whether smoking or chewing, is significantly associated with severe COVID-19 outcomes. Pre-existing comorbidities in tobacco users such as cardiovascular diseases, diabetes, respiratory diseases and hypertension were found to further aggravate the disease manifestations making the treatment of such COVID-19 patients more challenging due to their rapid clinical deterioration.

CONCLUSIONS

Current review indicates that nicotine exposure is linked to cardiopulmonary vulnerability to COVID-19 and tobacco use can be a potential risk factor for not only getting the viral infection but also its severe manifestations. The current pandemic provides a teachable moment to break the cycle of nicotine addiction and accelerate national tobacco control programs to achieve a tobacco-free world.

Project ECHO: a Potential Best-Practice Tool for Training Healthcare Providers in Oral Cancer Screening and Tobacco Cessation

The oral cancer pandemic and inadvertent tobacco consumption have rendered timely oral cavity screening and tobacco cessation essential, skills which most healthcare providers (HCPs) lack. Project "Extension for Community Healthcare Outcomes" (ECHO) is a proven best-practice tool for virtual telementoring of primary care providers by experts at academic health centers, in managing complex medical conditions in rural, expert-deficient setups. For the first time, our organization in India has utilized this method for training HCPs in oral cancer screening, across the country and abroad. The program comprised eight, weekly, hour-long sessions, on oral cancer screening and tobacco cessation, hosted online by our Organization (hub) through the Zoom web-conferencing application, with 48 HCPs (spokes) attending from their respective locations (pan-India, n = 47; Libya, n = 1). Each session comprised one expert-led didactic and two participant-led case presentations, culminating with educative discussions. Participants filled out online, program-evaluation (pre and post) questionnaires having 10 similar, multiple-choice questions each (score for every correct response = 1); total responses were later statistically analyzed. Lesser participants completed the post-evaluation questionnaire which could be due to it being optional, their busy schedule, or apprehension of being assessed. The program evaluation results illustrate a significant knowledge gain among participants regarding oral cancer screening and tobacco cessation, i.e., from a mean knowledge score of 6.7 in pre-evaluation to 7.4 in post-evaluation (p < 0.05). Thus, the ECHO model can be utilized as a convenient, cost-effective, large-scale, best-practice, telementoring tool for training HCPs in oral cancer screening and tobacco cessation, especially in populous, resource-deficient countries.

Behavioral Interventions for Smokeless Tobacco Cessation

INTRODUCTION

Consumption of smokeless tobacco (SLT) is on the rise (especially in the World Health Organization South-East Asian region) and has numerous repercussions over the consumer's health. This article reviews studies performed for SLT cessation using behavioral interventions, worldwide till 2017.

METHODS

A systematic review by PICO (Problem, intervention, comparison, outcome) of behavioral intervention-based SLT cessation studies with minimum 6 months' follow-up, reporting outcomes in terms of risk ratios (RRs) and 95% confidence interval (CI), published between 1992 and 2017 was performed. This was followed by a meta-analysis of the outcomes of these studies by deriving the pooled estimates by the random effects model, for those on adults and youth, categorized according to the type of country where the study was performed, that is, in terms of developed or developing. Publication bias among the included studies was assessed by the Begg's test.

RESULTS

Nineteen eligible studies comprising 24 498 participants, from all over the world were included. Behavioral interventions showed overall efficacy in SLT cessation 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, these interventions did not prove effective for SLT cessation among youth overall (RR = 1.07, 95% CI = 0.73 to 1.41), either in the developed (RR = 1.39, 95% CI = 0.58 to 2.21) or in the developing (RR = 0.87, 95% CI = 0.68 to 1.07) countries. Publication bias was noted in all the studies among adults (p = .22) and youth (p = .05).

CONCLUSION

Behavioral interventions as a single modality are effective in SLT cessation, both in the developed and developing countries. Health care providers should be sensitized to provide the same.

IMPLICATIONS

A recent literature survey by Cochrane reviewed studies on interventions for SLT, including behavioral interventions, which included only those from the developed countries. The current analysis provides a broader, global update on the same by including studies performed both in the developed and developing countries (specifically the South-East Asian region-the high burden countries of SLT products).

Smokeless tobacco cessation interventions: A systematic review

Background & objectives:

Smokeless tobacco (SLT) consumption is a global health issue with about 350 million users and numerous adverse health consequences like oral cancer and myocardial disorders. Hence, cessation of SLT use is as essential as smoking cessation. An update on the available literature on SLT cessation intervention studies is provided here.

Methods:

Through an extensive literature search on SLT cessation intervention studies, using keywords such as smokeless tobacco, cessation, interventions, quitlines, brief advice, nicotine replacement therapy, nicotine gum, nicotine lozenge, nicotine patch, bupropion, varenicline, mHealth, etc., 59 eligible studies were selected. Furthermore, efficacy of the interventions was assessed from the reported risk ratios (RRs) [confidence intervals (CIs)] and quit rates.

Results:

Studies were conducted in Scandinavia, India, United Kingdom, Pakistan and the United States of America, with variable follow up periods of one month to 10 years. Behavioural interventions alone showed high efficacy in SLT cessation; most studies were conducted among adults and showed positive effects, i.e. RR [CI] 0.87 [0.7, 1.09] to 3.84 [2.33, 6.33], quit rate between 9-51.5 per cent, at six months. Regular telephone support/quitlines also proved beneficial. Among pharmacological modalities, nicotine lozenges and varenicline proved efficacious in SLT cessation.

Interpretation & conclusions:

Globally, there is limited information available on SLT cessation intervention trials, research on which must be encouraged, especially in the low-resource, high SLT burden countries; behavioural interventions are most suitable for such settings. Appropriate training/sensitization of healthcare professionals, and school-based SLT use prevention and cessation programmes need to be encouraged.

A revisit at 16 years for individuals from peri-urban New Delhi for tobacco use and associated oral lesions

Objectives:

India has a high incidence of oral cancer due to multifarious tobacco use. The objective of this study was to assess the status of tobacco-related oral lesions over 16 years, in a screen-detected population.

Methods:

This cross-sectional study involved home visits of 2000 Delhi residents, previously screened for oral potentially malignant disorders/oral cancer and counseled for tobacco cessation. Their basic demographics and tobacco/alcohol history were noted followed by oral visual examination for any related mucosal abnormalities. The data thus obtained were statistically analyzed.

Results:

Two hundred and sixty-five individuals (13.2%) could be traced after 16 years. The status of oral lesions varied across the participants, mainly in terms of their location, type, number, and/or presence/absence; no oral malignancies were noted. Most individuals had either a decreased use (34%, p < 0.001) or had quit tobacco (25.7%, p < 0.001); 8.3% individuals from the former and 5.7% from the latter group showed complete lesion(s) regression. The overall change in the tobacco use and oral lesions showed a highly significant positive association ( p < 0.05).

Conclusion:

A direct relationship exists between tobacco use and oral lesions. Repeated, tobacco cessation counseling provided by health-care professionals is effective. Oral screening of high-risk individuals, along with tobacco cessation, is thus essential.

Ellis-van Creveld with an Unusual Dental Anomaly: A Case Report

The Ellis-van Creveld (EVC) syndrome is a chondroectodermal dysplasia and is characterized by the cardinal features of disproportionate short stature, polydactyly, hidrotic ectodermal dysplasia, and congenital heart malformations, along with other skeletal and dental abnormalities. It is a rare condition, with very few cases reported in the medical literature. It is inherited as an autosomal recessive disorder with variable expressions, due to the mutation of the EVC syndrome 1 and 2 genes, which are located on chromosome 4p16. The present case report describes the EVC syndrome in a 14-year-old girl, who presented with a tetrad of all the cardinal features and other associated features. Additional unusual dental findings such as single-rooted funnel-shaped molars, reduced crown size, enamel hypoplasia, supernumerary teeth, dental fusion, taurodontism, abnormal occlusal anatomy with wide grooves, and atypical cusps have been reported in most previous cases of this syndrome. However, in our patient, surprisingly, the teeth present were relatively non-anomalous, both clinically and radiographically (i.e., with none of the usually found abnormalities mentioned above). The only abnormal dental findings were those of absent maxillary and mandibular incisors (including impacted permanent incisors) and mild malocclusion, a novel point of this case.