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 Table of Contents  
Year : 2021  |  Volume : 33  |  Issue : 2  |  Page : 200-207

A New Approach to Tobacco Cessation by Using Chart of 5A's Based on National Guidelines

Department of Oral Medicine and Radiology, CSMSS Dental College and Hospital, Aurangabad, Maharashtra, India

Date of Submission22-Jun-2020
Date of Decision01-Nov-2020
Date of Acceptance19-Nov-2020
Date of Web Publication23-Jun-2021

Correspondence Address:
Dr. Rupali V Mhaske
Department of Oral Medicine and Radiology, CSMSS Dental College and Hospital, Kanchanwadi, Aurangabad, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaomr.jiaomr_115_20

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Background: The use of tobacco is linked to cultural and social practices in India. It is the primary cause of oral cancer. Dental health professionals are trained to identify signs of tobacco use following visual examinations of the oral cavity. Through the establishment of Tobacco cessation centers in dental colleges, the dentist receives training in providing tobacco cessation counseling to tobacco users. Thus each patient that seeks dental treatment in dental colleges is also screened for tobacco use and then counseled as appropriate.Aim and objectives: (1) To assess the nicotine dependence. (2) To assess the prevalence of oral diseases. (3) To carry out a detailed and effective tobacco cessation program.(4) To use the newly made chart of 5A's and assess the usefulness of the chart in tobacco cessation counseling. Materials and Methods: The sample size of 100 patients who were tobacco users age 15 to 80 years was selected. 06 questions from the Fagerstrom test for nicotine dependence were used to elicit the nicotine dependence. The tobacco cessation program and detailed counseling were carried out. Statistical Analysis: Data collected were subjected to statistical analysis. Results: Of 100 patients, 57 were highly dependent, 38 were moderately dependent, and 5 were minimally dependent on Nicotine. After Tobacco cessation counseling patients reported back within 8 months, and their nicotine dependence was assessed again using the Fagerstrom questionnaire and was found that: 28 patients were tobacco-free having 0 scores of nicotine dependence, 67 patients were minimally dependent having scored from 1 to 3, 06 patients were moderately dependent having score from 4 to 7. Not a single patient of 100 was highly dependent on nicotine. Conclusions: Establishing a Tobacco cessation center using cognitive and behavioral counseling through the pictorial chart of 5AS, informative leaflets, awareness videos, and regular follow-up has proven effective in helping tobacco users to quit tobacco.

Keywords: 5 A of Tobacco counseling, 5 days quit plan, Cold turkey method, National guidelines, Nicotine dependence

How to cite this article:
Mhaske RV, Kale LM, Sodhi S, Kadam VD, Bansode AM, Pawar K. A New Approach to Tobacco Cessation by Using Chart of 5A's Based on National Guidelines. J Indian Acad Oral Med Radiol 2021;33:200-7

How to cite this URL:
Mhaske RV, Kale LM, Sodhi S, Kadam VD, Bansode AM, Pawar K. A New Approach to Tobacco Cessation by Using Chart of 5A's Based on National Guidelines. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2021 Jul 29];33:200-7. Available from: https://www.jiaomr.in/text.asp?2021/33/2/200/319057

   Introduction Top

Excessive use of tobacco, also known as “the brown plague” is an example of a modern epidemic.[1] Nicotine dependence has been recognized as one of the major public health problems facing the human race, both in developing and developed countries.

India is equally affected by this single most preventable cause of death and disease, a major risk factor for a non-communicable disease that is slowly threatening human life.

Every form of tobacco such as cigarette, cigar, pipe tobacco, snuff, and chewing tobacco contain 4000 chemicals along with nicotine which is highly addictive and is readily absorbed into the bloodstream.[2] Smoking alone accounts for 7 lakh deaths annually and 8–9 lakh deaths annually due to all other forms of tobacco use/exposure, many of the deaths occur below 70 years of age (>50%).[3] The use of tobacco causes a temporarily pleasing effect in the brain predominantly by altering the mesolimbic pathway. Nicotine is the chief chemical in tobacco, which causes dependence both physical and psychological. The same is also true for smokeless forms of tobacco. Cotinine is a metabolite of nicotine, which is measured in serum/saliva/urine to find the level of nicotine dependence of an individual. However, the test is difficult to perform. Hence, many questionnaires were developed, which act as a surrogate marker of nicotine dependence. One such questionnaire is the Fagerström Test for Nicotine Dependence (FTND). The questionnaire was used on smokers and smokeless tobacco users in different parts of the world and its reliability is confirmed in a different population. This degree of nicotine dependence will further help determine the suitable plans for the cessation of tobacco use (counseling/pharmacotherapy/both).[1] Considering the importance of tobacco cessation, this study was aimed at assessing the frequency, duration, and level of nicotine dependence in a group of the population. This in turn helps us to decide whether counseling alone or along with nicotine replacement should be the chosen mode of deaddiction management.[3]

During tobacco cessation counseling there was not enough awareness material available for the counselor to educate the tobacco user regarding the ill-effects of tobacco and all the details related to tobacco. So one sincere attempt was made to create a huge attractive chart including 5A's and use it during the study to assess the usefulness of the chart along with the tobacco cessation counseling.

   Aim and Objectives Top

The aim and objectives of the study were:

  1. To assess the nicotine dependence level in tobacco users (smoked and smokeless form).
  2. To assess the prevalence of oral diseases due to tobacco use and its stage.
  3. To use the newly made chart of 5A's and assess the usefulness of the chart in tobacco cessation counseling.

Inclusion criteria

100 males and females of age ranging from 15 to 80 years who were tobacco users and were willing to participate were included.

Exclusion criteria

Patients who were mentally challenged and unable to respond to the questions (due to hearing problems or any other reason) were excluded.

   Materials and Methods Top

The study was conducted for 6 months. Written informed consent was obtained from the respondents after explaining the nature and objectives of the study in their local language. The study was approved by the Institutional Review Board and Institutional Ethical Committee (IERB/CSMSSDCH) with clearance number DCA/920 dated 05/07/2018. All procedures followed were by the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1964 and later versions. Study participants were informed about the nature of the study and their consent was obtained to use the relevant clinical details and images for the scientific publication purpose without revealing the identity.

Sample size determination (Power analysis): The sample size determined for the current study was 94 at a confidence interval of 95% (0.05% probability of alpha error) with the effect size of 0.35 and 95% power of the study. The sample size determination and power analysis were done using GPower 3.1 software. The sample size was rounded off to 100 to further reduce the chances of error. After the oral examination of the patient, he was asked about tobacco use and if the patient was a tobacco user he was sent to the tobacco cessation center.

A fully equipped Tobacco cessation center was developed according to the DCI guidelines along with:

  • A Huge 10 X 8 ft chart specially made for counseling attracted the attention of all tobacco users towards it after entering the tobacco cessation center.
  • Chart of 5 days quit plan in Marathi
  • Chart showing the De-addiction center address and phone numbers in the city.
  • Weighing machine
  • Digital blood pressure apparatus
  • Laptop for showing videos
  • 6 Files

  • 1st file containing the Registration form
  • nd file containing proforma of study and consent of the patient
  • rd file containing Fagerstrom nicotine dependence score proforma
  • th file containing the 60 colored charts for explaining the patient.
  • th file containing the leaflet and form to be given to the patient during 5 days quit plan and benefits of tobacco cessation.
  • 6th file containing the leaflets of Cold turkey method for the patient and list of alternative and healthy products instead of tobacco to overcome the craving of tobacco and leaflet of benefits of quitting.

The study was done in proper sequence according to 5 A's of Tobacco counseling. [Figure 1]
Figure 1: Sequence of Tobacco counseling

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A huge, colored, attractive chart of 10 feet by 8 feet was made and installed in the Tobacco cessation center based on National guidelines for tobacco cessation in which near about 60 small pictorial charts are shown, which gave information about 5A's on which the whole tobacco cessation program is based.[4] [Figure 2]
Figure 2: Chart showing 5 A's of Tobacco Cessation

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The contents of the chart were filed so that patient could see them from a closer view during counseling and make him understand each step of counseling. The contents of the sequence of counseling shown in [Figure 1] were modified into pictorial format in the 10 X 8 ft chart [shown in [Figure 2]. The entries of all the patients with their diagnosis and consent were filled in proforma made for the study.

The study was divided into 10 parts.

  1. Filling up the Tobacco cessation center registration form provided by National guidelines for Tobacco cessation Annexure 1.
  2. Assessment of Nicotine dependence using the Fagerstrom test, a validated questionnaire for a smoked and smokeless form of tobacco use.
  3. Diagnosis of oral disease.
  4. Detail counseling of patients in sequence based on 5A's {Process of Cessation- Interventional strategies the 5 A's}.
  5. Providing leaflets of the benefits of tobacco cessation.
  6. Providing a chart of 5 days quit plan with instructions on how to follow it.
  7. roviding leaflets of the Cold turkey method and making them aware of the use of healthy and alternative products instead of tobacco.
  8. Showing videos of awareness of the hazardous effects of tobacco and the benefits of tobacco cessation.
  9. Follow-up
  10. Assessment of nicotine dependence using the Fagerstrom test, a validated questionnaire for a smoked and smokeless form of tobacco use again during follow-up.

The registration form given as Annexure 1 in Final operational guidelines for establishing a tobacco cessation center[5] and appendix 1 in National guidelines for tobacco cessation center was filled by asking the detailed information of tobacco use to the patient. Data was collected by face- to- face interview method having questions about socio-demographic details and tobacco use.

Nicotine dependence was assessed using the Fagerstrom test, a validated questionnaire for nicotine dependence.[2] This was a questionnaire-based prospective cross-sectional survey.[6]

A standard questionnaire of Fagerstrom Test for Nicotine Dependence (FTND Revised Version) for smoking given by Heatherton et al. (1991) and smokeless form of tobacco given by Ebbert et al. (2006) was administered to each subject[7]

The questionnaire consisted of 12 questions:

  • Questions on the dependency of the smoking form of tobacco = 6
  • Questions on the dependency of the smokeless form of tobacco = 6

Each question carried some point/score based on the answer. The subjects were asked to answer the questions as per their experience of tobacco consumption. The overall score was the summation of scores of all questions. The minimum score was 0 and the maximum score was10. The total time taken to complete the questionnaire was 5 minutes.

Interpretation of scoring.[8]

  • 7-10: Person is Highly dependent on nicotine;
  • 4-6: Person is Moderately dependent on nicotine
  • Below 4: Person is Minimally dependent on nicotine.

The patients were told about their nicotine dependence score and their diagnosis of the oral condition due to tobacco use. Patients were told about the importance of tobacco cessation centers and the tobacco cessation program. The counseling was done by explaining the chart contents and 5 A's of counseling in proper sequence stepwise and point wise. The 60 colored charts were explained in detail through local and simple language about the harmful contents of cigarette, a vicious cycle of smoking, benefits of quitting, Ill-effects of tobacco on general and oral health, mechanism of action of nicotine, withdrawal symptoms, 5 days quit plan, 5 R chart if the patient is not ready to quit, if ready then START chart, tips of quitting smoking, 4D and 3R behavioral therapy, cessation methods, self-help interventions, individual and group counseling, other forms of therapy like yoga, acupuncture, meditation, hypnosis, follow-up, etc., as per given in [Figure 1].[9],[10],[11] After the counseling, patients were given leaflets of 5 days quit plan in which patient was advised to do entries of their craving of chewing tobacco or smoking in form of yes or no and time of craving and if they overcome their craving or not and were asked to maintain a record of 5 days sincerely and truly so that the counselor understands the patient's response for quitting to make a further plan according to the response and need of patients. As a result of this, counselor also understood the withdrawal symptoms and difficulties of the patient to overcome his tobacco use.

Then the patient was also given leaflets of the Cold turkey method which were found to be the most effective in quitting tobacco in this study. In this method, the patient was asked to take 4 to 5 black pepper and make a powder of it and mix 3 to 4 drops of lemon juice and eucalyptus oil into it and was asked to store it in a small box and was advised to smell whenever they had a craving of tobacco. This smell diverted their attention from tobacco. The patients were also given a list of alternative and healthy products instead of tobacco to use for the craving of tobacco and were asked to use almonds, cashew nuts, dates, amla candy, chocolate, a banana or apple or carrot or fennel seeds whenever they had severe desire or craving of tobacco so that whenever they would use these products instead of tobacco they would be benefitted health-wise.

Benefits of alternative products which were asked to use instead of tobacco are given below:

  • Dates are a good source of Iron, Copper, Vitamin B6, Magnesium, and Tannin
  • Amla candy is a very good source of Vitamin C
  • Limlet (local name) candy is rich in Vitamin C
  • Almonds have protein fiber, Vitamin E, Magnesium, Riboflavin, Calcium, and Potassium.
  • Cashew nuts are rich in Calcium, Iron, and Vitamin B6.
  • Apple is rich in antioxidants.
  • Banana is a good source of potassium.
  • Carrot is a good source of Beta carotene.

Then the patients were shown the videos of individuals who quitted tobacco and their feedbacks.

The patients were also provided with the addresses of the De-addiction centres as per the national guidelines for tobacco cessation. After 6 months the patients reported for the follow-up with positive results.

Constant reminders were given to the patients who did not report and when the patients came for the follow up the Nicotine dependence was assessed again using the Fagerstrom questionnaire.

   Results Top

The Data was compiled on a Microsoft office Excel sheet and subjected to statistical analysis Statistical package for the Social Sciences (SPSS) 22. The data collected was qualitative type and thus was expressed in the form of frequency and percentage. The comparison of before and after the score was done using the Wilcoxon Signed Rank Test. P value less than 0.05 was considered as statistically significant.

Of 100 patients,

  • 57 patients were Highly dependent on nicotine.
  • 38 were Moderately dependent on Nicotine.
  • 5 were Minimally dependent on Nicotine at their first visit to the tobacco cessation center [Graph 1].

The prevalence of oral diseases of 100 patients due to tobacco use and its stage is shown in [Table 1].
Table 1: Showing Prevalance of Oral Diseases Due To Tobacco Use at first visit to tobacco cessation centre

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After carrying out the Tobacco cessation counseling and detail and effective tobacco cessation program for the tobacco users based on National guidelines for tobacco cessation:

  • 10 patients reported back to the college soon after 2 weeks for their treatment in other departments. They were very happy and very positive towards this big change in their life and also gave their valuable feedback on this tobacco cessation counseling.

It was observed that before counseling score 1, score 3, and score 10 were observed in only 1 patient each. Score 8 was seen in the maximum number of patients (29) followed by score 6 and score 7. Whereas, after counseling the maximum number of patients (35) had a score of 2 followed by a score of 0 in 28 patients and a score of 3 in 22 patients. Only one patient was found having a score above score 4. The difference in Fagerstrom score among the patients before and after counseling was statistically significant with P value <0.001. [Table 2] and [Graph 2].
Table 2: Comparison of Fagerstrom Test Score before and after counseling

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The study showed that before counseling 57 patients were highly nicotine dependent whereas, 38 and 5 patients were moderately and minimally nicotine-dependent respectively. After counseling 28 patients were tobacco/nicotine-free; whereas 67 patients were minimally nicotine dependent, 5 were moderately dependent and no patients were highly dependent. The difference in nicotine dependence before and after counseling was statistically significant with P value <0.001 [Table 3] and [Graph 3].
Table 3: Comparison of Nicotine Dependence before and after counseling

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   Discussion Top

According to Global Adult Tobacco Survey[12] Fact sheet India, 2016-17 report 19.0% of men, 2.0% of (GATS2) women, and 10.7% (99.5 million) of all adults currently smoke tobacco. 29.6% of men, 12.8% of women, and 21.4% (199.4 million) of all adults currently use smokeless tobacco. 42.4% of men, 14.2% of women, and 28.6% (266.8 million) of all adults currently use tobacco (smoked and/or smokeless tobacco). 55.4% of current smokers are planning or thinking of quitting smoking and 49.6% of current smokeless tobacco users are planning or thinking of quitting smokeless tobacco use. 48.8% of current smokers were advised by a health care provider to quit smoking and 31.7% of current smokeless tobacco users were advised by a health care provider to quit the use of smokeless tobacco. 38.7% of adults were exposed to second-hand smoke at home. 30.2% of adults who work indoors are exposed to second-hand smoke at their workplace. 7.4% of adults were exposed to second-hand smoke at restaurants. 19.2% of adults noticed smoking tobacco advertisements and 18.3% of adults noticed smokeless tobacco advertisements. 68.0% of adults noticed anti-smoking tobacco information on television or radio and 59.3% of adults noticed anti-smokeless tobacco information on television or radio. 92.4% of adults believed that smoking causes serious illness and 95.6% of adults believed that the use of smokeless tobacco causes serious illness.[13]

Observations of the study during the counselling were that many patients were unaware of the hazardous effects of tobacco and its carcinogenic contents. Initially, when patients sat for counseling they had a casual approach but slowly after hearing all the ill-effects of tobacco sequentially ended up with a very serious and concerned approach. Many patients started to use the tobacco at an early age and maximum of them started due to friends insistence, some just for the sake of fun and pleasure, some started for preventing sleep during driving or studying, some for the night shift of their job and some for just time pass, also some started as leisure time when they had no work. Some of them reported using tobacco for tooth pain as a medicine. It was observed during the study that patients using tobacco were from ages ranging from 15 yrs to 90 yrs. Tobacco was used by patients irrespective of their education ,profession ,financial status etc.

Various studies have been done on tobacco cessation below are the comparison with the present study. Koothati et al concluded that the prevalence of oral mucosal lesions was seen in tobacco-related oral habits where palatal hyperkeratosis was found among smokers; similarly, Oral Submucous fibrosis (OSMF) was more among tobacco chewers and potentially malignant disorders were more prevalent in tobacco chewers than smokers. In the present study, it was found that 30 patients had tobacco pouch keratosis, 18 patients had leukoplakia, 17 patients had oral submucous fibrosis, 09 patients had smokers palate, 08 patients had smokers melanosis, 08 patients had periodontitis/gingivitis//gingival enlargement, 05 patients had extrinsic stains, 04 patients had a wearing defect.[14] Kamirul Islam et al. 2019: The mean FTND score was significantly higher among adolescents aged >15 years, males, Hindu, tobacco users from a joint family, who belonged to lower socioeconomic status, who started using tobacco at the age of 10–12 years, using tobacco for ≥5 years, who were not married, were illiterate, working, and not aware of the injurious effect of tobacco to health. In the present study, the FTND score was significantly higher in all tobacco users from a young age to old age. Samatha et al. 2015 determined the type of nicotine dependence, ranging from mild to severe variant. The majority of Nicotine dependence was mild noticed among 86 (66.15%). Smokers with the least numbers noticed as severe nicotine dependence among 6 (4.62%) smokers. Association of the duration of smoking with dependence statistical significance noticed. Statistical significance was noticed between the association of frequency of smoking with dependence. In the present study of 100 patients, 57 patients were Highly dependent on nicotine, 38 were Moderately dependent on Nicotine, 5 were Minimally dependent on Nicotine.[1]

According to Mishra et al in 2015, the average compliance in three intervention rounds was 95.2%. The mean age at initiation of tobacco was 17.3 years. Tobacco use among family members and in the community was the primary reason for initiation and addiction to tobacco was an important factor for continuation, whereas health education and counseling seemed to be largely responsible for quitting. The quit rate at the end of the program was 33.5%. Multivariate logistic regression analysis found that women in higher age groups and women consuming tobacco at multiple locations are less likely to quit tobacco. Changing cultural norms associated with smokeless tobacco, strict implementation of anti-tobacco laws in the community, and workplaces and providing cessation support are important measures in preventing the initiation and continuation of tobacco use among women in India.[10]

In the present study health education and counseling with the help of attractive audio-visual aids in the tobacco cessation center was responsible for quitting tobacco.

During counseling at the end of the session, 4 patients of 100 were not very much interested to see the full video of awareness and got up and asked they wanted to leave.

  • Outlook: Patients reporting to the dental college demand that their chief complaint is resolved on priority. It is also the responsibility of the dentist to change the attitude of the patient and give equal importance to primary prevention.[15]

Limitations and future prospects

There are many barriers perceived by the dentist toward tobacco cessation counseling and the most common is “lack of material”,“lack of time”. “lack of training,” followed by “lack of knowledge”.This study provides a complete and reliable “5A” chart including A to Z of tobacco cessation counseling stepwise based on national guidelines of tobacco cessation and authentic material for tobacco cessation counseling which will help the counselor to carry out the counseling effectively and will also save the time of counseling. Furthermore Oral physician and Radiologist practice their specific branch of diagnosing oral lesions related to tobacco on daily basis and would more likely to have effective and good practice in Tobacco Cessation interventions. This ascertains that if we improve the attitude of them toward TCC it will intensify their inclination toward TCC. Tobacco cessation practice should be strengthened in teaching institutions and given specially to oral medicine and radiologist so that primary prevention of diseases due to tobacco is achieved.

   Conclusion Top

As oral medicine post-graduates at the institution level, we are the first ones to handle and diagnose the oral diseases of the patient since we come across such patients on daily basis during the first examination in the department of Oral Medicine. Thereafter, the patients get distributed to other departments for their other dental treatments. During the check-up itself, if the patient is being told seriously about the ill-effects of tobacco and sends for counseling before starting any other dental treatment, the patient has a more serious impact on his mind regarding oral diseases. It should be made compulsory for all tobacco users that unless and until they attend the 30 minutes of tobacco counseling sessions they will not be sent to further treatment. This makes them aware that tobacco counseling is a very important and essential part of routine dental treatment. Due to this every patient consuming tobacco will undergo counseling for tobacco cessation and made aware of the ill-effects of tobacco thus preventing him from oral cancer. Using the novel chart of 5A's based upon National guidelines of tobacco counseling proved to be very beneficial for the tobacco users and can be recommended to use all over.

So establishing a Tobacco cessation center in dental college and actively running this center using cognitive and behavioral counselling through the pictorial chart of 5A's, informative leaflets, awareness videos and regular follow-up has proven to be very effective and helped tobacco users to quit tobacco thus helping to abolish this serious 'BROWN PLAGUE” from our country.


The authors would like to thank Mr. Arvind Sardar for all the cooperation and support needed for this article.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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