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Year : 2022  |  Volume : 20  |  Issue : 4  |  Page : 384-387

Tobacco habit abstinence through behavioral counseling among transgender persons of pune district: A quasi-experimental design

Department of Public Health Dentistry, Dr. D. Y. Patil Dental College and Hospital, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission12-Oct-2021
Date of Decision02-Sep-2022
Date of Acceptance23-Sep-2022
Date of Web Publication19-Dec-2022

Correspondence Address:
Sahana Hegde Shetiya
Former Prof and Head, Department of Public Health Dentistry, Dr. D. Y. Patil Dental College and Hospital, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune - 411 018, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_185_21

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Background: Transgender population are a high-risk group in the community, as their oral health gets neglected due to the stigma associated with them. Since it is an impediment to obtain oral care services, a group of such persons were identified with an intention of examining them orally and providing basic oral treatment. Aim: To identify a cohort of transgender persons using tobacco product and provide group behavioral counseling for cessation of their habit. Materials and Methods: A total of five locations wherein transgender persons were residing were identified. Demographic details of the participants such as age, education status, and occupation were recorded. The tobacco product use details regarding frequency, duration of use, and form of tobacco were documented. The identified tobacco users were provided with behavioral tobacco cessation counseling. Follow-up was done every month for 6 months and at 18th month through self-reported abstinence and urine cotinine test at 6th month. The data was analyzed using descriptive statistics in the form of numbers and percentages and the 95% confidence intervals (CIs) (Mid-P) were provided using WinPepi PORTAL. Results: A total of 52 transgender persons aged 18–58 years were identified. Tobacco product use was identified in 73%, out of which 13% smoked tobacco, 84% chewed tobacco, while 2% smoked and chewed both. Postintervention at 6th month, 21% (CI: 0.10–0.36) abstained from the habit of tobacco product use, which was self-reported and 7% (CI: 0.02–0.20) was validated with urine cotinine. By the 18th month, 15% (CI: 0.06–0.29) had self-reported abstinence. Conclusion: The prevalence of tobacco consumption was high among transgender population. Tobacco cessation program helped in quitting the adverse habit in 15% of the population. Cessation programs supplemented with nicotine replacement therapy use in this marginalized section of the society would help achieve a better abstinence.

Keywords: Quasi-experimental study, tobacco use cessation, transgender persons

How to cite this article:
Shetiya SH, Kumbhalwar A, Kale SS. Tobacco habit abstinence through behavioral counseling among transgender persons of pune district: A quasi-experimental design. J Indian Assoc Public Health Dent 2022;20:384-7

How to cite this URL:
Shetiya SH, Kumbhalwar A, Kale SS. Tobacco habit abstinence through behavioral counseling among transgender persons of pune district: A quasi-experimental design. J Indian Assoc Public Health Dent [serial online] 2022 [cited 2023 Oct 3];20:384-7. Available from: https://journals.lww.com/aphd/pages/default.aspx/text.asp?2022/20/4/384/364019

  Introduction Top

Oral diseases differ in prevalence from person to person. These diseases are strongly influenced by age, gender, socioeconomic classes, access to health care, and awareness regarding the preventive measures of the diseases.[1] Moreover, lifestyle too plays a major role in occurrence of a disease. In India, because of multiple socioeconomic disadvantages, there are particular groups in the community which are highly prone to oral diseases such as dental caries, periodontitis, and even premalignant lesions and conditions as a result of negligence portrayed toward them.[2] Transgender population are susceptible to oral diseases[3] and their needs may be unmet. The social stigma associated with this community comes as a hindrance toward their access to dental care services.

The Greek derivation of the word “Keeper of the bed” is the term EUNUCH.[4] In India, a synonym for eunuch is “Hijra” which refers to third gender. An uncommunicative and sidelined community of the transgender persons may not have an exact count in India.[3] Telegraphic report guessed that 1.5 million eunuchs may be living in India.[5]

These groups also report a high prevalence of around 83% of periodontal diseases.[6] One of the main reasons for advancing periodontitis in this group is the habit of consuming tobacco. The study[7] reports 35.5% transgender persons having a habit of smoking cigarette, 26.8% of cigars, and 21.3% of e-cigarettes. They are at higher risk of developing adverse habits due to social discrimination faced by the society.[7]

The severity of the health problems among this group becomes a concern because these people report various barriers toward their health care. Due to low level of education, they limit themselves from a professional stable life. The jobs they do include ritual performing at marriage and birth celebrations, begging for alms, and prostitution.[4] Hence, they find it difficult financially to take any oral health treatment. Moreover, this also becomes a hindrance for obtaining insurance policies toward their general health. Due to the stigma associated with this community, they avoid approaching a dentist to seek any treatment. Thus, treatment of transgender persons on a timely basis is one of the important factors to boost the oral health scene across the country.[8]

Because of this stigmatization and condition of transgender persons, oral heath gets neglected leading to various untreated problems of dental caries, periodontal disease, tooth loss, and ulcerative lesions due to adverse habits. A study[9] reports that around 28.5% transgender populations have oral lesion due to the use of tobacco. Moreover, when interventions were undertaken for cessation of tobacco among them, the cessation aids have proved to be effective and group tobacco cessation for Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) population was found to be easily possible.[10] There seems to be need for public health campaigns among LGBTQ smokers and chewers to focus on motivating them to quit their habit and ultimately improve their overall oral health. Thus, this study was designed with the aim to identify a cohort of transgender persons using tobacco products and provide group behavioral counseling for cessation of their tobacco habit.

  Materials and Methods Top

Tobacco cessation intervention through behavioral counseling was conducted among the cohort of transgender persons (transwomen) of Pune District recruited through census sampling after obtaining clearance from the Institutional Ethics Committee (Ref. No. DYPV/EC/230/2019) of Dr. D. Y. Patil Dental College and Hospital, Pimpri, Pune. They were recruited between January 2019 and March 2020 using a quasi-experimental design –uncontrolled pre–post comparison without blinding. Since these groups follow an isolated existence tradition, reaching out to them was accomplished through a snowball sampling technique. The 5 locations in the Pune city where majority of the transgender persons reside were identified by their chiefs (guru). They were Kalewadi, Dapodi, Pimpri, Yerwada, and Bibvewadi. These recruitment settings at the community level were visited and 52 transgender persons were identified (18–58 years). Those who gathered on the day of data collection on invitation by their guru/acquaintance during the first visit were part of the study.


Baseline data of 38 persons regarding their demographics (name, age, education level, and phone number) were obtained through a pro forma. Along with this, a detailed history about the habit of consumption of tobacco/smoking was recorded. Fagerstrom Test of Nicotine Dependence-Smokeless Tobacco scores and Fagerstrom Test of Nicotine Dependence-Smoking[11] were obtained to assess the dependency of tobacco among the transgender persons. The participants were in the precontemplation and contemplation stages as per transtheoretical stage of change.[12] Picture panel was shown to them making them aware of precancerous lesions and conditions that can develop because of tobacco product use. Oral examination (Type 3) and oral prophylaxis were carried out through the mobile dental clinic free of cost which was an incentive to increase compliance. After obtaining all the necessary data, the participants were given tobacco cessation counseling using 5As, 5Rs, and motivational interview for 25–30 min by a trained tobacco counselor who is a public health dentist in group of 15.


Follow-up was done every month for 6 months through a telephonic conversation to assess abstinence, slip/relapse, reduction in tobacco consumption/smoking, challenges faced, and how to resolve them. At 6th month, self-reported abstinence and urine cotinine (Nano-Check DAT) was recorded. The detection limit concentration (cutoff) of this test is cotinine at 200 mg/ml.


The demographic data along with data of tobacco consumption and self-reported abstinence and that validated through urine cotinine were recorded for the group onto a Microsoft Excel Spreadsheet 2010. The data were analyzed using descriptive statistics in the form of numbers and percentages and the confidence intervals (CIs) were provided using WinPepi PORTAL, Copyright J. H. Abramson, August 23, 2016, Version 11.65.

  Results Top

From among 52 transgender persons, 27% did not use and 73% (38 persons) used tobacco products. These were followed up to August 2019. Among 38, 71% of them were educated up to 8th to 10th class. The main occupation identified was begging involving 78%. When asked about their oral hygiene habits, 94% used toothbrush and toothpaste to brush their teeth.

The frequency and usage in years for smoking and smokeless tobacco among transgender persons is depicted in [Table 1]. A lower percentage of the sample smoked tobacco.
Table 1: Frequency of consumption of smokeless and smoking tobacco

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The number of transgender persons showing abstinence toward the tobacco habit during the follow-up of 6 months with respect to five locations in Pune city is represented. The highest abstinence was reported in Yerwada (n = 4), followed by Dapodi (n = 3) and Kalewadi (n = 1). Transgender persons of Pimpri and Bibvewadi area did not show any abstinence toward tobacco product use [Figure 1]. 21% self-reported abstinence and 7% was validated through urine cotinine at 6th month. At 18th month, 15% self-reported abstinence [Figure 2].
Figure 1: Bar diagram representing abstinence of tobacco habit in five locations of Pune

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Figure 2: Flow diagram of participants through each stage of the study

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  Discussion Top

General health and quality of life depends on good oral health. To plan a program, one needs to be well versed with the severity of diseases and causative factors in the study group. Thus, this study was an attempt to assess the habit of use of tobacco product in smoking and smokeless form and thereby provide tobacco cessation counseling. In the present study, it was found that only 5% of the transgender persons had either completed their university degree or professional/PG courses. The average education level of transgender persons is either secondary or senior secondary and very few would be found taking professional courses.[1] The lack of education among the transgender populations can be attributed to the fact that even if they start with their education, they have to face severe discrimination in the education sector wherein they are severely bullied and harassed by the society members leading to high dropouts in school.[13] Unacceptance by colleagues/supervisor at work makes the professional quit the job and life with their peer group is more satisfying for them. The lack of education further leads to a life with limited job opportunities, which makes them turn into a beggar or sex worker.[14]

The findings of Mithra and Vijaylakshmi[15] too reported that there was a strong correlation between education level and exposure to job opportunities for transgender. This is in consensus with the present study, wherein 78% of transgenders are engaged in begging for their daily expenses, which is because of low-level literacy. Verma et al.[16] reported 53.1% Kinnars working as beggars and also provided with an interesting fact that each area is divided into ilaqa and the guru of each ilaqa assigns work of begging and badhai to the kinnars/hijras of that area according to their traditional occupation.

In the present study, majority of the transgender persons had a habit of using tobacco product. The consumption in the smokeless form was seen more often than smoking. The results were in agreement with a study that reported 35% transgender persons consuming gutka, 29.9% consuming tobacco, and only 6.6% smoking tobacco.[17] 34.16% either used cigarette or beedi, while 43.3% consumed gukta, pampura, or betel leaves with tobacco. 17% of the transgender persons were addicted to smoking, of which 18.7% smoked 20 cigarettes per day.[18] Similar was reported by Padhmini and SrideviSivakami[19] with 19 cigarettes and 22 beedis smoked per day, whereas in the present study, the maximum frequency of tobacco use was 16–20 times a day.

When intervention was given with behavioral counseling and 5As 5Rs[20] for quitting tobacco habit, the present study reported only 21% [Exact 95% CI (Mid-P) 0.10-0.36] transgender persons who abstained from the habit by the end of 6 months, while the remaining either reduced their consumption/smoking or continued with the habit. 7% of these could be validated through urine cotinine and self-reported quit at 18 months was 15%. Since the studies among transgender persons for tobacco cessation are scarce in Indian context, the results of the present study could not be compared with other Indian studies but with the results of the western studies. The quit rates were found higher in study reported by Walls and Wisneski,[21] wherein 88.9% of the LGBTQ community members had quit the smoking habit postclassroom group cessation program. Sixty in Eliason et al.[22] provided self-reported abstinence due to group cessation program delivered in 7 weeks. The variation in the results can be accounted to the use of different tailored and nontailored cessation programs provided. A scoping review[23] concluded that group cessation counseling does help with quitting and programs at the community level have been executed, but very little evidence of outcomes exist.

The low abstinence in the present study can be because of underestimation of the reports as few of the transgender persons could not be contacted (not answering the call) on monthly basis and even at the end of 6 months and 18 months (change of telephone number and residence, relocation) and hence were considered to have continued with the habit. Moreover, in the present study even after counseling through telephonic conversation by the certified tobacco counselor, low abstinence was reported as support with nicotine replacement therapy was lacking. Limitation of the study includes self-reported abstinence which can over/underestimate the abstinence. Along with this, no confirmatory cotinine test was done among all the transgender persons as they were unavailable, except for three to guarantee on the reported results. However, a group comprising 3–4 persons who were motivated to improve oral health visited the dental hospital for further treatment.

  Conclusion Top

Within the limitations of this study, it can be concluded that there is a high prevalence of tobacco product use among transgender persons with preference given to smokeless form over smoking. The intervention provided for self-reported tobacco cessation did help in abstinence of tobacco habit (21% at 6 months vs. 15% at 18 months). Vulnerable groups in low–middle-income country can benefit from counseling and this can prevent premature death.

Financial support and sponsorship

The project was funded by the Narottam Sekhsaria Foundation, Mumbai through a grant of Rs. 16,000.

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2]

  [Table 1]


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