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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 24  |  Issue : 4  |  Page : 163-167

Knowledge, attitude, and practice of office-based laryngeal assessment among adult smokers in Saudi Arabia


1 Department of Otolaryngology, Head and Neck Surgery, King Saud University Medical City, College of Medicine, King Saudi University, Riyadh, Saudi Arabia
2 Department of Emergency Medicine, Prince Abdulaziz Bin Musaed Hospital, Arar, Saudi Arabia
3 Department of Otolaryngology, Head and Neck Surgery, Hafar Central Hospital, Hafar Al-Batin, Saudi Arabia
4 Department of Otolaryngology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
5 Department of Family Medicine, Al Midhnab General Hospital, Qassim, Saudi Arabia
6 Department of Otolaryngology, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Date of Submission10-Oct-2022
Date of Decision10-Nov-2022
Date of Acceptance13-Nov-2022
Date of Web Publication30-Dec-2022

Correspondence Address:
Dr. Manal Ahmed Bukhari
Department of Otolaryngology, Head and Neck Surgery, King Saud University Medical City, College of Medicine, King Saudi University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjoh.sjoh_51_22

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  Abstract 


Background: Voice change or dysphonia can be caused by many factors. Smoking is one significant risk factor that has been proven to impact voice quality significantly. The smoker's prevalence has increased recently in Saudi Arabia, mainly among men. In this study, we will assess the prevalence of Saudi smokers' knowledge and practice of visiting ENT clinics due to their voice change and the importance of laryngeal assessment. Methods: This descriptive cross-sectional study collected 448 adult smokers throughout the Kingdom of Saudi Arabia using a validated electronic questionnaire from March to September 2022. We interpret and assess the data of knowledge and demographic variables and ENT clinic visits. To determine the association between our variables, we analyzed the data using SPSS Statistics, version 25. Results: Most participants were between 18 and 34-year-old. The majority of the participants are males (81.5%). The vast majority have never undergone a laryngeal exam (71.4%), and 70.5% do not know about such an assessment. The knowledge questions found that most participants answered as “I do not know,” ranging from 27.7% to 71.2%. Only 123 (27.5%) participants noticed voice changes. Conclusion: Voice change is a common symptom frequently noticed by active smokers. It can be a warning sign of severe hidden pathology. Such a type of pathology can be spotted by simple laryngeal assessment. For early recognition of these lesions, it is crucial for smokers' to be aware of the efficacy and advantages of laryngeal assessment and its importance.

Keywords: Dysphonia, Saudi Arabia, smoking, voice change


How to cite this article:
Bukhari MA, Alenezi AQ, Abohelaibah FH, Alfawaz FS, Alkhamis RS, Ashour HA. Knowledge, attitude, and practice of office-based laryngeal assessment among adult smokers in Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg 2022;24:163-7

How to cite this URL:
Bukhari MA, Alenezi AQ, Abohelaibah FH, Alfawaz FS, Alkhamis RS, Ashour HA. Knowledge, attitude, and practice of office-based laryngeal assessment among adult smokers in Saudi Arabia. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2022 [cited 2023 Jan 31];24:163-7. Available from: https://www.sjohns.org/text.asp?2022/24/4/163/366338




  Introduction Top


The normal physiology of phonation or voice production is affected by different factors, including normal laryngeal anatomy, strength, and quality of sound, good nerve supply, and proper opening and closure of vocal folds. However, a change among these factors can negatively impact voice production, quality, or strength, leading to voice disorders.[1] Smoking is an essential factor in affecting the quality of voice, given that it can change the normal anatomy of the larynx and lead to many laryngeal diseases, including laryngitis, Reinke's edema, leukoplakia, and various cancers.[1]

Smoking is a significant risk factor that negatively impacts vocal health through its harmful effects on the mucosal membrane of the oral cavity. Chronic smoking can lead to the inability to move the vocal cords completely during vocalization, resulting in impairment of vocal quality and pitch.[2]

Adult smokers are increasing rapidly in the Kingdom of Saudi Arabia (KSA). In 2013 a survey was conducted in KSA to assess tobacco consumption. The overall results of tobacco smokers were 12.2%.[3] An updated survey was done by the Saudi Food and Drug Authority in 2018 to see the prevalence of current adult smokers showed that 21.4% of adults are smoking, in comparison to 12.2% in 2013, inflicting an increase in prevalence between 2013 and 2018[3],[4] as the smoking prevalence increases the risk of developing smoking-related disorders increases. Various cancers, such as oral, pharyngeal, and laryngeal cancer, will also become more prevalent.[1]

As the harmful effects of smoking on voice hygiene are well known, the unrecognized problem most smokers have is inadequate self-perception of vocal symptoms.[5] The voice handicap index (VHI), is a validated scale used to assess individuals' self-perception of the physical, functional, and emotional effects of anyone with vocal symptoms.[6] Smokers need to know that a change in voice or hoarseness is one of the early and vital symptoms noticed at the early stages of laryngeal cancer. Office Laryngoscopy is an essential and easy procedure that can pick up early changes in vocal folds, visualize the larynx and help detect early laryngeal cancer.[7] In our study, we will assess the Arabic-speaking active adult smokers in the KSA regarding their knowledge, attitude, and practice of visiting ENT clinics and the importance of laryngeal assessment.


  Methods Top


In this descriptive cross-sectional study, we reviewed the data collected through a self-administered electronic questionnaire distributed among smokers who live in KSA. The questionnaire was designed to meet the research objective based on previous researches addressing the same issue and based on the experience of the senior author; after developing the first version, a pilot study was done with 20 consented adult smoker participants, then the questionnaires were finalized after getting feedback from the pilot study. A total of 448 Arabic-speaking adult smokers participated from March to September 2022. The inclusion criteria were: (1) Smokers, (2) Age ≥18 years, (3) Arabic speakers, (4) living in KSA. Exclusion criteria were: (1) Nonsmokers, (2) Age <18-year-old, (3) underwent previous laryngeal surgery, (4) have current/previous laryngeal malignancy, (5) voice changes before smoking, (6) nonArabic speakers. The informed consent was added to the first page of the self-administered validated electronic questionnaire.

Measurements

The data collected from each case were demographic information and questions regarding knowledge, attitude, and practices of office-based laryngeal assessment. In the demographic variable, we looked for participant age, gender, occupation, education, income, and habit of smoking. In the knowledge variable, we measured how aware and educated are the participants regarding laryngeal assessment, smoking-related disorders, and their clinical manifestations. Finally, the practice variable looked at the participant's visits to an ENT clinic and their smoking practice, whether they quit smoking or changed their habit after the visit, and the impact on their voice after quitting smoking or changing the smoking habit.

Data collection and analysis

Collection and analysis of data were conducted from March to September 2022. The participants' variables were first entered into an Excel sheet after extracting them from Google Forms. The data coding was conducted on the Excel program before transferring to SPSS Statistics for Windows, version 25 (IBM Corp., Armonk, NY., USA) for data analysis. The analysis started by running frequencies for the participants' demographic details, their knowledge of office-based laryngeal assessment, and the effects of smoking on vocal cords and voice. More frequencies were run concerning the participants' experience with voice changes, their relation to smoking and smoking cessation, the frequency of visiting the ENT clinic, and the regularity of undergoing office-based laryngeal assessment.


  Results Top


The main focus of this study is to investigate the Saudi population; successfully, this survey has captured 93.1% of Saudi nationals. A Total of 448 participated in this survey. The distribution of participants ranged between 14.3% in the southern region and 24.1% in the central region. The male-to-female ratio was skewed in this study, where 81.5% of the participants were males. The majority of the participants were falling between 18 and 34-year-old. Most of the participants have a Bachelor's degree (64.5%). Most participants have an occupation (57.8%), and the majority of participants' monthly income is <5000 SAR (36.4%). The most common type of smoking was regular cigarettes (53.6%), and the most prevalent duration of smoking was 1 year (27.7%). For more information about the participant's characteristics are shown in [Table 1].
Table 1: Baseline demographics and characteristics for participants who take the survey concerning smoking and its effect on vocal cords and voice changes (n=448)

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This study aimed to shed light on smoking's effect on vocal cords and the awareness of the periodic need for office-based laryngeal assessment. The vast majority of the participants have never undergone a laryngeal exam (71.4%) [Figure 1]. When participants were questioned about their knowledge regarding such an assessment, 70.5% had no information about it. The most commonly reported source of information was social media comprising only 13.4% of the participants. For details about the sources of information reported by the participants are shown in [Table 2].
Figure 1: The frequency of office-based laryngeal assessment

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Table 2: Participant's sources of information they used to gain knowledge about office-based laryngeal assessment (n=448)

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Among the 448 participants of this study, only 123 (27.5%) reported noticing voice changes, given that all of them are smokers. The most common type of voice change is voice hoarseness (44.7%), followed by voice straining and tiredness (25.8%), voice breaking while talking (10.6%), and difficulty being heard (8.9%) [Table 3].
Table 3: Most common reported voice change types among participants (n=123)

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The participants were surveyed on a set of questions, nine precisely, about their knowledge of the need for office-based laryngeal assessment and the short- and long-term effects of smoking. A noticeable finding was that most of the questions answered as “I do not know,” ranging from as low as 27.7% to 71.2%. For the details of knowledge and questions, refer to [Table 4].
Table 4: Participant's knowledge about the effects of smoking on the larynx and the importance of periodic clinical examination (n=448)

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In [Table 5], despite more than half of the participants (56.5%) having visited the ENT clinic, only 4.7% were due to voice changes. Among those who visited the ENT clinic, 58.5% did not stop or change their smoking habits. According to participants who attempted smoking cessation, 62.3% reported improved voice changes. Moreover, a close percentage (62.2%) reported improvement in voice changes after changing their smoking habits; for more details [Table 5].
Table 5: The frequency of ear, nose, and throat clinics visits, impact on smoker's behavior and the difference of habits changes on voice problems (n=448)

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  Discussion Top


Voice quality depends on multiple factors, including normal laryngeal anatomy, good nerve supply, sound strength, quality, fluidity, and proper opening and closure of vocal folds. Different mechanisms can disturb these factors due to smoking, which has significant to moderate effects on voice, as concluded in a recent meta-analysis study.[1] The smoking effect is not limited only to dysphonia. It plays an essential role in developing other severe conditions, including Reinke's edema, Leukoplakia, Laryngitis, Laryngeal cancer, oral cancer, and pharyngeal cancer.[1]

Smoking prevalence in Saudi Arabia has been increasing significantly in recent years. A recently updated survey conducted by the Saudi Food and Drug Authority in 2018 showed that adult smokers account for 21.4% of the population 17% of them are daily smokers, while 5% were nondaily smokers; furthermore, 32.5% were males, and 3.9% were females.[4] The survey shows a predominance of adult male smokers,[4] which can help us explain why the majority of our study participants were males (81.5%). The same survey by the Saudi Food and Drug Authority found that low education levels and those employed are more likely to smoke.[4] Similarly, our results showed that more than half of our participants are employed (57.8%). However, most of our participants showed a high level of education (64.5%), which is unexpected considering that smoking carries a high risk of developing a wide range of disabilities and disorders, from slight nonworrisome voice changes to severe conditions such as laryngeal cancer.[1] Chronic smoking is a significant risk factor that negatively affects the larynx and vocal health through its harmful effects on the mucosal membrane of the oral cavity.[2]

Voice change can come in different forms, including hoarseness, tiredness, straining, weakness, and voice breaking. Dysphonia is considered one of the early and vital symptoms noticed at the early stages of laryngeal cancer, which can be detected by office laryngoscopy examination.[7] Smoking-associated voice disorders can be detected early in the office, By Different diagnostic tools which can identify these early changes, including VHI and office Laryngoscopy.[6],[7] Interestingly the vast majority of the participants have never undergone an office-based laryngeal assessment (71.4%); this high percentage can be explained by the fact that 70.5% of participants do not know about such an assessment and most of the participants lack awareness of the short- and long-term effects of smoking, demonstrating a low level of knowledge. Although it is essential to point out that only a minority of participants (4.7%) who visited ENT clinics were due to changes in their voice. Another possible explanation for the high percentage of smokers who are unaware of laryngeal assessment (70.5%) is a study that found that smokers did not experience an increased fear of laryngeal cancer compared to former smokers or nonsmokers,[8] which we believe is a strong motive that can change the awareness level.

Among the 448 participants of this study, only 123 participants (27.5%) reported noticing voice changes, given that all of them are smokers. Voice hoarseness (44.7%) was the most common type of voice change [Table 3]. A validated tool called VHI used to assess individuals' self-perception of the physical, functional, and emotional effects of vocal changes is an efficient tool in assessing this problem.[6] Two studies that used this scale found that smokers scored lower (less handicapped) in opposition to nonsmokers indicating that smokers did not perceive their vocal symptoms to be debilitating.[5],[7]

A retrospective study aimed to identify the level of voice fatigue in different smoking habits, including active smokers, passive smokers, and nonsmokers. It showed that active smokers are three times more susceptible to voice fatigue and 3.8 times in passive smokers compared to nonsmokers.[9] In our study, out of 167 smokers who stopped smoking, 62.3% have shown improvement in their voice, and from 201 smokers who changed their smoking habits, 62.2% noticed an improvement in their voice. Unfortunately, our study did not clarify the exact habit and duration, in which smokers' voice improves. A possible alternative habit offered to heavy smokers who are unwilling to quit smoking and whose sole issue is dysphonia is to try reducing the number of smoking packs/cigarette per day, nicotine replacement therapy, and e-cigarettes. A recent cross-sectional study was done in 2019 to show the impact of e-cigarettes on voice performance and compare it to conventional cigarettes by analyzing the voice subjectively and objectively. The results revealed that the effect of e-cigarettes on voice was mild compared to conventional cigarettes.[10] Although e-cigarettes are not generally safe, it must be clarified that there is limited scientific evidence of e-cigarettes' harmful effects on head and neck cancers. The current literature in this regard is still limited.[11],[12]

Finally, it is essential to point out that more than half of smokers (58.5%) who visited ENT clinics did not quit or change their smoking habits. Thus, ENT health-care providers should encourage and advocate smoking cessation and offer habitual changes, especially to those willing to quit smoking. It is important to point out that the limitations we faced in this study were in the methodology of electronic questionnaire distribution, the inability to know the exact duration when voice improves after smoking cessation, or which habits had a significant effect on improvement in voice quality.


  Conclusion Top


The prevalence of smokers is increasing in Saudi Arabia. Since smoking carries a significant risk of developing many disorders and various cancers, a regular follow-up plan should be addressed, especially in dysphonic smokers. To our knowledge, there is a lack of local and international studies assessing the awareness and importance of regular office-based laryngoscopy screening of vocal cords among adult smokers. We believe that guidelines for the smoking population and dysphonic smokers help to gain knowledge about the importance of office-based laryngeal assessment in the early detection of these disorders and prevent possible poor outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Byeon H, Cha S. Evaluating the effects of smoking on the voice and subjective voice problems using a meta-analysis approach. Sci Rep 2020;10:4720.  Back to cited text no. 1
    
2.
Menvielle G, Luce D, Goldberg P, Bugel I, Leclerc A. Smoking, alcohol drinking and cancer risk for various sites of the larynx and hypopharynx. A case-control study in France. Eur J Cancer Prev 2004;13:165-72.  Back to cited text no. 2
    
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Moradi-Lakeh M, El Bcheraoui C, Tuffaha M, Daoud F, Al Saeedi M, Basulaiman M, et al. Tobacco consumption in the Kingdom of Saudi Arabia, 2013: Findings from a national survey. BMC Public Health 2015;15:611.  Back to cited text no. 3
    
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Algabbani A, Almubark R, Althumiri N, Alqahtani A, BinDhim N. The prevalence of cigarette smoking in Saudi Arabia in 2018. Food Drug Regul Sci J 2018;1:1.  Back to cited text no. 4
    
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Wiskirska-Woźnica B, Wojnowski W. The smokers voice self assessment based on Voice Handicap Index (VHI). Przegl Lek 2009;66:565-6.  Back to cited text no. 5
    
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Jacobson BH, Johnson A, Grywalski C, Silbergleit A, Jacobsen G, Michael S. The Voice Handicap Index (VHI): Development and validation. Am J Speech Lang Pathol 1997;6:66-70.  Back to cited text no. 6
    
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Glas K, Hoppe U, Eysholdt U, Rosanowski F. Smoking, carcinophobia and voice handicap index. Folia Phoniatr Logop 2008;60:195-8.  Back to cited text no. 7
    
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Laryngeal and Hypopharyngeal Cancer Early Detection, Diagnosis, and Staging. Available from: https://www.cancer.org/cancer/laryngeal-and-hypopharyngeal-cancer/detection-diagnosis-staging/signs-symptoms.html#references on April 2, 2022.  Back to cited text no. 8
    
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Widuri A, Wiratama E. The Influence of smoking habit to voice handicap index score. Egypt J Ear Nose Throat Allied Sci 2021;22:1-5.  Back to cited text no. 9
    
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Tuhanioğlu B, Erkan SO, Özdaş T, Derici Ç, Tüzün K, Şenkal ÖA. The effect of electronic cigarettes on voice quality. J Voice 2019;33:811.e13-811.e17.  Back to cited text no. 10
    
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Szukalska M, Szyfter K, Florek E, Rodrigo JP, Rinaldo A, Mäkitie AA, et al. Electronic cigarettes and head and neck cancer risk-current state of art. Cancers (Basel) 2020;12:3274.  Back to cited text no. 11
    
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Flach S, Maniam P, Manickavasagam J. E-cigarettes and head and neck cancers: A systematic review of the current literature. Clin Otolaryngol 2019;44:749-56.  Back to cited text no. 12
    


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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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