Timing and causes of death to 1 year among children presenting to emergency departments.

BACKGROUND AND OBJECTIVES: A better characterization of deaths in children following emergency care is needed to inform timely interventions. This study aimed to describe the timing, location, and causes of death to 1 year among a cohort of injured and medically ill children. METHODS: We conducted a retrospective cohort study of children <18 years requiring emergency care in six states from January 1, 2012, through December 31, 2017, with follow-up through December 31, 2018, for patients who were not discharged from the emergency department (ED). In this cohort, 1-year mortality, time to death within 1 year, and causes of death were assessed from ED, inpatient, and vital status records. RESULTS: There were 546,044 children during the 6-year period. The 1-year mortality rate was 2.2% (n = 1356) for injured children and 1.4% (n = 6687) for medically ill children. Matched death certificates were available for 861 (63.5%) of 1356 deaths in the injury cohort and for 4712 (70.5%) of 6687 deaths in the medical cohort. Among deaths in the injury cohort, 1274 (94.0%) occurred in the ED or hospital. The most common causes of death were motor vehicle collisions, firearm injuries, and pedestrian injuries. Among the 6687 deaths in the medical cohort, 5081 (76.0%) children died in the ED or hospital (primarily in the ED) and 1606 (24.0%) occurred after hospital discharge. The most common causes of death were sudden infant death syndrome, suffocation and drowning, and congenital conditions. CONCLUSIONS: The 1-year mortality of children presenting to an ED is 2.2% for injured children and 1.4% for medically ill children with most deaths occurring in the ED. Future interventional trials, quality improvement efforts, and health policy focused in the ED could have the potential to improve outcomes of pediatric patients.

Trajectories of care and outcomes of Veterans receiving home-based primary care.

BACKGROUND: Veterans Affairs (VA) home-based primary care (HBPC) provides comprehensive longitudinal care to patients with complex, chronic disabling disease. While enrollment is associated with lower hospitalization rates and costs, detailed trajectories have not been well described. METHODS: We performed a longitudinal descriptive study of patients newly enrolled in VA HBPC in fiscal year (FY) 2015. We extracted demographics, comorbidities, functional status, and social supports from VA and Medicare data and examined patterns of care and clinical outcomes, including hospital, nursing home (NH), hospice use and mortality from FY2015-2017. We present results using descriptive statistics, alluvial plots, and heat maps. RESULTS: We identified 10,571 HBPC enrollees in FY2015; mean age was 77.7. HBPC patients commonly had chronic medical conditions with high self-management burden (e.g., diabetes 48.2%) and disabling conditions such as dementia (39.3%). Over half had ≥2 deficits in activities of daily living, 46% had caregivers with functional limitations or no caregiver, and 25% resided in a socially deprived area. Patients experienced variable care trajectories. Mean time enrolled in HBPC was 331 days, 8.3% of patients were discharged after 3 months, and 22.8% stayed enrolled for over 2 years. Institutional health care use declined in the 6 months after initial enrollment: (e.g., hospital: 41%-25%, NH: 34%-11%). At 2 years, 36% of patients had died; among decedents, 58% received hospice and 72% died in a non-institutional setting. In the last 180 days of life, 84% of time was spent at home, and once enrolled in hospice, 97% of time was spent outside of institutional care. CONCLUSIONS: HBPC patients experience highly variable care trajectories but on average have reductions in acute care use and spend a majority of time in non-institutional settings. These data allow for a nuanced understanding of HBPC, providing a platform for monitoring, evaluating, and improving program function.

Association of Transport Time, Proximity, and Emergency Department Pediatric Readiness With Pediatric Survival at US Trauma Centers.

Importance: Emergency department (ED) pediatric readiness is associated with improved survival among children. However, the association between geographic access to high-readiness EDs in US trauma centers and mortality is unclear. Objective: To evaluate the association between the proximity of injury location to receiving trauma centers, including the level of ED pediatric readiness, and mortality among injured children. Design, Setting, and Participants: This retrospective cohort study used a standardized risk-adjustment model to evaluate the association between trauma center proximity, ED pediatric readiness, and in-hospital survival. There were 765 trauma centers (level I-V, adult and pediatric) that contributed data to the National Trauma Data Bank (January 1, 2012, through December 31, 2017) and completed the 2013 National Pediatric Readiness Assessment (conducted from January 1 through August 31, 2013). The study comprised children aged younger than 18 years who were transported by ground to the included trauma centers. Data analysis was performed between January 1 and March 31, 2022. Exposures: Trauma center proximity within 30 minutes by ground transport and ED pediatric readiness, as measured by weighted pediatric readiness score (wPRS; range, 0-100; quartiles 1 [low readiness] to 4 [high readiness]). Main Outcomes and Measures: In-hospital mortality. We used a patient-level mixed-effects logistic regression model to evaluate the association of transport time, proximity, and ED pediatric readiness on mortality. Results: This study included 212 689 injured children seen at 765 trauma centers. The median patient age was 10 (IQR, 4-15) years, 136 538 (64.2%) were male, and 127 885 (60.1%) were White. A total of 4156 children (2.0%) died during their hospital stay. The median wPRS at these hospitals was 79.1 (IQR, 62.9-92.7). A total of 105 871 children (49.8%) were transported to trauma centers with high-readiness EDs (wPRS quartile 4) and another 36 330 children (33.7%) were injured within 30 minutes of a quartile 4 ED. After adjustment for confounders, proximity, and transport time, high ED pediatric readiness was associated with lower mortality (highest-readiness vs lowest-readiness EDs by wPRS quartiles: adjusted odds ratio, 0.65 [95% CI, 0.47-0.89]). The survival benefit of high-readiness EDs persisted for transport times up to 45 minutes. The findings suggest that matching children to trauma centers with high-readiness EDs within 30 minutes of the injury location may have potentially saved 468 lives (95% CI, 460-476 lives), but increasing all trauma centers to high ED pediatric readiness may have potentially saved 1655 lives (95% CI, 1647-1664 lives). Conclusions and Relevance: These findings suggest that trauma centers with high ED pediatric readiness had lower mortality after considering transport time and proximity. Improving ED pediatric readiness among all trauma centers, rather than selective transport to trauma centers with high ED readiness, had the largest association with pediatric survival. Thus, increased pediatric readiness at all US trauma centers may substantially improve patient outcomes after trauma.

Veteran Perspectives on Population-Based Suicide Risk Screening in VHA Primary Care: Mixed-Methods Study.

BACKGROUND: In late 2018, VHA implemented a multi-stage suicide risk screening and evaluation initiative, Suicide Risk Identification Strategy, or "Risk ID," in primary care settings. OBJECTIVE: The main objective of this study was to characterize VHA primary care patient perspectives regarding population-based suicide risk screening through the Risk ID program. DESIGN: Mixed methods; survey and qualitative interviews. PARTICIPANTS: Veterans screened for suicide risk using Risk ID in primary care (n = 868) participated in a survey of veteran attitudes about screening (45% response rate); thirty additionally participated in follow-up qualitative interviews. MAIN MEASURES: The quantitative survey consisted of three questions on attitudes about screening for suicidal thoughts in primary care. In qualitative interviews, veterans were asked about their experiences with the Risk ID processes and recommendations for improving Risk ID. KEY RESULTS: Over 90% of veterans reported that it is appropriate for primary care providers or nurses/medical assistants to ask veterans about thoughts of suicide during primary care visits. Approximately half of veterans indicated that veterans should be asked about suicidal thoughts at every visit. Qualitative findings revealed that while most veterans were generally supportive and appreciated VHA screening for suicidal thoughts, they also expressed concern for the potential for inadvertent harm. Participants expressed conflicting preferences for how screening should be handled and delivered. CONCLUSIONS: Findings suggest that most veterans support the integration of standardized suicide risk assessment into routine primary care visits. However, findings also suggest that population-based suicide risk assessment should further consider patient experiences and preferences. Specifically, additional guidance or training for staff conducting suicide risk screening may be warranted to ensure patients feel heard (e.g., eye contact, expressing empathy) and increase patient understanding of the purpose of the screening and potential outcomes. These patient-centered approaches may improve patient experience and facilitate disclosure of suicidal thoughts.

Factors associated with a lack of health care utilization among Veterans after a positive suicide screen in the emergency department.

OBJECTIVES: Many Veterans at high risk for suicide are identified in Veterans Health Administration (VHA) emergency departments (ED). Little is known about what may predict care utilization in this population. To address this knowledge gap, we explored factors associated with Veterans' lack of VHA care utilization following a positive suicide risk screen in the ED. METHODS: In a retrospective observational study, we identified all patients who were seen in a VHA ED from October 1, 2019, to September 30, 2020. We examined factors associated with not utilizing VHA mental health (MH) and all VHA care in the 6 months following a positive suicide ED screen. Predictors included comorbidity, homelessness, and MH visit and diagnosis history. RESULTS: We identified 23,446 Veterans with a positive suicide risk screen in the ED in fiscal year 2020. Overall, 4.1% had no VHA MH visits 6 months postscreen. The probability of not utilizing MH care was significantly higher for Veterans with no comorbidity (4.7% vs. 3.4% for mild comorbidity), no MH diagnosis (10.5% vs 2.8%), no past-year MH visits (13.6% vs 2.3%), and no past-year homelessness (5.4% vs. 1.1%). A smaller proportion of the population did not receive any VHA care 6 months postscreen (0.5%). Veterans who did not experience homelessness (0.6% vs 0.2%), had no MH diagnosis (1.6% vs. 0.3%), and had no previous MH visits (1.9% vs 0.2%) were significantly more likely to not utilize VHA care. CONCLUSIONS: Veterans who do not utilize VHA care after a positive suicide risk screen appear to have fewer documented health and housing concerns than those who do receive care. Yet, Veterans with a positive suicide risk screen who are otherwise healthy may remain at elevated risk for suicide following their ED visit. ED providers may consider enhanced follow-up care to mitigate suicide risk for these Veterans.

Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care.

Importance: Emergency departments (EDs) with high pediatric readiness (coordination, personnel, quality improvement, safety, policies, and equipment) are associated with lower mortality among children with critical illness and those admitted to trauma centers, but the benefit among children with more diverse clinical conditions is unknown. Objective: To evaluate the association between ED pediatric readiness, in-hospital mortality, and 1-year mortality among injured and medically ill children receiving emergency care in 11 states. Design, Setting, and Participants: This is a retrospective cohort study of children receiving emergency care at 983 EDs in 11 states from January 1, 2012, through December 31, 2017, with follow-up for a subset of children through December 31, 2018. Participants included children younger than 18 years admitted, transferred to another hospital, or dying in the ED, stratified by injury vs medical conditions. Data analysis was performed from November 1, 2021, through June 30, 2022. Exposure: ED pediatric readiness of the initial ED, measured through the weighted Pediatric Readiness Score (wPRS; range, 0-100) from the 2013 National Pediatric Readiness Project assessment. Main Outcomes and Measures: The primary outcome was in-hospital mortality, with a secondary outcome of time to death to 1 year among children in 6 states. Results: There were 796 937 children, including 90 963 (11.4%) in the injury cohort (mean [SD] age, 9.3 [5.8] years; median [IQR] age, 10 [4-15] years; 33 516 [36.8%] female; 1820 [2.0%] deaths) and 705 974 (88.6%) in the medical cohort (mean [SD] age, 5.8 [6.1] years; median [IQR] age, 3 [0-12] years; 329 829 [46.7%] female, 7688 [1.1%] deaths). Among the 983 EDs, the median (IQR) wPRS was 73 (59-87). Compared with EDs in the lowest quartile of ED readiness (quartile 1, wPRS of 0-58), initial care in a quartile 4 ED (wPRS of 88-100) was associated with 60% lower in-hospital mortality among injured children (adjusted odds ratio, 0.40; 95% CI, 0.26-0.60) and 76% lower mortality among medical children (adjusted odds ratio, 0.24; 95% CI, 0.17-0.34). Among 545 921 children followed to 1 year, the adjusted hazard ratio of death in quartile 4 EDs was 0.59 (95% CI, 0.42-0.84) for injured children and 0.34 (95% CI, 0.25-0.45) for medical children. If all EDs were in the highest quartile of pediatric readiness, an estimated 288 injury deaths (95% CI, 281-297 injury deaths) and 1154 medical deaths (95% CI, 1150-1159 medical deaths) may have been prevented. Conclusions and Relevance: These findings suggest that children with injuries and medical conditions treated in EDs with high pediatric readiness had lower mortality during hospitalization and to 1 year.

Emergency Department Pediatric Readiness Among US Trauma Centers: A Machine Learning Analysis of Components Associated With Survival.

OBJECTIVE: We used machine learning to identify the highest impact components of emergency department (ED) pediatric readiness for predicting in-hospital survival among children cared for in US trauma centers. BACKGROUND: ED pediatric readiness is associated with improved short-term and long-term survival among injured children and part of the national verification criteria for US trauma centers. However, the components of ED pediatric readiness most predictive of survival are unknown. METHODS: This was a retrospective cohort study of injured children below 18 years treated in 458 trauma centers from January 1, 2012, through December 31, 2017, matched to the 2013 National ED Pediatric Readiness Assessment and the American Hospital Association survey. We used machine learning to analyze 265 potential predictors of survival, including 152 ED readiness variables, 29 patient variables, and 84 ED-level and hospital-level variables. The primary outcome was in-hospital survival. RESULTS: There were 274,756 injured children, including 4585 (1.7%) who died. Nine ED pediatric readiness components were associated with the greatest increase in survival: policy for mental health care (+8.8% change in survival), policy for patient assessment (+7.5%), specific respiratory equipment (+7.2%), policy for reduced-dose radiation imaging (+7.0%), physician competency evaluations (+4.9%), recording weight in kilograms (+3.2%), life support courses for nursing (+1.0%-2.5%), and policy on pediatric triage (+2.5%). There was a 268% improvement in survival when the 5 highest impact components were present. CONCLUSIONS: ED pediatric readiness components related to specific policies, personnel, and equipment were the strongest predictors of pediatric survival and worked synergistically when combined.

Does sequencing matter? A cross-over randomized trial to evaluate a bi-level community-based intervention to improve oral hygiene among vulnerable adults.

OBJECTIVES: To evaluate whether the cumulative effect of an individual-level intervention followed by a building-level intervention, both based on Fishbein's Integrated Model of Behavior Change, has a better effect on oral hygiene clinical outcomes than the sequence of the building-level intervention followed by the individual-level intervention; to determine the added effect of each intervention on the other; to identify the psychosocial mechanisms that might explain the differences. METHODS: Six low-income senior housing complexes were enrolled in the study, and participants were recruited from these buildings. Buildings were randomly assigned to receive either the individual counselling intervention first followed by the building-level intervention, or the building-level intervention first followed by the individual intervention. Participants were assessed for gingival inflammation using the gingival index (GI) and plaque scores (PS) at T0, prior to the interventions, T1, about one month after each intervention and T2, about a month after the interventions switched and were completed. Data were collected on background moderators and cognitive/emotional/behavioural mediators in surveys administered at T0, T1 and T2. General linear mixed models were used to assess changes over time by condition and to analyse the effects of moderators and mediators over time. RESULTS: Three hundred and thirty-one people completed T0; 306 completed T1 assessments (92.4% retention rate) and 285 completed T2 assessments (86.1% retention rate). All participants improved on GI and PS at T1 and T2 compared to T0. Those in the individual-level intervention condition improved more than those in the building-level condition. Those who were in the building-level intervention followed by the individual intervention continued to improve on GI from T1 to T2. Those in the individual-based intervention followed by the building intervention did not improve significantly from T1 to T2 but remained about the same. For PS, neither group improved significantly from T1 to T2. Several cognitive/behavioural variables significantly affected improvements in GI and PS. CONCLUSIONS: Both interventions were successful in improving GI and PS. The building-level intervention did not provide much additional benefit when it followed the individual intervention although it may have had a sustaining effect. The findings on the cognitive/emotional/behavioural variables support the importance of these factors and should be considered when implementing oral hygiene interventions.

Evaluating Cognitive/Emotional and Behavioral Mediators of Oral Health Outcomes in Vulnerable Older Adults.

Inconsistent outcomes of oral hygiene interventions require testable theories combining cognitive and behavioral domains to guide intervention and improve results. This article evaluates the integrated model as a cognitive-behavioral approach to improve oral health clinical outcomes in ethnically diverse low-income older adults. Baseline data from a clinical trial utilizing the integrative model (IM) model evaluated predictors of gingival index (GI) and plaque score (PS). Individual logistic regression was performed for all predictors in relation to GI and PS. Multiple logistic regression was performed with significant predictors of GI and PS only. Greater locus of control and more brushing predicted lower GI; greater locus of control predicted lower PS. Both cognitive and behavioral domains impact GI, requiring more prolonged effort for improvement while locus of control, a cognitive variable, predicts PS, immediately improved by daily brushing/flossing. A streamlined IM including locus of control and tooth brushing should improve oral hygiene of low-income older adults.

Oral health-related quality of life outcomes in a randomized clinical trial to assess a community-based oral hygiene intervention among adults living in low-income senior housing.

BACKGROUND: Quality of life outcomes have been used frequently in clinical trials of oral health interventions. This study assessed the effects of a randomized trial on oral health related quality of life comparing an individual-based oral hygiene intervention to a community-based intervention. METHODS: Participants were recruited from six low-income senior housing residences. Buildings were randomly assigned to receive the individual-based intervention followed by the community-based intervention or to receive the community-based intervention followed by the individual intervention. Participants' oral hygiene was assessed at baseline (T0), one month after the first intervention (T1) and one month after the second intervention (T2) and six months after the T2 assessment (T3). Oral hygiene was measured by the Gingival Index (GI) and Plaque scores (PS). Surveys collected data on beliefs, attitudes, behaviors and self-reported health status at T0, T1 and T2. Only oral hygiene and quality of life, measured by the General Oral Health Assessment Index (GOHAI), was assessed at all time points. general linear mixed models (GLMM) were used to assess changes in GOHAI over time, the interaction of condition by time and the contribution of psychosocial, behavioral, health status and background variables to changes in GOHAI. RESULTS: 331 people completed T0 assessments; 306 completed T1; 285 completed T2 and 268 completed T3. Scores on GOHAI at T0 ranged from 10 to 48 with a mean of 39.7 (sd = 7.8) and a median of 42. At T1, mean GOHAI was 40.7 (sd = 8.2), at T2 mean GOHAI was 41.1 (sd = 7.8) and at T3, GOHAI was 42.3 (sd = 8.2). GLMM showed that GOHAI improved significantly from T0 to T3 (p = 0.01) but the time by intervention interaction was not significant indicating that both interventions were effective in improving GOHAI but one intervention was not better than the other. Ethnicity, health status, worries, self-efficacy, number of missing teeth and symptoms of dry mouth were related to improvements in GOHAI. Neither GI nor PS were related to GOHAI. CONCLUSIONS: The participants reported relatively good oral health related quality of life which improved significantly over time. Improvement occurred among all participants regardless of condition, suggesting that either intervention would be effective in future studies. TRIAL REGISTRY: Clinicaltrials.gov, Clinical Trials ID #NCT02419144; Title: A Bi-level Intervention to Improve Older Adult Oral Health Status; Registered 04/07/2015 URL: https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S0005H9X&selectaction=Edit&uid=U0000KBK&ts=2&cx=-rajj5q.

Evaluating mechanisms of change in an oral hygiene improvement trial with older adults.

BACKGROUND: This paper compares the relationship between theoretically-driven mechanisms of change and clinical outcomes across two different interventions to improve oral hygiene of older adults participating in a group randomized trial. METHODS: Six low-income senior residences were paired and randomized into two groups. The first received a face to face counseling intervention (AMI) and the second, a peer-facilitated health campaign (three oral health fairs). Both were based on Fishbein's Integrated Model. 331 participants were recruited at baseline and 306 completed the post-assessment one month after intervention. Clinical outcomes were Gingival Index (GI) and Plaque score (PS), collected by calibrated dental hygienists. Surveys obtained data on patient background characteristics and ten mechanisms of change including oral health beliefs, attitudes, norms and behaviors. GLMM was used to assess the effects of time, intervention arm, participant characteristics, intervention mechanisms and differences between the two interventions over time in relation to outcomes. RESULTS: At baseline, both groups had similar background characteristics. Both groups improved significantly in outcomes. Overall GI scores changed from baseline mean of 0.38 (SD = .032) to .26 (SD = .025) and PS scores changed from baseline mean of 71.4 (SD = 18%) to 59.1% (SD = 21%). T-tests showed that fears of oral disease, oral health intentionality, oral health norms, worries about self-management of oral health, flossing frequency and sugar control improved significantly in both interventions from baseline to post intervention. Oral health self-efficacy, perceived risk of oral health problems, oral health locus of control and brushing frequency improved significantly only in the counseling intervention. GLMM models showed that the significant predictors of GI improvement were intentionality to perform oral hygiene, locus of control, and improvement in frequency of brushing and flossing in association with the counseling intervention. Predictors of PS improvement were worries about oral hygiene self-management and fear of oral diseases, in association with the counseling intervention. In the reduced final models, only oral health locus of control (predicting GI) and fears of oral diseases (predicting PS) were significant in association with the counseling intervention. Locus of control, a key concept in oral hygiene interventions including the IM was the main contributing mechanism for GI improvement. Fear, an emotional response, drove improvement in PS, reinforcing the importance of cognitive/emotional mechanisms in oral hygiene interventions. CONCLUSIONS: Though both groups improved in outcomes, GI and PS outcomes improved more in response to the counseling intervention than the campaign. The counseling intervention had an impact on more mechanisms of change than the campaign. Improvements in intervention mechanisms across both interventions however, suggest a closer examination of the campaign intervention impact on outcomes over time. TRIAL REGISTRATION: Clinicaltrials.gov NCT02419144, first posted April 17, 2015.

Building a new scale to measure worries about oral hygiene self-management in vulnerable older adults.

OBJECTIVE: This paper describes a new scale to measure worries about self-management of oral hygiene in low-income older adults. BACKGROUND: Oral hygiene that prevents oral diseases and worsening of chronic conditions improves with instruction, but other cognitive/emotional factors impede oral hygiene practice especially among older adults. Many scales measure dental anxiety, but none measures oral hygiene self-management worries. MATERIALS AND METHODS: Formative research with diverse older adults 55-95 in low-income housing identified scale items. A 23-item scale was tested in a pilot intervention study (n = 84) and formalised with a new sample (N = 331). RESULTS: In both studies, PCA/factor analysis produced two subscales: (a) worries about cleaning teeth and (b) consequences of cleaning. Chronbach's alpha coefficient evaluated internal consistency, and Pearson's r and Kendall tau/Spearman's rho evaluated scale predictability, convergent and divergent validity. The scale and subscales showed good internal consistency in both studies (over 0.90) and stability T0 0.90; T1: 0.90). In the larger sample, statistically significant correlations between the scale, subscales; plaque score, and similar scales (perceived risk of oral health problems, and fears of oral diseases) demonstrated convergent validity. For divergent validity, the worries scale, not the GOHAI, a similar scale measuring oral health life quality, was associated with Plaque Score. Each scale was associated with different mediators suggesting different constructs. CONCLUSION: The overall scale has good internal consistency, test-retest reliability, predictability and convergent and divergent validity. It captures a psycho-emotional construct useful in oral health research and hygiene education with older adults.

The Impact of Perceptions of Community Stigma on Utilization of HIV Care Services.

The relationship between perceived community stigma and treatment adherence has been established in previous literature. Yet, less is known about explicit circumstances in which perceived community stigma deters people living with HIV (PLWH) from maintaining care. This research examines the impact of perceived community stigma against PLWH on self-reported barriers and supports to remain in HIV care services. We used survey data from a 3-year study of the HIV test and treat (T&T) continuum of services in Hartford, CT, surveying 200 PLWH. Logistic regression was used to determine if perceived community stigma had a statistically significant effect on the willingness of PLWH to utilize HIV care services. Results revealed that an increase in perceived stigma predicted willingness to see a doctor in 6 months for those who 'had a fear of poor treatment' (χ2(6) = 21.995, p < 0.001) and 'were concerned about privacy' (χ2(6) = 16.670, p < 0.01). An increase in perceived stigma was also a significant factor in the belief that supportive case managers helped with accessing HIV care services (χ2(1) = 6.817, p < 0.01). Our findings suggest that having a high degree of perceived community stigma is impactful in instances where individuals anticipate stigma or discrimination.

Factors associated with dependence on smokeless tobacco, Navi Mumbai, India.

OBJECTIVE: Nearly 300 million people in India use some type of tobacco product, with about 60% of those using smokeless tobacco. Smokeless tobacco use has been associated with a number adverse health outcomes in India and across South Asia. METHOD: A cross-sectional study of outpatients at a dental hospital in Navi Mumbai, India was conducted between January and June 2015. Trained interviewers administered a 19-item questionnaire to all patients receiving regular dental care. In addition to demographic information, data about the use of smokeless tobacco was collected. Nicotine dependence was assessed using the six-item Fagerstrom Nicotine Dependence Scale, adapted for smokeless tobacco. RESULTS: Approximately one third of 1,067 respondents (30.55%; N = 326) reported use of smokeless tobacco. Neither use of smokeless tobacco nor nicotine dependence was associated with any demographic variables. High nicotine dependence was associated with a younger age of initiation of smokeless tobacco use (RD = 0.14; 95% CI: 0.03, 0.25) and with frequency of use, with those who reported daily use having an excess risk of high nicotine dependence of 14% (95% CI: 2%, 27%). CONCLUSION: To reduce dependence on smokeless tobacco in India and subsequent adverse health outcomes, interventions should emphasize a combination of policy and public health interventions focused on increasing the age at which a person initially uses smokeless tobacco and decreasing the frequency of use.