|Year : 2016 | Volume
| Issue : 2 | Page : 211-217
Tobacco use cessation interventions: Views and practices among clinical dental students in Chennai, India
Chandra Sekhara Reddy Vuyyuru1, Jamil David2, Rajeshree Narayan Rangari3
1 Department of Public Health Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
2 Department of Health Services Research, School of Dentistry, University of Liverpool, Liverpool, UK
3 Department of Periodontology, Meenakshi Ammal Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Web Publication||10-Jun-2016|
Chandra Sekhara Reddy Vuyyuru
Department of Public Health Dentistry, Narayana Dental College and Hospital, Chinthareddypalem, Nellore, Andhra Pradesh - 524 003
Source of Support: None, Conflict of Interest: None
Introduction: A dental visit provides the patient with an opportunity to discuss the habit of tobacco consumption and its detrimental effects on oral and general health. Cessation advice, as well as pharmacological therapy, has been used by health professionals to help patients quit tobacco use. Aim: To investigate the knowledge and practices of tobacco use cessation (TUC) interventions among final year students and interns in Chennai, India. Materials and Methods: A cross-sectional random sampling technique was used to collect information from final year students and interns, from four dental colleges in Chennai. Data regarding TUC interventions were obtained using a structured and self-administered questionnaire, comprising 30 questions. Results: A total of 53% and 47%, final year students and interns, respectively participated in the study. The response rate was 75%. Statistically significant associations were observed between the students' year of study and their views on the inclusion of TUC in clinical practice (P < 0.05) as well as the advice/interventions practiced by them (P < 0.05). Significantly higher proportions of interns, when compared to the final year students (P < 0.05) regarded periodontal disease as a symptom of tobacco consumption, agreed that tobacco use could cause implant failure, informed patients about the negative effects of smoking on oral health, discussed the ill-effects of passive smoking and admitted to helping their patients quit smoking. Conclusion: Several parameters related to TUC interventions were different among final year dental students and interns. This study reveals that significant numbers of dental students are not practicing any TUC methods in their routine dental curriculum which might help patients discontinue tobacco use.
Keywords: Curriculum, dental, education, internship and residency, students, tobacco use cessation
|How to cite this article:|
Vuyyuru CS, David J, Rangari RN. Tobacco use cessation interventions: Views and practices among clinical dental students in Chennai, India. J Indian Assoc Public Health Dent 2016;14:211-7
|How to cite this URL:|
Vuyyuru CS, David J, Rangari RN. Tobacco use cessation interventions: Views and practices among clinical dental students in Chennai, India. J Indian Assoc Public Health Dent [serial online] 2016 [cited 2019 May 19];14:211-7. Available from: http://www.jiaphd.org/text.asp?2016/14/2/211/181819
| Introduction|| |
Tobacco use terminates 6 million lives a year worldwide, with the numbers expected to rise to 8 million by 2030. A majority of these deaths are caused due to direct tobacco use, while a relatively smaller proportion is due to exposure of nonsmokers to second-hand smoke. India is at the top of the table with the highest number of tobacco-related mortalities (700,000 per annum), which could rise to 1.5 million by 2020. Tobacco, in any form, has deleterious effects on the human body., In India, oral cancers are the second and fourth most common types of cancer seen in men and women, respectively. It is a major concern as about 70,000 cases are detected annually in India, with >75% of them leading to the death of the individual.
Research from occidental countries has demonstrated that dentists can play a pivotal role in assisting patients to reduce or quit tobacco use.,,, A dental visit provides the patient with an opportunity to discuss the habit of tobacco consumption and its detrimental effects on oral and general health.,,
Cessation advice, as well as pharmacological therapy, has been used by health professionals to help patients quit tobacco use. Furthermore, tobacco use cessation (TUC), as a counseling technique, has been used by health care professionals and shown to be a cost-effective method for patients to quit the habit., The intervention, if implemented in a dental setting, has the potential to achieve patient tobacco quit rates of around 10–15% per year.
However, dentists, compared to other health professionals, have generally been complacent in providing appropriate tobacco cessation interventions to their patients., Studies from dental schools have revealed that patient disinterest/resistance/motivation,,,, lack of training/knowledge, lack of educational materials, lack of time, and lack of referral centers, were some of the perceived barriers to providing tobacco cessation interventions. If the above-mentioned predicaments are subjugated, TUC can be incorporated into the dental curriculum for appropriate application during future clinical practice.,
There is sparse information available regarding TUC interventions among dental students in the state of Tamil Nadu. In view of this, this study was designed to evaluate the beliefs, views, knowledge, advices/interventions and barriers of TUC interventions among final year dental students and interns, in Chennai, Tamil Nadu.
| Materials and Methods|| |
A cross-sectional questionnaire study with a random sampling technique was used to invite final year clinical dental students and interns from four dental schools in Chennai. Ethical clearance was obtained from the Institutional Review Board before commencing the study.
Before administering the questionnaire, the students were briefed about the objectives of the study. They were informed that their participation was voluntary with no incentives provided. Following this, if a student participated in the study, it was considered to having given consent. The study was conducted during March-June 2011 and was anonymized. The total strength of final years (n = 325) and interns (n = 312) in the four dental schools were 637.
The questionnaire used to collect the data from students was developed on the basis of earlier studies,,, and was standardized based on findings from a pilot study. To ensure content validity, the questionnaire was reviewed by experts who were actively practicing tobacco cessation.
The first part of the questionnaire provides sociodemographic information regarding age, gender, institution of study, study level, marital status, smoking status/tobacco consumption habits, including family members with similar habits. The second part of the questionnaire consists the following: (1) Beliefs (five categories) and views (three categories) about the effectiveness of TUC interventions. (2) Knowledge about tobacco cessation relevant to dentistry (two categories). (3) TUC advices/interventions practiced (five categories – ”Always, frequently, sometimes, occasionally and never” to two categories). (4) Perceived barriers in the provision of TUC counseling (three categories).
The data collected was classified and tabulated in Microsoft Excel and further analysed by using Statistical Package for Social Sciences (version 22.0, IBM). Responses were analyzed by calculating the percentages based on the number of students' who answered the questionnaire. Univariate and bivariate analyses were conducted to evaluate significant differences in demographic variables and other given responses between the two groups of participants. The level of significance adopted was P < 0.05.
| Results|| |
A total of 475 students (final year dental students, 52.8%; interns, 47.2%) participated in this study (response rate - 75%). [Table 1] depicts the demographic distribution of the study sample. Majority of the students were females (74.3%, n = 353, P < 0.001). The age of the students ranged from 20 to 28 years (mean age 21.8), with the largest proportion belonging to the 20–21 age group (45.7%), followed by the 22 years age group (30.1%).
|Table 1: Distribution of students according to age, gender, and year of study|
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Significantly higher number of male interns resorted to the use of tobacco when compared to their counterparts in the final year (P < 0.05). Females in both the groups did not smoke. There was no statistically significant association between the students' year of study and the use of tobacco by their respective family members. None of the study participants used smokeless tobacco [Table 2].
|Table 2: Association of smoking habits between students and family members|
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A statistically significant association was observed between the students' year of study and their belief on inclusion of tobacco use interventions in the clinical practice (P < 0.05) [Table 3], and a marginally higher proportion of final year students were in agreement with the idea, when compared to the interns (5%). Interestingly, close to 7% of the final year students and interns were of the opinion that dentists should not, or may, to a small extent, include tobacco use interventions in their clinical practice. Statistical significance notwithstanding, nearly 10% of the students in both the study groups answered “not at all” or “to a small extent” to the questions: Should dentists ask patients who smoke to quit smoking and was the dental clinic a suitable place to provide information about the harmful effects of tobacco. Furthermore, a large percentage of the 4th year students and interns (30% and 25%, respectively) were of the opinion that the dentist's recommendation would have very little or no effect on the patients' likelihood to quit tobacco use, but no statistically significant difference was found [Table 3].
|Table 3: Final year students' and interns' beliefs on the effectiveness of tobacco use cessation interventions|
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Likewise, no statistically significant association was noted between the students' views on the effectiveness of TUC intervention and their year of study [Table 4]. Nevertheless, approximately 60–90% of the final year students and 70–92% of interns, deemed the following as recommendable: Routine oral cancer screening by the physician, establishment of TUC cell in the institution and inclusion of TUC counseling in the dental curriculum [Table 4]. It was also remarkable to identify that some of the students in this study were unsure about the effectiveness of the above-mentioned strategies.
|Table 4: Dental students' and interns views on the effectiveness of tobacco use cessation interventions|
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As shown in [Table 5], a significantly higher proportion of interns, when compared to 4th year students, regarded periodontal disease as a symptom of tobacco consumption or cigarette smoking (P < 0.05), and agreed that tobacco use could cause implant failure (P < 0.05). Similarly, a higher proportion of final year dental students, compared to interns, were of the opinion that tobacco use or cigarette smoking did not cause laryngeal cancer, congestive heart disease, peripheral arterial disease or oral candidiasis; however, the difference was not statistically significant [Table 5].
|Table 5: Dental students and interns knowledge about tobacco cessation relevant to dentistry|
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[Table 6] illustrates the association between tobacco use advice/interventions practiced by the students and their year of study. A statistically significant association (P < 0.05) was found between the implementation of advice regarding the negative effects of smoking on oral health and the year of study, wherein, a greater proportion of interns than final year students (63% vs. 54%) were found to inform patients about the negative effects of smoking on the oral health [Table 6]. Furthermore, a significantly higher percentage of interns than 4th year students (62.5% vs. 51.8%) discussed the ill-effects of passive smoking with their patients (P < 0.05). As illustrated in [Table 6], a significantly higher percentage of interns admitted to helping their patients quit smoking during the course of training, when compared to the 4th year dental students (66% vs. 54%; P < 0.05).
|Table 6: Tobacco use cessation advices/interventions practiced by dental students and interns|
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Although not statistically significant, a higher proportion of final year dental students (68%), compared to interns (64%), implied that patients' disinterest was one of the main barriers in providing TUC counseling in the clinical practice [Table 7]. Likewise, more number of final year students identified lack of education materials as a reason for not counseling patients on TUC when compared to the interns (47% vs. 37%).
| Discussion|| |
The present survey analyzed various parameters that may influence tobacco cessation counseling in 224 dental interns and 251 4th year dental students, from dental colleges in Chennai, India. Due to logistical and financial constraints, and based on convenience, only four dental schools were selected in this study. This might, therefore, preclude us from making general comparisons to students and interns from all dental schools in Tamil Nadu (total number of dental schools = 25). However, we assume that, as TUC is not a major component of the dental curriculum in India, the findings from this study will provide information on the current scenario with regards to students' knowledge, perceptions and practice in the clinics. To the best of our knowledge, this is the first study identifying the issue of TUC intervention in dental schools in Chennai.
The average number of current smokers in our study population (7%) closely resembled that of the local population (10%) in Chennai. Smoking among dental students in other parts of India has been reported to range from 6% to 10%., Furthermore, the proportion of male smokers in the present study (24%) was similar to the figures recorded in the national data in Chennai (27%), whereas no female smokers were found in both studies. These findings suggest that the current study population might share common attributes with the general population in Chennai.
A high proportion of students, in this study, recommended (considerable extent and great extent) the inclusion of tobacco use interventions in dental clinics. This finding corroborates the results reported by other studies from Britain, Bangladesh, and Italy.,, However, recent studies have shown that dentists were not receptive of the proposal to include tobacco cessation interventions in their clinic., Undergraduate and graduate dental students, in the study from Nigeria, were of the opinion that providing tobacco cessation activities in the dental clinic seldom helped a patient to quit tobacco use, and instead, preferred to use the time to tend to a large number of patients reporting to the clinics.
Some researchers have postulated that provision of appropriate training to the dentists might encourage them to advocate tobacco cessation interventions in the clinics. In the present study, more number of final year students compared to interns indicated the need to include tobacco use interventions in dental clinics. This might reflect on the lack of information or training provided to the interns during the time of the study. The inclusion of tobacco cessation interventions in the dental curriculum has been shown to be effective in the short-term quitting of the habit. However, additional cessation studies need to be carried out to determine long-term behavior changes with relation to tobacco use.
A higher proportion of interns when compared to dental students (81% vs. 72%) regarded periodontal disease as a symptom of tobacco consumption or cigarette smoking. Two recent studies from Europe had reported the knowledge levels of dental students regarding tobacco and periodontal problems to be 66% and 97%., In comparison, a lower proportion of interns and dental students, in this study, indicated that tobacco use could cause implant failure (67% vs. 53%). Although these figures (concerning the dental students) are higher than those reported previously in India (45%) and Italy (40%), they were lower than those observed in a study conducted recently, in the UK (97%).,, The reason for better knowledge among interns than final years may be attributed to increased clinical experience in the case of the interns, and lack of adequate teaching/training provided to the final year students. Although not statistically significant, an unexpectedly higher proportion of the interns and final year dental students were of the opinion that tobacco use did not cause certain pathological conditions. This might reflect upon the deficiencies of the dental curriculum and need for further training with respect to the overall hazards of tobacco use.
In this study, more interns compared to final year students were found to advise patients about the ill-effects of tobacco use (63% vs. 54%) and passive smoking (48% vs. 38%). Previous studies from India and UK have reported that approximately 95% of the dental students and interns informed their patients regarding the negative effects of tobacco use. Although information regarding TUC interventions is not normally included in the didactic dental course in India, the harmful effects of tobacco are given due importance in the dental curriculum., A recent study among interns in 25 dental schools in India revealed that only 33% of the interns discussed the risks of tobacco with their patients, in spite of 99% of them being were aware of its inclusion in their dental curriculum. The researchers from the afore-mentioned study postulated two reasons for their discouraging results. Firstly, the prevention aspect of oral cancer in the dental curriculum is not as comprehensive as it should be. Secondly, the interns from postgraduate institutes avail higher standards of teaching when compared to those from undergraduate institutes. All four schools included in the present study were postgraduate institutes, thereby, leading us to question the comprehensiveness of the course in dealing with tobacco use. The same reason might hold true for the low percentage of students' providing patients with advice regarding passive smoking. A review by Preet  indicated that dental students in India were not aware of the deleterious effects of passive smoking on health.
Sixty-six percent of the interns and 54% of the final year students, in the present study, had assisted patients in quitting smoking during their study period at the dental school. This is in variance with the results reported in previous studies conducted in India by Rajasundaram et al. (16%) and Murugaboopathy et al. (75%), respectively. One of the possible reasons for the non-adherence of dental students and interns inassisting patients to quit the habit might be the lack of training or confidence to provide tobacco intervention techniques., It has been noted that the proportion of students assisting patients to quite tobacco use, depends on the number of students who believe that counseling can help in quitting the habit.
There was no significant difference in perceived barriers between the final year students and the interns. Almost all the variables dealing with perceived barrier to TUC in this study were not statistically significant. However, patients disinterest and lack of education materials showed a tendency toward statistical significance between the two groups of students (0.055 and 0.056, respectively). Patients' disinterest towards TUC intervention has been reported as an important factor affecting the provision of the service in dental clinics., Lack of interest among patients in India might be because they seldom expect students in dental schools to carry out TUC interventions. This is contrary to a previous study in the UK, where 90% of the patients wanted students to play a pivotal role in helping them to quit tobacco use. Murugaboopathy et al. suggested that the traditional health educational approach could be one of the reasons why patients are disinterested, and recommended the introduction of novel health behavior modeling approaches. Further research might be required to extrapolate the reasons behind dentist's perception of patient non-compliance when it comes to the use of tobacco cessation interventions in dental clinics, in India.
This study included only four dental colleges of Chennai. Although similar trends are observed in various studies on TUC interventions among dental students, a wide range of dental colleges needs to be included to confirm the same.
TUC intervention is not a part of the dental curriculum in India, yet. Its inclusion into the curriculum may have long-term implications on the oral as well as general health of the population, and may help people to quit using tobacco in any form.
| Conclusion|| |
This study revealed differences in TUC among dental students and interns with regards to several parameters. As future dental practitioners, dental students play a major role in society and therefore, it is vital that they receive appropriate didactic and clinical training during the dental course. However, although TUC interventions have proven to be beneficial in reducing tobacco use, they need to be used in conjunction with other health promoting strategies.
The authors would like to thank the principals and students of the dental schools for participating in the research project. We are grateful to them for contributing their valuable time and support to the project. We would also like to thank Professor Preetha Chaly, for her valuable suggestions during the study, and all the staff at the Department of Public Health Dentistry, where the study were conducted.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]