|Year : 2015 | Volume
| Issue : 4 | Page : 438-443
Health professional's perception toward tobacco cessation: A cross-sectional study
Vikram Pal Aggarwal, Anmol Mathur, CL Dileep, Manu Batra, Diljot Kaur Makkar
Department of Public Health Dentistry, Surendera Dental College and Research Institute, Sri Ganganagar, Rajasthan, India
|Date of Web Publication||7-Dec-2015|
Vikram Pal Aggarwal
Department of Public Health Dentistry, Surendera Dental College and Research Institute, Sri Ganganagar, Rajasthan
Source of Support: None, Conflict of Interest: None
Introduction: Tobacco smoking is a major cause of preventable morbidity and mortality. The prevention and control of adverse health effects associated with tobacco consumption is an emerging issue of public health significance. Aim: To assess the knowledge, attitude, and practices among health professionals (HPs) toward tobacco cessation (TC). Materials and Methods:A cross-sectional study, using pretested structured questionnaire was conducted among 422 medical and dental practitioners, to obtain information on the TC. The data were descriptively analyzed and Chi-square tests and multivariate analysis was applied using SPSS version 20. Results: Dental professionals had better knowledge about various preventive measures regarding TC as compared to medical professionals. Nonsmoker professionals advised patients to quit tobacco 10 times more than the smokers. Most of the HPs (91.9%) had a similar belief that TC counseling is not effective due to lack of formal training (P < 0.001). Conclusion: This study suggests a need and a desire for HPs to improve knowledge, attitudes, and practices in dealing with tobacco smoking cessation in their practice.
Keywords: Attitude, dentists, knowledge, practices
|How to cite this article:|
Aggarwal VP, Mathur A, Dileep C L, Batra M, Makkar DK. Health professional's perception toward tobacco cessation: A cross-sectional study. J Indian Assoc Public Health Dent 2015;13:438-43
| Introduction|| |
Tobacco consumption is the leading cause of preventable illness and death in the developing world. The promotion of adverse effects accompanying tobacco consumption is an evolving issue of public health significance. Tobacco usage in any form is the second major etiological factor responsible for the death, and nearly 1 out of 10 deaths worldwide is due to tobacco. By 2030, tobacco is expected to rise and become the forerunner among causes of death worldwide. Every 6.5 s, one tobacco user dies from a tobacco-related disease somewhere in the world. It is assumed to account for more than 10 million deaths/year by 2030, 70% of which will be from developing countries. Current statistics indicate that it will not be possible to reduce tobacco-related deaths over the next 30–50 years, unless tobacco users are encouraged to quit.
More than one-third (35%) of adults in India use tobacco in some form or the other. According to the Global Adult Tobacco Survey, 26% of adults in India consume smokeless tobacco - 33% of men and 18.4% of women. As per the World Health Organization (WHO), Global Report  on "Tobacco Attributable Mortality 2012" 7% of all deaths (for age's ≥ 30) in India are attributed to tobacco.
While taxation and prohibition of advertising have been effective, nonlegislative and cost-effective approaches for cessation should be utilized as well. One of the strategies to reduce morbidity and the number of smoking-related deaths is to encourage the involvement of health professionals (HPs) in tobacco use prevention and cessation counseling. HPs (medical and dental) have a key role to play by working through the health care system to motivate and advise users to quit. Since doctors are well regarded and their advice well-accepted, they form the most likely persons from whom advice on quitting would be taken seriously and accepted by the users.
Tobacco cessation counseling (TCC) in dentistry is critical to reduce the effect of a major risk factor for both oral and systematic diseases. Randomized clinical trials have found that even brief dental office-based interventions can be effective in motivating and assisting tobacco users to quit. Dentists play an important role in educating patients about health risks of tobacco use and TC because of the regular contact many patients have with their dentists.
Even a brief advice from HPs to tobacco consumers can significantly increase the quit rate. One-way to make HPs' involvement even more effective in tackling tobacco use is a multi-professional approach which has been advocated by the WHO. Despite the potential, not many HPs are involved in TCC activities. Barriers that have been associated with provision of TCC include lack of time, no monetary benefits, lack of professional training in TCC activities along with anticipated negative feedback from patients, lack of confidence in their ability, and skills to provide effective counseling.,,
To be able to effectively participate in the anti-tobacco effort, HPs' knowledge, attitudes, and practices toward tobacco use cessation are important. In the light of currently available guidelines and little that is known about the extent to which the dentists engage themselves in performing TCC, the study explored the factors associated with their performance. The objective was to assess and compare knowledge, attitudes and practices of medical and dental professionals' role in TC.
| Materials and Methods|| |
A cross-sectional study was conducted among medical and dental practitioners in Sri Ganganagar city from September to December 2014. The study was approved by the Institutional Ethical Committee. The sampling frame comprised of 491 medical and dental practitioners from Sri Ganganagar city registered with the state medical and dental council. The inclusion criteria were that doctor must be a registered practitioner and must be having clinical/patient interaction. Those who did not give consent and failed to return the questionnaire or incomplete questionnaire were excluded from the study. The final sample was 422 medical and dental doctors with a response rate of 85.7%.
A questionnaire in English language was used to record the knowledge, attitude, and practice of medical and dental surgeons regarding TC. The present questionnaire was based on previous WHO  guidelines to conduct tobacco smoking surveys among HPs. The questionnaire was viewed by three experts in Public Health Dentistry to ensure its suitability for the present study. The questionnaire was pretested on a group of 20 professionals to check the feasibility of the study. Six out of twenty-nine questions of the initial questionnaire were removed and appropriate modifications were made. The reliability of the questionnaire was evaluated by: (1) Cronbach's coefficient alpha to measure the internal consistency; (2) test-retest method to examine the stability of the questionnaire. The alpha coefficient of 0.7 was considered adequate. Test-retest reliability was measured by having the same set of respondents to complete a questionnaire at two different points of time within which there was no change of the constructs of interest. Intra-class correlation coefficient (ICC) with 95% confidence interval (CI) was used for assessing this reliability. The value of the ICC was 0.70. The questionnaire included sections on demographic data and questions on knowledge, attitudes, awareness of smoking cessation, willingness to provide cessation services, and barriers to smoking cessation advice in the dental setting. All the attitude and some knowledge questions ,, responses was based on a Likert scale where the respondents were asked to indicate their agreement with the statement on a scale of 1–5, (strongly agree strongly disagree) and for the remaining questions, where appropriate, the answers were dichotomized.
The questionnaire was personally administered, and the professionals were explained regarding the motive of the study and how to complete the questionnaire. It was emphasized that the confidentiality of the responses made by them would be strictly maintained. Strengthening the Reporting of Observational Studies in Epidemiology guidelines were followed while conducting the research.
Data were examined, and the responses were coded. The data were then descriptively analyzed and Chi-square tests and multivariate analysis was applied using SPSS version 20 (IBM SPSS. Statistics Windows, Version 20.0. (Armonk, NY: IBM Corp)). The Chi-square test of association was used to assess differences among HPs in all variables. Bivariate and multivariate analyses were conducted for two outcomes. Odds ratio were calculated with 95% CIs, and two-tailed significance was set at 5% (P < 0.05) in all analyses.
| Results|| |
The sample comprised of 70.1% and 29.9% males and females, respectively. The participants comprised medical (54.74%) and dental professionals (45.26%). More than 50% of the dentists and medical professionals were aged 20–29 years and 40–49 years respectively. Most of the medical professionals (87.9%) had done postgraduation when compared to the dentist (46.6%). Approximately, all the medical professionals (90.5%) had at least 5 years of practicing experience, while 61.8% of dental professionals had < 5 years of experience. Altogether, 23.2% of participants reported being smokers [Table 1].
|Table 1: Demographic characteristics and smoking status of the study sample|
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When knowledge was assessed regarding tobacco smoking effects on general health among medical and dental professional, it was found that medical professional has better knowledge than dental professionals. When knowledge about various preventive measures regarding TC was assessed among HPs, it was found that dental professionals had better knowledge as compared to medical professionals [Table 2].
|Table 2: Health provider's knowledge, attitudes, and practices regarding smoking cessation|
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A total of 38.5% and 28.3% medical and dental professional respectively had a view that enquiring about tobacco habits has a negative impact on clinical practice (P < 0.05). Most of the HPs (91.9%) had a similar belief that TCC is not effective due to lack of formal training (P < 0.001). A total of 61.8% HPs enquired from their patients regarding tobacco habits. Among the dental professionals (81.2%) recommend nicotine replacement therapy when helping smokers to quit tobacco, whereas only 71.9% medical professionals recommend nicotine replacement therapy (P < 0.05) [Table 2].
Multivariate analysis showed that asking about smoking and advising patients to quit was significantly associated with health providers being female, age more than 40 years and nonsmokers [Table 3]. The probability of counseling patients to quit tobacco was 10 times more among the nonsmokers HPs as compare to smokers HPs.
|Table 3: Multiple logistic regression analyzing the odds of engaging in cessation counseling practices among HPs|
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| Discussion|| |
HPs, due to their position in society, have a unique role in tobacco control. Whether HPs personal tobacco use behavior affects their professional attitude and clinical behavior is unknown, yet it represents a critical issue in public health policy, as they are usually the primary health care providers. The study revealed several lacunae in the knowledge, attitudes and practices among the HPs.
In the present study, 61.8% of dentists reported that they enquired the patients regarding their tobacco habits which are comparatively higher than that was reported by Sahoo et al. (52%), but less as compared Parakh et al. (83%) and Khalaf  (72.1%). In the present study, 57.1% of the dentists were engaged in TC practices actively whereas Khalaf  reported that most of the dentist never got engage in TC practices. However, Chandrashekar et al. reported that 60% of the dentists enquired regarding TC from the patients in their practices. The reason cited with this finding is that negative impact may incur on their practice due to TC practices among the patients. However, as per a study, patients who had tobacco habit in any form were quite positive in their attitude toward reception of TCC in the dental setting. Saud et al. reported that 95% of physicians asked patients about their smoking status compared to 61.9% of physicians in the present study which is similar to the study conducted by Thankappan et al. (57%) and Klink et al. (57.6%).
In the current study, 26.8% of the physicians smoked in office in the presence of a patient while in contrary Jiang et al.reported only 8.5% but in case of dental professionals only 18.5% smoke in office in the presence of a patient. This may be due to longer working hours and getting adapted to such habits among medical professionals.
Parakh et al. reported that 93% of the dental professional explained to the patients about the health risks associated with tobacco use whether in smoke or smokeless form compared to 63.9% of the dental professional in this study. This difference may be due to lack of interest among the dental professionals to understand their role and importance in TC interventions.
Standard smoking cessation practices like nicotine replacement therapy was used by 71.9% of the physician in the current study but a study conducted by Jiang et al.and Abdullah et al. reported only approximately 7% of the physicians use nicotine replacement therapy. In case of dentist, 81.2% recommend nicotine replacement therapy when helping smokers to quit tobacco.
Regarding the knowledge about preventive measures, more than 90% of the dentists were aware about different forms of nicotine replacement therapy in the current study which is high as compared to study done by Sahoo et al. (approximately 50%). Twenty-six percent of the dentists were aware of the pharmacotherapy reported by Sahoo et al. in their study, whereas present study stated 44.5%. Medical professional's knowledge regarding preventive measures was low as compared to dental professionals, reflecting the urgent need to sensitize medical professionals on the different modalities of TC.
Medical professional 87.4% have the belief that proper counseling will lead to patient quitting the habit in the present study, whereas only 49.4% of the medical professional reported the same in a study by Klink et al. In the present study, both medical and dental professionals (approximately 90%) favored strict legislation on tobacco use. More than two-third of the HPs also felt that the media and celebrities promoted tobacco, either directly or indirectly, calling for measures to control such surrogate promotion of tobacco use. This is similar to the earlier studies on dental students who support the same.
Ehizele  and Uti et al. reported that 74.1% of the dentists feel lack of training as a barrier in providing cessation services which is low as compared to the present study with (86.4%). The reasoning for such poor attitudes among the HPs may be due to lack of formal training in TCC.
Rajasthan government has taken substantial efforts toward TC such as to make mandatory for all persons seeking government jobs to give an undertaking that they are not tobacco users (both smoking and smokeless). Rajasthan has the highest value added tax on tobacco products in the country. Significant improvements were observed in compliance with Cigarettes and Other Tobacco Products Act Section 4, in terms of curtailing smoking in public places, provisions of sale, and placement of no smoking signs.
This is the first study to assess and compare the knowledge, attitudes, and practices among medical and dental professionals, according to which strategies can be formulated in this region. The limitations of the present study are that in spite of anonymous questionnaire, there are chances of social desirability bias among respondents toward tobacco consumption. The authors recommend a change in curriculum toward practical, skill-based training, and education on TC among HPs by Government Organizations in India.
There is an urgent need to sensitize and train HPs at the community level toward the treatment of nicotine dependence as most people in India cannot afford to go to a specialist TC clinic nor can the government afford to operate them at mass level. Such sensitization on the preventive measures would certainly benefit patients by improving cessation rates among them. We, therefore, believe that HPs can and should ascertain and record tobacco use status of their patients on a routine basis; deliver brief TC advice at every opportunity; and advocate for the inclusion of training of TC methods in medical school curricula of their respective professional bodies.
| Conclusion|| |
In the present study, it is concluded that HPs lacked the necessary knowledge of smoking cessation. They showed positive attitudes toward their role in smoking cessation, prohibition of tobacco promotion, its advertisement, and to provide smoking cessation intervention.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Klink K, Lin S, Elkin Z, Strigenz D, Liu S. Smoking cessation knowledge, attitudes, and practice among community health providers in China. Fam Med 2011;43:198-200.
World Health Organization. World Health Report: Shaping the Future. Geneva: World Health Organization; 2003.
World Health Organization. The Millennium Development Goals and Tobacco Control. Geneva: World Health Organization; 2005.
Saddichha S, Rekha DP, Patil BK, Murthy P, Benegal V, Isaac MK. Knowledge, attitude and practices of Indian dental surgeons towards tobacco control: advances towards prevention. Asian Pac J Cancer Prev 2010;11:939-42.
World Health Organization. Global Report on 'Tobacco Attributable Mortality, 2012. Geneva: World Health Organization; 2012.
Fiore MC, Baily WC, Cohen SJ. Treating Tobacco Use and Dependence, Clinical Practice Guideline. US Department of Health and Human Services. Rockville (MD): Public Health Service; 2000.
Albert D, Ward A, Ahluwalia K, Sadowsky D. Addressing tobacco in managed care: a survey of dentists' knowledge, attitudes, and behaviors. Am J Public Health 2002;92:997-1001.
Ibrahim H, Norkhafizah S. Attitudes and practices in smoking cessation counselling among dentists in Kelantan. Arch Orofac Sci 2008;3:11-6.
Mohanty VR, Rajesh GR, Aruna DS. Role of dental institutions in tobacco cessation in India: current status and future prospects. Asian Pac J Cancer Prev 2013;14:2673-80.
World Health Organization. Guidelines for the Conduct of Tobacco-Smoking Surveys among HPs. Geneva: World Health Organization; 1984.
Parakh A, Megalamanegowdru J, Agrawal R, Hathiwala S, Chandrakar M, Tiwari R, et al.
Dental practitioners self reported performance of tobacco cessation counseling interventions: a cross sectional study. Asian Pac J Cancer Prev 2013;14:6141-5.
Khalaf M. Smoking cessation practices in Kuwaiti general dental clinics. Med Princ Pract 2013;22:576-82.
Chandrashekar J, Manjunath BC, Unnikrishnan M. Addressing tobacco control in dental practice: a survey of dentists' knowledge, attitudes and behaviours in India. Oral Health Prev Dent 2011;9:243-9.
Victoroff KZ, Lewis R, Ellis E, Ntragatakis M. Patient receptivity to tobacco cessation counseling in an academic dental clinic: a patient survey. J Public Health Dent 2006;66:209-11.
Saud M, Madhu B, Srinath KM, Ashok NC, Renuka M. Physician's practices and perspectives regarding tobacco cessation in a teaching hospital in Mysore City, Karnataka. Indian J Psychiatry 2014;56:24-8.
Thankappan KR, Pradeepkumar AS, Nichter M. Doctors' behaviour & skills for tobacco cessation in Kerala. Indian J Med Res 2009;129:249-55.
Jiang Y, Ong MK, Tong EK, Yang Y, Nan Y, Gan Q, et al.
Chinese physicians and their smoking knowledge, attitudes, and practices. Am J Prev Med 2007;33:15-22.
Abdullah AS, Rahman AS, Suen CW, Wing LS, Ling LW, Mei LY, et al.
Investigation of Hong Kong doctors' current knowledge, beliefs, attitudes, confidence and practices: implications for the treatment of tobacco dependency. J Chin Med Assoc 2006;69:461-71.
Shah NM. HPs in Tobacco Control: Evidence from Global Health Professional Survey (GHPS) of Dental Students in India. Geneva: World Health Organization; 2005.
Ehizele A, Azodo C, Umoh A, Akinboboye B. Attitude of dental students to tobacco cessation services. Internet J Dent Sci 2009;7:1.
Uti OG, Sofola OO. Smoking cessation counseling in dentistry: attitudes of Nigerian dentists and dental students. J Dent Educ 2011;75:406-12.
Rimal NR, Mead LE, Cohen J, Feighery E, Yang J. Implementation of the Cigarettes and Other Tobacco Products Act (COTPA) in India: City Population Size as a Predictor of Compliance. New Delhi: George Washington University School of Public Health and Health Services;2013.
[Table 1], [Table 2], [Table 3]
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