|Year : 2020 | Volume
| Issue : 1 | Page : 60-65
Tobacco cessation counseling: Are dentists doing enough?
Soni Rajput1, Akshatha Gadiyar1, Amit Kumar2, Amita Kenkre Kamat1, Ridhima Gaunkar1, Akanksha Jain3
1 Department of Public Health Dentistry, Goa Dental College and Hospital, Bambolim, Goa, India
2 Department of Public Health Dentistry, Oral Health Sciences, PGIMER, Chandigarh, India
3 Department of Periodontics, Goa Dental College and Hospital, Bambolim, Goa, India
|Date of Submission||25-Aug-2019|
|Date of Decision||07-Sep-2019|
|Date of Acceptance||23-Jan-2020|
|Date of Web Publication||2-Mar-2020|
Dr. Soni Rajput
No. 8, Department Public Health Dentistry, Goa Dental College and Hospital, Bambolim, Goa
Source of Support: None, Conflict of Interest: None
Background: Tobacco use is one of the leading causes of premature death and preventable illness. Tobacco cessation counseling (TCC) is one of the ways to prevent the rising mortality. Dentists hold an important role in TCC. Aim: The aim of this study was to assess the attitudes, practices, and perceived barriers in TCC among dental practitioners in Goa, India. Materials and Methods: A cross-sectional questionnaire study was conducted among 150 dentists in Goa. The survey instrument included a close-ended self-administered 27-item questionnaire, assessing demographics, attitudes toward TCC, practices in TCC, and perceived barriers in performing TCC. The data were evaluated using SPSS version 22.0. Chi-square/Fisher's exact test, Pearson's correlation, and unconditional logistic regression were used keeping P value at 5%. Results: The mean age of the study participants was 30.91 ± 5.28 years (24–42 years) and 111 (74.0%) were female. Seventy-three percent of the dentists agreed that TCC is their responsibility. Very few (18.0%) dentists provide tobacco cessation pamphlets and posters in waiting room. The most common barrier (70.0%) was “patient disinterest” in receiving advice. The respondents who have used tobacco were more likely (odds ratio [OR] =2.02, 1.49–2.46) to have positive attitude toward TCC than those who never used tobacco. Older respondents (OR = 2.10, 2.05–2.80) and those having more years of experience (OR = 3.10, 2.86–3.54) were more likely to practice TCC. Conclusion: This study shows that very few dentists were current smokers in Goa. They showed a constructive attitude toward TCC, especially those who were older than 29 years and never used tobacco. Dentists who were positive for TCC were practicing TCC better.
Keywords: Attitude, barrier, dentist, India, tobacco
|How to cite this article:|
Rajput S, Gadiyar A, Kumar A, Kamat AK, Gaunkar R, Jain A. Tobacco cessation counseling: Are dentists doing enough?. J Indian Assoc Public Health Dent 2020;18:60-5
|How to cite this URL:|
Rajput S, Gadiyar A, Kumar A, Kamat AK, Gaunkar R, Jain A. Tobacco cessation counseling: Are dentists doing enough?. J Indian Assoc Public Health Dent [serial online] 2020 [cited 2021 Sep 24];18:60-5. Available from: https://www.jiaphd.org/text.asp?2020/18/1/60/279828
| Introduction|| |
Tobacco use is one of the leading causes of premature death and preventable illness. The extensive use of tobacco plays a pivotal role in increasing the burden of noncommunicable diseases comprising lung cancer, oral cancer, hypertension, and cardiovascular diseases.
Tobacco use is also a significant risk factor in causation of periodontal disease and delayed wound healing.
The latest nationally representative Global Adult Tobacco Survey estimated that India had 266 million current tobacco users (smoked and/or smokeless) in the year 2016–2017 (over 28.6% of adults). Majority of them used smokeless tobacco (199.4 million) and 99.5 million used smoked forms of tobacco. As per the Global Adult Tobacco Survey 2 Goa (2016–2017) statistics, 4.2% currently use smoked tobacco and 6.5% use smokeless tobacco.
All the forms of tobacco contain a highly addictive chemical called nicotine which makes it difficult for the habitués to quit the habit as nicotine leads to dependency. Quitting cold turkey can result in various physical as well as psychological withdrawal symptoms., Studies have reported that although 70% of smokers would like to stop smoking, only 7.9% are able to do it without help.
Health-care professionals play a vital role in assisting their patients with tobacco cessation.
Among health professionals, dentists play a major role in educating patients regarding the oral health risks of tobacco use and motivating them to quit. The increasing use of tobacco among the youth warrants the need for dental health professionals to effectively provide tobacco cessation counseling (TCC) in the office as well as in community setting.
Tobacco dependence requires repeated interventions. The dentist has the opportunity to meet his/her patient repeatedly for follow-up visits, which provides the opportunity to further reinforce TCC. Dentists are capable and well trained in diagnosing any change in the oral cavity ranging from minor problems such as tooth staining and odor as well as potentially malignant disorders or malignant lesions.,
Literature review suggests that majority of the dentists felt that it was their responsibility to provide TCC and they were confident in providing such counseling., The various barriers perceived by the dental practitioners in providing TCC include the amount of time required to counsel patients, lack of knowledge about referrals as well as lack of training. Nevertheless, dentists with further training and appropriate remuneration could guide many of their patients to successful quit attempts.
However, there is a paucity of literature concerning tobacco cessation attitude and practices among dental professionals in Goa. Hence, the present study is conducted with the aim to assess the attitudes, practices, and perceived barriers in TCC among dental practitioners in Goa state.
| Materials and Methods|| |
Study design and participants
The present cross-sectional study was conducted among dental practitioners in Goa from February to April 2019. Ethical approval was obtained from the institutional ethical committee and was carried in full accordance with the World Medical Association Declaration of Helsinki. All participants signed informed consent.
In the pilot study, the prevalence of practice was found to be 73%.
The sample size was estimated using the formula:
Statistical power of 80%, 95% confidence interval, 10% margin of error (E), Zα/2 = 1.96, and P = 0.73.
The sample size obtained was 142 and it was rounded off to 150.
The study population included dental professionals with private practice and those employed in general and dental hospitals. A list of private clinics and dental practice in general hospital was prepared. Dental clinics and dental wing in general hospital were selected randomly, and all dentists working in these practices and having at least 1 year of work experience were included till the sample size of 150 was met.
The questionnaire was based on previous studies, with some modifications and addition of new questions to suit the Indian scenario. Face validity and content validation were done with the help of panel of experts. Internal consistency was also assessed using Cronbach's alpha, and it was found to be good (α = 0.80) during pilot survey.
The survey instrument included a close-ended self-administered 27-item questionnaire, assessing demographics (9 items), attitudes toward TCC (8 items) in one direction, practices in TCC (11 items), and perceived barriers in performing TCC (8 items).
Self-administered questionnaires were distributed to the dentists in their respective practices. Questionnaires were collected immediately and checked for its completeness. It took 10–15 min for them to complete the questionnaire.
Data collected were entered in an Excel format, and the Statistical Package for the Social Sciences version 22 (IBM Corporation, SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Attitude (range: 0–32), practice (range: 0–44), and perceived barrier question responses were based on a 5-point Likert scale. Based on the median of practice domain, scores were dichotomized as “high score (>30)” and “low score (≤30).” Attitude scores were dichotomized as “positive“ (>21) and “negative“ (≤21) based on responses toward TCC.
Descriptive statistics with frequency, mean, and standard deviation were computed. The difference between the groups was tested using Chi-square statistics/Fisher's exact test for categorical variable. Pearson's correlation was used to explore the relationship between attitude and practice scores. Unconditional logistic regression was used to analyze factors affecting attitude and practice. A P value was set at 5% using two-tailed test with 95% confidence interval.
| Results|| |
The present study was conducted among 150 dentists in Goa state.
Descriptive statistics for demographic details
The mean age of the study participants was 30.91 ± 5.28 years (24–42 years) and 111 (74.0%) were female. Majority (60%) of them were practicing in the North Goa region and were undergraduates. Sixty-one percent of the dentists were from academic background and were doing group practice. The mean years of experience was 5.36 ± 4.57 years (1–18 years). Eighty-one percent of them “never used” tobacco [Table 1].
The mean attitude score for all the 5 items of the respondents was 19.96 ± 3.93 which is around 70% of the highest possible attitude score (29). More than two-third of the dentists (73.3%) agreed that TCC is their responsibility; they can serve as a role model for their patients (78.7%), and TCC should be given equal priority as the dental treatment (74.0%). Attitude scores were statistically significant associated with age (P < 0.001), gender (P = 0.04), practice (P < 0.001), practice type (P < 0.001), years of experience (P < 0.001), and tobacco status (P = 0.02) [Table 2].
[Figure 1] shows the involvement of the respondents in tobacco cessation activity. Very few dentists provide tobacco cessation pamphlets and posters in waiting room (18.0%), assess patient willingness to quit (35.0%), refer patients to institutions and TCC centers (47.3%), recommend nicotine replacement therapy, and follow up with patients in giving up tobacco (35.3%).
|Figure 1: Barriers among dentists regarding tobacco cessation counseling|
Click here to view
There was a statistically significant association between practice scores and age (P < 0.001), area of practice (P < 0.001), practice (P < 0.001), practice type (P < 0.001), years of experience (P < 0.001), and tobacco status (P = 0.04) [Table 3]. There was a moderate positive (r = 0.37) statistically significant correlation (P < 0.001) between attitude and practice scores.
[Figure 2] shows the perceived barriers toward TCC. The most common barrier was “patient disinterest” in receiving advice (70.0%) followed by “lack of training“ (42.0%), “time-consuming“ (33.4%), and “lack of knowledge“ (32.0%).
|Figure 2: Practices among dentists regarding tobacco cessation counseling|
Click here to view
Factors predicting attitude and practice scores
With regard to attitude, only tobacco status remained statistically significant (P = 0.003). The respondents who have used tobacco were more likely (odds ratio [OR] =2.02, 1.49–2.46) to have positive attitude toward TCC than those who never used tobacco [Table 4].
Pertaining to practice scores, older respondents (OR = 2.10, 2.05–2.80) and those having more years of experience (OR = 3.10, 2.86–3.54) were more likely to practice TCC, whereas those in academics (OR = 0.80, 0.68–0.90) and having group practice (OR = 0.91, 0.75–0.98) were less likely to practice TCC [Table 5].
| Discussion|| |
This cross-sectional study aimed to assess the attitude, practices, and perceived barriers of dentists in Goa. The present study is first of its kind in Goa to the best of our knowledge. Social desirability and response bias can be expected since it is a questionnaire study, but its clarity, simplicity, and comprehensiveness may be considered as its strength and would have achieved a reasonable degree of validity. Moreover, the selection of study participants was done carefully to include dentists from three major practices, coming in contact with patients from different strata of the society, which will facilitate the extrapolation of the research findings.
Dentists play a crucial part in ensuring provision of proper and professional oral health care to the patients, and it will be of great importance if we imbibe the habit of TCC as regular practice during patient management from the very start of their clinical career. Dentists who were older than 29 years had a more positive attitude and willingness to conduct TCC. The age correlation was found in two other studies., However, a study conducted in India and Iran reported the opposite trend; young dentists were more eager to conduct TCC. The maturity level of older dentists is more, and this is further added by relatively higher number of patients who exposure with oral diseases related to smoking and smokeless tobacco.
With respect to gender, there is a preponderance of females in dentistry in India; this is reflected in their positive attitude, but with regard to practice, there was no significant difference. These results were in agreement with another three studies,,, whereas a study conducted by Naziya et al. reported that females had a higher practice score than males. Goa is divided into two districts: North and South. Dentists practicing in the South scored significantly higher, but no difference was elicited in attitude score. The practice score was lesser in North Goa which can be attributed to more patient in flow in the area leading to lack of time or perhaps interest among the dentists. Moreover, dental tourism being more prevalent in North Goa and Dentists practicing in North Goa, concentrate more on need-based practice. There was no statistically significant difference in attitude and practice scores with respect to qualification. This can be due to lack of training and knowledge as well as patient's lack of interest which is reflected in their perceived barriers. This was in conformity with other studies,, but a study conducted by Shaheen et al. stated that dentists possessing a Bachelor of Dental Surgery degree had higher mean scores for domain item “beliefs about consequences.” Dentists who are in academics are completely submerged with clinical work and have a lot of challenges on their hands with different types of cases. Furthermore, they only practice their specific branch and would refer for TCC to the concerned specialty. Hence, TCC may not figure in their list of priorities.
A study done in India by Shah et al. found no statistically significant difference between private, academicians, and both. Dentistry is a profession, and no single profession can provide optimum patient care when working alone. However, due to the distribution of work duties, TCC takes a trivial position. Dentists with solo practice have a positive attitude and practice scores which can be attributed to the comprehensive treatment they provide and they are not influenced by others practicing under the same roof. A similar trend was reported in a study. However, a study conducted in the United Arab Emirates found no statistically significant difference between solo and group practice. The dentists who have more clinical experience tend to encounter more patients with oral conditions related to tobacco habits, and they appear to give equal importance to preventive as well as therapeutic care, which explains a more positive attitude and higher practice score among such professionals. This result was in agreement with a previous study. Surprisingly, dentists who are current smokers showed less interest in TCC which is reflected in the association between tobacco status, attitude, and practice scores also in binary logistic regression. In comparison, a study in Saudi Arabia was in line with the present study, whereas in contradiction, a study done in the UAE and India showed that current smokers were more likely to have good practice and positive attitude than former smokers and never smokers. This indicates improved awareness among nonsmokers about the adverse effects of tobacco. The inference is that the effectiveness of tobacco cessation can be enhanced if counseling is done by dentists who do not consume tobacco. It was found that dentists with a positive attitude toward TCC were significantly more likely to have good practice in tobacco cessation interventions. This ascertains that if we improve the attitude of dentists toward TCC it will intensify their inclination toward TCC. Bivariate logistic regression determined four important factors for practice scores, which shows the area where we have to focus more to gain better efficiency. These lacunae have to be given importance, and continuous reinforcement and motivation should be provided to young dentists, dentists working in a group, and dentists having academic practice.
This study identified perceived barriers by the dentist toward TCC and the most common was “lack of training,” followed by “lack of knowledge” and “lack of time.” These findings are in accordance with studies which also identified the same.,,,, Dental procedures are mainly operative where less importance is given to primary prevention. It is responsibility of the dentist to record all the medical and dental history to prevent complications in treatment. This is quite challenging as it compromises the working time on patients. There is only one Government Dental Institute in Goa. Any patient who comes with a dental emergency has to be given priority. Another barrier found was “patient disinterest in receiving advice.” In general, patients reporting to the dental clinic demand that their chief complaint be resolved on priority. It is also the responsibility of the dentist to change the attitude of the patient and give equal importance to primary prevention. This was seen in their response that none of them felt that “TCC was not their duty.” There is a surfeit of dentists in India, they should be channeled toward TCC, continuous Motivation and reinforcement should be present. Moreover, dentists should be imparted comprehensive training in TCC as a part of their undergraduate curriculum. This would go a long way in rending the young India tobacco free.
| Conclusion|| |
This study identified attitudes, practices, and perceived barriers in TCC among dental practitioners in Goa state. Surveyed dentists had a constructive attitude toward TCC, especially those who were older than 29 years and never used tobacco. Dentists who were positive for TCC were practicing TCC better. Very dentists refer patients to institutions and TCC centers. Patient disinterest and lack of training was the most common barrier encountered. Tobacco cessation practice should be strengthened in teaching intuitions, so it is carried forward later in clinical practice also. Moreover, favorable environment should be created for them to counsel the patient in a better way.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. World Health Report: Shaping the Future. World Health Organization; 2003. Available from: http://www.who.int/whr/2003/en/
. [Last accessed on 2018 Mar 21].
Johnson GK, Guthmiller JM. The impact of cigarette smoking on periodontal disease and treatment. Periodontol 2000 2007;44:178-94.
Preber H, Bergström J. Effect of cigarette smoking on periodontal healing following surgical therapy. J Clin Periodontol 1990;17:324-8.
Moxham J. Nicotine addiction. BMJ 2000;320:391-2.
Hatsukami DK, Hughes JR, Pickens RW, Svikis D. Tobacco withdrawal symptoms: An experimental analysis. Psychopharmacology (Berl) 1984;84:231-6.
Hughes JR, Hatsukami D. Signs and symptoms of tobacco withdrawal. Arch Gen Psychiatry 1986;43:289-94.
Bates RC, Bueltel LM. Creating a comprehensive smoking cessation program. AARC Times 1999;23:46-53.
Mojica WA, Suttorp MJ, Sherman SE, Morton SC, Roth EA, Maglione MA, et al
. Smoking-cessation interventions by type of provider: A meta-analysis. Am J Prev Med 2004;26:391-401.
Shaheen S, Reddy S, Doshi D, Reddy P, Kulkarni S. Knowledge, attitude and practice regarding tobacco cessation among Indian dentists. Oral Health Prev Dent 2015;13:427-34.
Tomar SL. Dentistry's role in tobacco control. J Am Dent Assoc 2001;132 Suppl:30S-5S.
Albert DA, Severson H, Gordon J, Ward A, Andrews J, Sadowsky D. Tobacco attitudes, practices, and behaviors: A survey of dentists participating in managed care. Nicotine Tob Res 2005;7 Suppl 1:S9-18.
Al-Kayyal M. A-HN: Dental records and what they can reveal about tobacco use intervention practices. Tob Prev Cessat 2017;3:1-7.
Smith DR, Leggat PA. Tobacco smoking prevalence among a cross-section of dentists in Queensland, Australia. Kurume Med J 2005;52:147-51.
Amit S, Bhambal A, Saxena V, Basha S, Saxena S, Vanka A. Tobacco cessation and counseling: A dentists' perspective in Bhopal city, Madhya Pradesh. Indian J Dent Res 2011;22:400-3.
] [Full text]
Bhat N, Jyothirmai-Reddy J, Gohil M, Khatri M, Ladha M, Sharma M. Attitudes, practices and perceived barriers in smoking cessation among dentists of Udaipur city, Rajasthan, India. Addict Health 2014;6:73-80.
Gould KA, Eickhoff-Shemek JM, Stacy RD, Mecklenburg RE. The impact of National Cancer Institute training on clinical tobacco use cessation services by oral health teams. J Am Dent Assoc 1998;129:1442-9.
Dolan TA, McGorray SP, Grinstead-Skigen CL, Mecklenburg R. Tobacco control activities in U.S. dental practices. J Am Dent Assoc 1997;128:1669-79.
Stacey F, Heasman PA, Heasman L, Hepburn S, McCracken GI, Preshaw PM. Smoking cessation as a dental intervention – Views of the profession. Br Dent J 2006;201:109-13.
Prabhu A, Jain JK, Sakeenabhi B, Kumar PGN, Imranulla M, Ragher M. Smoking cessation advice: Knowledge, attitude, and practice among clinical dental students'. J Pharm Bioallied Sci 2017;9:S117-20.
Alajmi B, Abu-Hammad O, Al-Sharrad A, Odeh ND. Tobacco cessation support among dentists: A cross-sectional survey in Saudi Arabia and Kuwait. Tob Prev Cessat 2017;3:121.
Mitra DK, Pawar SD, Mandal A, Shah RA, Rodrigues SV, Desai AB, et al
. Attitudes of dental professionals toward tobacco use. J Indian Soc Periodontol 2015;19:317-21.
] [Full text]
Parkar S, Pandya E, Sharma A. Attitudes, practices, and barriers in tobacco cessation counselling among dentists of Ahmedabad city, India. SRM J Res Dent Sci 2016;7:140-5. [Full text]
Razavi SM, Zolfaghari B, Doost ME, Tahani B. Attitude and practices among dentists and senior dental students in Iran toward tobacco cessation as an effort to prevent oral cancer. Asian Pac J Cancer Prev 2015;16:333-8.
Bangera D, Takana M, Muttappallymyalil J. Tobacco cessation: Attitude and practice of dentists in Northern United Arab Emirates. East Mediterr Health J 2018;24:419-26.
Naziya KB, Sakthi DS, Arumugham IM, Kumar RP. Knowledge, attitude, and practice about barriers to tobacco intervention services among dental students in Chennai, Tamil Nadu. J Adv Pharm Edu Res 2017;7:128-31.
Shah S, Rath H, Sharma G. Knowledge, attitude and practices of institution-based dentists toward nicotine replacement therapy. Indian J Dent Res 2017;28:629-36.
] [Full text]
Hashim R, Ismail S. Self-reported smoking cessation interventions among dental practitioners: A cross-sectional study. Eur J Gen Dent 2016;5:53-7. [Full text]
Clareboets S, Sivarajasingam V, Chestnutt IG. Smoking cessation advice: Knowledge, attitude and practice among clinical dental students. Br Dent J 2010;208:173-7.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]