tobacco 9 india

7/27/2019 Tobacco 9 India

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December 2011 Journal of Dental Education 1603

Perceptions of Dental Students in IndiaAbout Smoking Cessation CounselingPrakash Rajasundaram, B.D.S.; Peter Simon Sequeira, M.D.S.; Jithesh Jain, M.D.S.Abstract: Smoking kills 900,000 people every year in India. Many studies have shown that counseling rom a health proes-

sional is an eective method o helping patients quit. The aim o this study was to evaluate the knowledge and attitudes o dental

students in Karnataka, India, towards smoking cessation counseling. A questionnaire study was conducted among a convenience

sample o 329 dental students comprised o III year and IV year students and interns in three dental colleges in Karnataka, India.

O the 329 students who completed the questionnaire, twenty-two (7 percent) were current smokers, and teen (5 percent) were

ex-smokers. Although 94 percent responded they were giving antismoking advice to their patients, only 47 percent said they had

been taught antismoking advice suitable or patients. While a majority (95 percent) planned to advise patients about tobacco use

in their proessional careers, signicantly ewer (66 percent) indicated that such counseling would help patients to quit. This study

o dental students and interns ound that a majority intended to provide smoking cessation counseling in their proessional career

and agreed it is part o their proessional role.

Dr. Prakash is a Postgraduate Student, Department o Public Health Dentistry, Coorg Institute o Dental Sciences; Dr. Sequeira

is Proessor and Principal, Department o Public Health Dentistry, Coorg Institute o Dental Sciences; and Dr. Jithesh Jain is

Proessor and Head, Department o Public Health Dentistry, Coorg Institute o Dental Sciences. Direct correspondence and

requests or reprints to Dr. Prakash Rajasundaram, Department o Public Health Dentistry, Coorg Institute o Dental Sciences,Virajpet 571 218, Karnataka, India; 91-93430 27344 phone; [email protected].

Keywords: smoking, dental students, attitudes, tobacco, tobacco counseling, smoking cessation counseling, India

Submitted for publication 1/9/11; accepted 4/29/11

Tobacco use is described as the single most

preventable cause o morbidity and mortality

globally, with the World Bank predicting over

450 million tobacco deaths in the next ty years.1

Tobacco-related mortality in India is among the high-

est in the world, with about 900,000 annual deaths

attributable to smoking in the last decade.2 Annual

oral cancer incidence in the Indian subcontinent

has been estimated to be as high as 10 per 100,000

among males, and oral cancer rates are steadily in-

creasing among young tobacco users.3 The National

Family Health Survey or 200506 ound that 32.7

percent o males and 1.4 percent o emales are

smokers in India.4

Many studies have shown that counseling

with a health proessional is an eective method

o helping smokers quit. A survey o smokers in

the United States ound that i given a choice, theywould preer to receive smoking cessation counseling

rom a health proessional.5 Cessation rates o 10 to

20 percent have been ound ater patients received

proessional advice and appropriate assistance rom

their physicians.6 A recent survey in Hungary ound

that advice rom health care proessionals to quit

ranked second in eectiveness ater requests by the

smokers own amily.7 Cessation rates o up to 18

percent have been seen when dental proessionals

counseled their patients to quit.8

The dental oce is an ideal setting or tobacco

cessation services (TCS) since preventive treatment

services, oral screening, and patient education have

always been a large part o the dental practice. More

than 60 percent o adults and 83 percent o teen-

to nineteen-year-olds see their dentist at least once

a year.9 Surveys o Americans and Canadians have

ound that 58 percent o smokers made regular ap-

pointments with their dentists.10,11 These regular in-

teractions provide dental teams with the opportunity

to provide a range o TCS.

However, compared to physicians and other

health proessionals, dentists are less likely to provide

tobacco use cessation advice and counseling and eel

inadequately prepared to provide tobacco cessation

education to their patients.12 The reasons or not

providing it include time and reimbursement issues,

poor education and lack o urther postgraduate train-ing, and poor coordination o dental and smoking

cessation services.13

Another area o research is the attitudes o

dental students, the uture dentists, towards tobacco

control programs. In a survey o American dental

students, those students who adhered best to the

our-aceted cessation model held positive attitudes

regarding dentists role in tobacco cessation practices,

especially their role in speaking out to lay groups

about tobacco use, and had received ormal training


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1604 Journal of Dental Education Volume 75, Number 12

in smoking cessation counseling. There was a general

agreement that their educational program adequately

prepared them to help smokers quit.14 In another

study, the majority o Australian dental students

said they planned to advise patients about tobacco

use, although their perception o the eectiveness o

smoking cessation counseling seems to be low.15 The

same trend was observed in Europe where Greek stu-

dents considered tobacco cessation counseling a duty

or every dentist, although a large part (32 percent)

believed it to be ineective. On the other hand, these

students were ound to possess signicant knowledge

about the health eects o tobacco.16

In 2002, Tobacco Cessation Clinics (TCCs)

were set up in India to provide the rst ormal tobacco

cessation intervention. Thirteen clinics were set up in

oncology, cardiology, psychiatry, surgery, and NGO

settings; coverage was later expanded to nineteen clin-

ics. These were supported by the World Health Organi-

zation Country Oce and the Ministry o Health and

Family Welare, Government o India. Tobacco ces-

sation services in India are provided through various

tools such as behavioral counseling, pharmacotherapy,

and a combination therapy ater assessing the degree

o nicotine dependence o the tobacco user.17 Smoking

cessation counseling is not yet part o routine Indian

dental or medical practice, and it is not incorporated

into the medical or dental curricula. In India, there

is a paucity o inormation regarding the attitudes o

dental students towards smoking cessation counseling.This study was conducted to evaluate the knowledge

and attitudes o one group o dental students towards

smoking cessation counseling.

Materials and MethodsA descriptive, questionnaire study was de-

signed to assess the knowledge, attitudes, and views

about smoking cessation counseling among clinical

dental students. The study population consisted o a

convenience sample o III year and IV year students

and interns rom three dental colleges in Karnataka,

India. Those in these groups who were present on the

day o the survey were invited to participate. Out o

a total o 341 subjects, 329 agreed to complete the

survey and twelve declined, yielding a response rate

o 96 percent.

A pretested, structured survey consisting o

twenty-two closed-ended questions was used. Its

comprehensibility was tested in a pilot test with a

convenience sample o twenty-our students who

were not included in the nal study. The rst set o

questions asked or demographic inormation, includ-

ing age, gender, year o study, name o the institution

where studying, smoking status, marital status, and

smoking status o any other amily members. The

second set o questions was divided into six groups:

policies and practices in ones institution; views about

smoking cessation counseling; knowledge about

smoking cessation counseling relevant to dentistry;

strategies or smoking cessation counseling; smok-

ing cessation counseling resources; and barriers to

smoking cessation counseling

The data were collected in August 2009. The

surveys were administered during scheduled class

times or the III year and IV year students and in

clinical courses or the interns. Ethical approval was

obtained rom the Institutional Ethical Committee o

Coorg Institute o Dental Sciences, and permission

to conduct the study was obtained rom the princi-

pals o the respective dental colleges. The students

were inormed about the study, and only those who

consented to participate were included.

The collected data were classied and tabulated

in Microsot Oce Excel. SPSS or Windows, ver-

sion 16 (2007), was used or statistical analysis. Re-

sponses to the questions were analyzed by calculating

percentages based on the number who answered the

questions. Chi-square test was used to determine any

signicant dierences among the responses and the

respondents demographic variables. A probabilityvalue o p


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(n=306) said they have taken tobacco usage histories

rom all patients, and 97.2 percent (n=320) have been

taught about the role o tobacco in the etiology o

oral cancer (Table 2).

Most o the respondents (n=310; 94.2 percent)

answered that they gave antismoking advice to pa-

tients. About 96 percent o the emales said they gave

antismoking advice, which was higher than the males

(90 percent). This item was signicantly associated

with respondents smoking status (Table 3) and

gender (Figure 1) (p


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Most o the respondents (n=145; 44.1 percent)

answered that practical skills training (role-play,

standardized patients, objective structured clinical

exam) to promote smoking cessation was a useul

Figure 1. Respondents agreement that they give antismoking advice to smoking patients, by gender

88

222

310

Figure 2. Respondents agreement that they were taught antismoking advice that was suitable for patients, bystudents year of training

56

43

57

Table 3. Responses regarding practices in the individuals institution according to their smoking status

Smoking Status

Current Smoker Ex-Smoker Never Smoker Totaln (%) n (%) n (%) n (%)

I give antismoking advice to patients who smoke.* 16 (72.7%) 12 (80.0%) 282 (96.6%) 310 (94.2%)

I am taught antismoking advice suitable or patients.** 13 (59.1%) 12 (80.0%) 131 (45.2%) 156 (47.1%)

*Chi square=32.871, d=4, p


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do not expect smoking cessation counseling rom a

dental student (Table 7).

DiscussionDentists play a key role in tobacco use cessa-

tion counseling (TUCC) programs directed toward

the community as a whole and toward the individual

patient. Moreover, the training o dental students in

TUCC counseling might lead to higher rates o TUCCintervention in subsequent proessional practice.18

Our study investigated the attitudes and views

o clinical dental students rom three dental colleges

in Karnataka, India. The study sample consisted o

329 respondents, comprised o III year and IV year

students and interns. The percentage o current smok-

ers was 6.6 percent, which is less than percentages

reported or many other countries, or example, Great

Britain (7 percent), Australia (13 percent), Ireland

Table 4. Distribution of responses regarding actions and views about smoking cessation counseling

Yes No Unsure

n % n % n %

In the course o your training, have you ever helped a patient to 51 15.9% 235 70.9% 43 13.0%

quit smoking?

Do you plan to advise patients about smoking cessation in your 313 95.2% 7 2.1% 9 2.7%proessional career?

Do you think smoking cessation counseling provided by dentists 218 66.3% 27 8.2% 84 25.5%would help patients to quit smoking?

Note: Percentages may not total 100% because o rounding.

Table 5. Distribution of responses regarding strategies that respondents think will be useful for smoking cessationcounseling, according to year of study

Year o Study

III IV Interns Totaln (%) n (%) n (%) n (%)

Counsel smokers about the eects o smoking on 50 (43.5%) 71 (71.0%) 52 (45.6%) 173 (52.6%)their oral health.

Provide smoking patients with written inormation 8 (7.0%) 10 (10.0%) 9 (7.9%) 27 (8.2%)and sel-help material to help them to quit.

Suggest nicotine replacement therapy or patients 36 (31.3%) 14 (14.0%) 25 (21.9%) 75 (22.8%)who wish to quit.

Arrange ollow-up visits to discuss smoking cessation 21 (18.3%) 5 (5.0%) 28 (24.6%) 54 (16.4%)with smoking patients.

Chi square=29.811, d=6, p


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Table 6. Distribution of responses regarding smoking cessation counseling resources that respondents think are useful,according to year of study

Year

III IV Interns Totaln (%) n (%) n (%) n (%)

Teaching audiotapes or videotapes 28 (24.3%) 39 (39.0%) 48 (42.1%) 115 (35.0%)

Seminars with experts 15 (13.0%) 13 (13.0%) 10 (8.8%) 38 (11.5%)

Practical training in skills to promote smoking cessation 52 (45.2%) 43 (43.0%) 50 (43.9%) 145 (44.1%)

Access to smoking cessation research literature via 20 (17.4%) 5 (5.0%) 6 (5.3%) 31 (9.4%)CD-ROM or Internet

Chi square=18.984, d=6, p


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Table 7. Distribution of respondents agreement regarding barriers to smoking cessation counseling

Agree Disagree

n % n %

Many patients who smoke do not have the motivation to quit. 262 79.6% 67 20.4%

Patients do not expect smoking cessation counseling rom a dental student. 143 43.5% 186 56.5%

Smoking cessation counseling is ineective unless the patient has a related 223 67.8% 106 32.2%health problem.

I do not have sufcient skills to provide smoking cessation counseling at this 236 71.8% 93 28.2%stage o my training.

I do not have the time to provide smoking cessation counseling during clinical 51 15.5% 278 84.5%consultations.

I do not consider smoking counseling part o the dentists proessional role. 22 6.7% 307 93.3%

I am concerned that the antismoking message may alienate patients who smoke. 185 56.2% 144 43.8%

Providing good dental care is enough. 66 20.1% 263 79.9%

Even though 95.2 percent o our respondents

planned to advise their patients about smoking

cessation in their proessional career, only 66.3

percent thought that such counseling would help

patients to quit smoking. This rather low perception

o eectiveness is consistent with other ndings

reported in the literature.15,16,20 These responses

suggest that many students remain skeptical about

the extent to which tobacco cessation counseling is

eective in helping patients to quit. Much remains

to be done in dental education to promote awarenesso the scientic evidence on both the ecacy and

cost-eectiveness o tobacco prevention, including

the value o such standardized and simple models

as the Four As, which is widely used.8 The Four

As model, advocated by the U.S. National Cancer

Institute, is a our-pronged cessation approach or

dental providers, incorporating Asking patients about

tobacco use, Advising them to stop, Assisting them

in quitting, and Arranging ollow-up. In our study,

93 percent o the respondents took tobacco usage

history rom all patients (Asking) and 94.2 percent

gave antismoking advice (Advising). Although 52.6percent responded that counseling smokers about

the eects o smoking on their oral health is a use-

ul strategy, only 22.8 percent said they suggested

nicotine replacement therapy and 8.2 percent written

inormation and sel-help material (Assisting). Only

16.4 percent suggested ollow-up visits as a useul

strategy (Arranging). These ndings were similar to

a study done in United States.14

A majority o respondents (93 percent) in our

study agreed that smoking cessation counseling

is part o a dentists proessional role, which has

been reported in other studies.14-16,18 With respect

to barriers to smoking cessation counseling, almost

72 percent o our respondents agreed that not hav-

ing sucient skills is a barrier or their providing

counseling. This lack o skills in turn is perceived

as a barrier to incorporating tobacco intervention

into clinical practice. In act, a number o studies

conducted amongst health care proessionals have

ound that clinicians who receive ormal training

in cessation counseling are more likely to providetobacco intervention or their patients.18

This study suggests the need to help dental

students develop proessional competence in smok-

ing cessation by encouraging the development o a

prevention mindset, in which smoking counseling is

included with other oral disease prevention practices

such as brushing and fossing. More emphasis should

be placed on conveying inormation regarding the cli-

nicians potential ecacy in tobacco cessation eorts

by ocusing on the doubling and tripling o long-term

quit rates attributable to clinician eorts compared

to sel-help methods. This evidence-based teachingshould help dispel the undue pessimism with which

students tend to view their potential or success.14 A

comprehensive tobacco education curriculum could

provide knowledge and clinical experience that would

help students expand their concept o a dentist to that

o a caring health care provider who is interested in

all health behaviors that impact their patients oral

and overall well-being. This may help them eel more

comortable including tobacco prevention and ces-

sation as a normal part o patient care.


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The design o this study had some limitations

that should be considered when interpreting the re-

sults. The data were collected by sel-report, which

could be subject to the respondents recall bias and

desire to present their clinical practices in a avorable

light. Also, these ndings may not be generalizable

due to the sample size and sampling procedure.

As there have been very ew studies o students

knowledge and attitudes regarding smoking cessation

counseling among Indian students, there is a need or

urther research to conrm our ndings.

ConclusionThis study ound that a majority o these stu-

dents and interns in three dental schools in India

intended to provide smoking cessation counseling

in their proessional career and saw it as part o theirproessional role as dentists. However, it also ound

that lack o smoking cessation training and inad-

equate knowledge o smoking cessation counseling

are barriers to counseling practices. Dental curricula

in India include didactic instruction on the oral health

impact o tobacco use, but practical training in clini-

cal intervention like cessation counseling is not part

o the curriculum. The results o this study indicate

that tobacco cessation counseling may be practiced

more widely i dental students were given additional

training during their undergraduate education.

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