The use of all forms of tobacco continues to. Assessment of Tobacco Dependence Curricula in Italian Dental Hygiene Schools. Global Dental Education

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1 Global Dental Education Assessment of Tobacco Dependence Curricula in Italian Dental Hygiene Schools Giuseppe Pizzo, D.D.S.; Joan M. Davis, R.D.H., C.T.T.S., Ph.D.; Maria E. Licata, D.D.S., Ph.D.; Giovanna Giuliana, D.D.S. Abstract: The aim of this study was to assess the level of tobacco dependence education offered by Italian dental hygiene programs. A fifty-question survey was mailed to the thirty-one active public and private dental hygiene programs in Italy during the academic year. The survey assessed faculty confidence in teaching tobacco treatment, which courses contained tobacco dependence content, the number of minutes spent on specific content areas, and the level of clinical competence that dental hygiene graduates should be able to demonstrate. Surveys were returned by sixteen programs for a response rate of 52 percent. Respondents indicated tobacco dependence education was included in clinic or clinic seminar (56 percent), periodontics (44 percent), oral pathology (31 percent), and prevention (19 percent). All programs reported including the effects of tobacco on general and oral diseases in courses. However, more in-depth topics received less curriculum time; these included tobacco treatment strategies (63 percent) and discussion of cessation medications (31 percent). Interestingly, 62 percent of the respondents indicated they expected dental hygiene graduates to demonstrate a tobacco treatment competency level of a moderate intervention or higher (counseling, discussion of medications, follow-up) rather than a brief intervention in which patients are advised to quit then referred to a quitline. The results of this study indicated that Italian dental hygiene students are not currently receiving adequate instruction in tobacco treatment techniques nor are they being adequately assessed. This unique overview of Italian dental hygiene tobacco dependence education provides a basis for further discussion towards a national competency-based curriculum. Dr. Pizzo and Dr. Davis contributed equally to this article. Dr. Pizzo is Assistant Professor, Department of Surgical, Oncological, and Oral Sciences, University of Palermo, Italy; Dr. Davis is Professor, Department of Dental Hygiene, College of Applied Sciences and Arts, Southern Illinois University, Carbondale, IL; Dr. Licata is Postdoctoral Research Fellow, Department of Surgical, Oncological, and Oral Sciences, University of Palermo, Italy; and Dr. Giuliana is Professor, Department of Surgical, Oncological, and Oral Sciences, University of Palermo, Italy. Direct correspondence and requests for reprints to Dr. Giuseppe Pizzo, Dipartimento di Discipline Chirurgiche, Oncologiche e Stomatologiche (Plesso di Odontostomatologia), Università di Palermo, Via del Vespro 129, Palermo, Italy; giuseppe.pizzo@unipa.it. Keywords: tobacco dependence, tobacco treatment, tobacco cessation, dental hygiene education, Italy Submitted for publication 5/23/12; accepted 8/12/12 The use of all forms of tobacco continues to be a significant environmental factor in the development of disease and possible death. The World Health Organization (WHO) estimates that tobacco-related deaths will increase to more than eight million per year by The 2010 U.S. surgeon general s report How Tobacco Smoke Causes Disease states that tobacco smoke damages every organ in the body and causes disease and death. 2 The oral consequences of tobacco use are well documented; these include chronic/aggressive periodontitis, necrotizing periodontal disease, poor periodontal therapy and root coverage outcome, dental implant failure, and a significant oral cancer risk. 3-6 Article 14 of the WHO Framework Convention on Tobacco Control emphasizes the need for health care professionals to provide effective, comprehensive tobacco dependence treatment for their tobacco-using patients. 7 Research has shown that clinicians who provide tobacco treatment can significantly increase the likelihood of a patient successfully quitting. 8 Unfortunately, medical and oral health care providers continue to report offering a minimal cessation intervention consisting of the identification of patients tobacco use and, to a lesser degree, advising them to quit. Barriers to a more comprehensive and effective tobacco intervention include lack of time, training, and reimbursement One mechanism that may affect change in the level of tobacco treatment interventions (counseling, medication recommendations, quitline referral, and follow-up) in clinical practice would be the inclusion of evidence-based tobacco dependence training based on established models such as found in the U.S. Public Health Service s Treating Tobacco Use and Dependence. 8 The research supports the 5A 1072 Journal of Dental Education Volume 77, Number 8

2 model (Ask, Advise, Assess, Assist, Arrange). In this model, the greater the intervention, the greater is the likelihood a patient will successfully quit and remain abstinent. A brief intervention, consisting of identifying tobacco use, a recommendation to quit, and referral to a quitline, has been found to be somewhat beneficial. A more intensive intervention in which counseling strategies such as brief motivational interviewing are used, cessation medications are explored, and a personalized reduction or quit plan is created can yield greater, long-term results. Behaviorally based tobacco dependence education could be incorporated into existing chronic disease curricula requiring health behavior change such as maintaining periodontal health and caries control. Studies have shown that dental and dental hygiene students are aware of the general and oral effects of tobacco use and are interested in learning how to address tobacco use with their patients. They also report lacking the knowledge and confidence to provide effective tobacco treatment. Clareboets et al. 12 found that dental students possessed a strong knowledge of the health effects of tobacco on oral health, but only a third of the students consistently provided tobacco cessation advice to their patients. In addition, only 11.9 percent of the students provided information on tobacco cessation medications with even fewer referred patients to cessation services. Though European dental schools have shown improvements in both tobacco policies and practices, the didactic focus continues to be on identifying the oral effects of tobacco use and clinical focus on identifying tobacco use, with only a few schools requiring students to provide cessation advice. 13 A similar focus was reported by U.S. dental hygiene educators. 14 The majority of programs in that study reported teaching students the oral and general health effects of tobacco use. However, only 26 percent of the participating programs required a clinical tobacco treatment competence. Finally, in a recent study exploring Italian dental and dental hygiene student attitudes towards tobacco treatment, 68 percent of dental and 78 percent of dental hygiene students were aware of an association between tobacco use and negative oral health outcome, but had limited tobacco treatment knowledge. 15 The aim of this study was to assess the current level of tobacco dependence education (defined as all aspects of preventing and treating nicotine addiction) offered by Italian dental hygiene programs. The Theory of Planned Behavior 16 was used as the theoretical framework to assess the internal confi- dence or self-efficacy of faculty to teach tobacco dependence education. This investigation provides a unique assessment of the confidence and activity level of Italian dental hygiene faculty members. Methods A survey instrument developed by Stockdale et al. in and used in 2007 by Davis and Koerber 14 to assess tobacco dependence education in the United States was chosen for this study. A dental hygiene faculty member (author GP) from the University of Palermo, Italy, translated the survey into Italian and modified the content to better reflect terminology used in Italian dental hygiene programs. Using a cross-sectional study design, all active dental hygiene programs in Italy (n=31) were mailed the fifty-question survey at the start of the academic year. Program directors were asked to answer the survey or delegate the task to a faculty member familiar with tobacco education. Schools not responding within six weeks were contacted by phone to encourage survey completion. The questionnaire contained four primary sections: 1) faculty attitudes and perceived self-efficacy when providing tobacco dependence education, 2) how tobacco information was presented in the classroom and clinic, 3) the level of competence dental hygiene graduates should be able to demonstrate upon graduation, and 4) general program information. Faculty attitudes were assessed using a rating scale in which 1=Not confident at all and 5=Very confident. An answer of 3 was deemed Confident. Specific tobacco dependence topics were assessed using a Yes/No answer as well as requesting the number of minutes faculty spent on specific topic areas. Respondents were also asked to indicate the type (formal or informal) of clinical competencies that were utilized, the method or format in which tobacco education was presented, and sources of educational information used. Finally, the participants were asked to indicate the skill level candidates should demonstrate upon graduation: Brief (Ask about tobacco use, Advise patients to quit, and refer patients to other tobacco cessation resources); Moderate (same as Brief with the addition of discussion of cessation medications, use of motivational interviewing, and follow-up); or Intensive (all of the components of the Moderate intervention over several appointments). This multilevel tobacco intervention model is an adaptation of the U.S. Public Health Service brief and August 2013 Journal of Dental Education 1073

3 intensive interventions Survey data were entered into a database using an anonymous coding system and analyzed using SPSS Version 16 software and descriptive analysis. Results Completed questionnaires were returned by sixteen schools for a return rate of 52 percent. Fiftysix percent of the respondents (9/16) indicated they were program directors, with 100 percent indicating their program was for three years. The majority of programs (88 percent of respondents) reported being a part of a dental school. The mean number of students that programs accepted each year was 16.19±6.88 (range: 6-29). The mean number of fulland part-time faculty members was 22.46±13.81 (range: 4-44) and 9.69±9.29 (range: 0-30), respectively. The respondents selectively answered the fifty questions. Therefore, the specific number of respondents answering is indicated for each set of results. Faculty Confidence and Attitudes The sixteen respondents reported a high level of confidence (4.50 on a scale of 1-5) that faculty members were able to adequately teach oral pathology associated with tobacco use including periodon- tal disease, leukoplakia, and oral cancer (Table 1). Conversely, when asked if the faculty members felt confident to teach tobacco treatment techniques, the respondents were moderately strong (2.56). Faculty confidence slightly increased (2.88) when asked if the respondents were confident in helping students overcome their own resistance to providing tobacco treatment interventions. When asked about perceived barriers to including tobacco dependence education and treatment in their programs, the respondents moderately agreed (3.06) they lacked enough time to adequately cover the topic. Respondents somewhat disagreed (2.99) that their clinical faculty supported and encouraged tobacco treatment in the clinic. When looking at the skill level of clinical and didactic faculty members, respondents agreed (3.6) that they possessed basic motivational counseling skills and strongly agreed (4.13) that faculty members would benefit from tobacco dependence training. Curriculum Content All participating programs indicated they provide instruction on both general diseases (lung cancer, emphysema, and heart disease) and oral diseases (chronic periodontitis and oral cancer) in their programs (Table 2). An important consideration when reading this table is the total number of respondents Table 1. Respondents confidence in and perceived barriers to tobacco dependence education in their dental hygiene programs Level of Confidence 1=not confident to 5=very confident SD 1. With regard to teaching tobacco-related pathology (e.g., periodontal disease, leukoplakia, oral cancer) I feel our faculty are 2. With regard to teaching students how to work with patients to encourage them to quit using tobacco, I feel our faculty are 3. With regard to overcoming dental hygiene students resistance to engaging in tobacco cessation activities, I feel our faculty are Perceived Barriers 1=strongly disagree to 5=strongly agree SD 4. As a program, we lack enough class and clinic time to devote to tobacco education. 5. Our clinical faculty (hygienists and dentists) support and encourage tobacco cessation in our clinics. 6. Our faculty currently possess the basic counseling skills to teach, model, and assess brief motivational interviewing in the classroom and clinic. 7. Our faculty would benefit from training in tobacco cessation interventions including brief motivational intervention Journal of Dental Education Volume 77, Number 8

4 answering each question. Only two questions in this section (regarding general and oral tobacco-related diseases) were answered by all sixteen schools, who reported a mean of sixty minutes spent on the topic. The number of participants responding to this section fell incrementally with subsequent questions. However, the lack of respondents answering the remaining questions may indicate that they do not include these topic areas. Nonetheless, the schools that did respond to questions on tobacco treatment, prevention strategies, student tobacco use, and cessation medication indicated a substantial amount of time dedicated to these topics (forty-seven to fifty-seven minutes). Educational Methods When asked what methods their programs used to incorporate tobacco dependence education into their curricula, all sixteen respondents answered the majority of questions (Table 3). Overall, the majority of programs included tobacco dependence education in multiple courses (94 percent, n=15), with 100 percent indicating the material was presented in either a clinical seminar or clinic. Most schools (75 percent, n=12) indicated the use of case studies signifying a higher level of integration of tobacco dependence into the learning experience. Regarding tobacco treatment activities or services conducted in clinic, only 12 percent (n=2) of the participants reported that dentists in their clinic prescribe tobacco cessation medications for patients. However, most programs (69 percent, n=11) reported that their students provide more attention than simply identifying tobacco use and then referring the patient to the national quitline or cessation services. The courses or content areas in which tobacco dependence education was covered included periodontics (44 percent, n=7), oral pathology (31 percent, n=5), and clinic seminar/clinic (56 percent, n=9). Other courses or content areas included pharmacology, oral pathology, and community oral health. The primary tobacco treatment resources used were reported to be textbooks (56 percent, n=9) and professional journals (50 percent, n=8), with websites, government agencies, and private organizations also mentioned. Table 2. Frequency with which a tobacco-cessation content area is covered in Italian dental hygiene programs, in order of frequency, and mean minutes spent on each area % Including Topic in Curriculum (number of respondents) Mean Minutes Spent on Topic (Standard Deviation) Oral diseases related to tobacco use 100% (16) 60 (0) General diseases related to tobacco use 100% (16) 60 (0) Nicotine dependence 69% (11) 53 (16) Tobacco cessation strategies 63% (10) 57 (9) Tobacco prevention strategies 56% (9) 57 (10) Dental hygiene students own use of tobacco 50% (8) 47 (19) Medications to assist cessation 31% (5) 51 (20) Table 3. Educational methods by which tobacco cessation content is presented in class and clinic No Percent (n) Yes Percent (n) We offer most or all of our tobacco-related materials in one course. 94% (15) 6% (1) We offer our tobacco-related materials in several courses including lecture and clinic. 12% (2) 88% (14) We offer some of our tobacco-related material in case study format. 25% (4) 75% (12) We offer our tobacco-related material in clinic seminar/clinic only. 100% (16) 0 We offer a dedicated tobacco cessation clinic as a component of our clinic. 88% (14) 12% (2) In our clinical setting, our dentists prescribe tobacco-cessation medications. 88% (14) 12% (2) In our clinic, our tobacco cessation intervention primarily identifies tobacco use, then 69% (11) 31% (5) refers the patient to an outside tobacco cessation resource such as the national quitline. Note: For specific tobacco dependence interventions, see WHO s website at (accessed July 27, 2012). August 2013 Journal of Dental Education 1075

5 Clinical Competency Assessment When respondents were asked if they formally (with an assessment form), informally, or did not assess specific tobacco treatment skills in the clinical setting, 31 percent (n=4 of 13) reported formally assessing whether a patient used tobacco and 69 percent (n=9 of 13) reported assessing tobacco use informally. A total of 60 percent (n=9 of 15) of respondents reported formally assessing the student s being able to relate the head and neck exam findings to tobacco use, and 40 percent (n=6 of 15) reported assessing this skill informally. As with the curriculum content questions, the number of respondents answering the remainder of assessment questions dropped dramatically. Only six schools answered the question about whether they assess the skill of students discussing tobacco treatment/prevention strategies with patients. Of these six schools, three reported assessing tobacco treatment interventions formally, and three reported an informal assessment. When participants were asked what level of tobacco cessation competence should dental hygiene students be able to demonstrate upon completion of their formal education, an interesting spread of opinion was reported by the sixteen respondents. The highest percentage (44 percent, n=7) reported they would like to see dental hygiene students be able to provide a moderate level of intervention in which patients would be asked if they used tobacco, encouraged to quit, and offered information on tobacco cessation strategies and available medications as well as follow-up. The brief level of care was chosen by the next highest percentage of respondents (38 percent, n=6) in which patients would be asked if they use tobacco, encouraged to quit, and then referred to the national quitline or cessation service. Finally, 19 percent (n=3) of the respondents chose the intensive level in which patients would receive multiple, extended tobacco treatment interventions and follow-up. Discussion Dental patients who use tobacco are at greater risk of developing chronic periodontitis and oral cancer and have poor healing following periodontal treatment. 3,6 Oral health care providers have a unique opportunity to detect tobacco-related symptoms in apparently healthy dental patients seeking preventive care. Providers have a professional and ethical obligation to be trained in and provide evidence- based tobacco interventions both treatment and prevention. 8,9 In addition, it is widely recognized that tobacco dependence education should be a component of all health care curricula. 7,21,22 Unfortunately, McCartan and Shanley 13 reported that only 51 percent of European dental schools teach students anti-smoking advice suitable for patients. Similar results were found in a study of Italian dental and dental hygiene students where a poor knowledge of tobacco treatment interventions was reported. 15 Our study represents the first study designed to explore tobacco dependence education in Italian dental hygiene schools. With a 52 percent response rate from primarily program directors, the results are likely to be an accurate description of current dental hygiene education practices. As with other studies in the dental 12,14 and medical fields, 23,24 our findings indicated the majority of Italian undergraduate dental hygiene programs commit a sizeable portion of the tobacco dependence curricular content and time to health effects and minimal time to treatment skills or prevention. Less than half of the respondents provided student training in tobacco treatment techniques, spending less than one hour on these important skills a year. If clinical competence was assessed, an informal assessment was utilized. Given that important skills are assessed formally in dental hygiene labs and clinics, this situation begs the question of why tobacco treatment is not formally assessed. Correspondingly, the level of faculty confidence and attitudes towards being able to train tobacco treatment interventions were moderately low. This lack of faculty self-efficacy was evidenced by further report of limited tobacco treatment activities, assessments, and services conducted in clinic. It would seem reasonable that there would be limited teaching emphasis on a skill set that faculty members have limited confidence in providing. To the credit of the program directors, they recognized the potential benefit of training in tobacco treatment interventions. The majority of these program directors indicated that a graduating dental hygiene student should be able to demonstrate a moderate level (five- to fifteen-minute tobacco treatment intervention) of clinical competence upon graduation. Unfortunately, most of the respondents indicated they did not allow sufficient time each year to adequately prepare students to reach the desired level of clinical competence to reach that goal. The number of minutes reported reinforced the notion that most programs teach to a minimal intervention level of competence of asking, 1076 Journal of Dental Education Volume 77, Number 8

6 advising, and referring to the quitline. On a positive note, the minimal intervention level could be viewed as a strong foundation for educators to more fully adopt the U.S. Public Health Service s clinical practice tobacco treatment guidelines, which recommend offering the full 5As. 8 A more robust and effective intervention could be achieved by teaching to a moderate intervention level of competence. It would seem unlikely that a move to a moderate level will ever be accomplished until more training and guidance is offered to Italian dental hygiene programs. Interestingly, a comparison of our findings with a recent U.S. survey of tobacco dependence curricula in dental hygiene education revealed a few key differences and many similarities. Davis and Koerber reported that most U.S. dental hygiene programs included some level of tobacco treatment strategies in both didactic and clinical settings. 14 Our study revealed few Italian dental hygiene programs did the same. Similarities reflect that both Italian and U.S. dental hygiene faculty members spent the majority of their teaching time on tobacco-related oral and general diseases with limited time spent on tobacco treatment skills and clinical assessment. These results support similar tobacco dependence curriculum studies. 12,25-27 In addition, both Italian and U.S. program directors wanted their dental hygiene graduates to be competent at the moderate level but in reality were teaching to the brief level of intervention. Several studies have suggested that health care education is an opportune time for tobacco dependence education to be presented. 9,12,23,25 The results of this study indicate that though Italian dental hygiene students are receiving information on the oral and health effects of tobacco use, they are not receiving adequate instruction in tobacco treatment techniques and are not adequately assessed in clinic. To our knowledge, there is not a national tobacco dependence curriculum for dental hygiene programs in Italy. Increased national efforts to reach a higher level of tobacco treatment in dental hygiene education are critical for achieving a nationwide reduction in tobacco use. A major emphasis on this key educational objective by administrators, faculty, and government officials could increase the level of tobacco dependence education in Italian dental hygiene schools. Standardization of tobacco treatment guidelines needs to be established on the institutional curriculum/research level and with the Italian Ministry of Education, University, and Research. In addition, funding needs to be made available for the support of curricular development and faculty train- ing. These innovations would provide dental hygienists with adequate education and training needed to provide patients with evidence-based and effective tobacco treatment. Conclusion The effects of tobacco use and dependence can be deadly. The state of tobacco dependence education continues to be an important component of health promotion and disease prevention in dental and dental hygiene education. The results of our study indicated that Italian dental hygiene students are not currently receiving adequate instruction in tobacco treatment nor are they being adequately assessed in a clinical setting. The creation of a national tobacco dependence curriculum focused on multilevel interventions should hold tremendous potential in bringing evidence-based tobacco treatment into the dental setting. Acknowledgments This work was carried out despite the drastic reduction of public funding for universities and research by the Italian government (see the article Cut-Throat Savings in the October 2008 issue of Nature). REFERENCES 1. World Health Organization. WHO report on the global tobacco epidemic, 2011: warning about the dangers of tobacco. Geneva: World Health Organization, U.S. Department of Health and Human Services. How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease. Rockville, MD: Public Health Service, Office of Surgeon General, Warnakulasuriya S, Dietrich T, Bornstein MM, et al. Oral health risks of tobacco use and effects of cessation. Int Dent J 2010;60: Danaei G, Vander Hoorn S, Lopez AD, Murray CJ, Ezzati M. Causes of cancer in the world: comparative risk assessment on nine behavioral and environmental risk factors. Lancet 2005;366: Chambrone L, Chambrone D, Pustiglioni FE, Chambrone LA, Lima LA. The influence of tobacco smoking on the outcomes achieved by root-coverage procedures: a systematic review. J Am Dent Assoc 2009;140: Johnson GK, Guthmiller JM. The impact of cigarette smoking on periodontal disease and treatment. Periodontol ;44: World Health Organization. Framework convention on tobacco control. Geneva: WHO Document Production Services, Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Clinical practice guideline. August 2013 Journal of Dental Education 1077

7 Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Edwards D, Freeman T, Roche AM. Dentists and dental hygienists role in smoking cessation: an examination and comparison of current practice and barriers to service provision. Health Promot J Austr 2006;17: Vogt F, Hall S, Marteau TM. General practitioners and family physicians negative beliefs and attitudes towards discussing smoking cessation with patients: a systematic review. Addiction 2005;100: Zanis DA, Derr D, Hollm R, Ibrahim J. Variability of health care practitioner intervention among 18- to 24-yearold tobacco users. J Adolesc Health 2008;42: Clareboets S, Sivarajasingam V, Chestnutt IG. Smoking cessation advice: knowledge, attitude, and practice among clinical dental students. Br Dent J 2010;208: McCartan BE, Shanley DB. Policies and practices of European dental schools in relation to smoking: a ten-year follow-up. Br Dent J 2005;198: Davis JM, Koerber A. Assessment of tobacco dependence curricula in U.S. dental hygiene programs. J Dent Educ 2010;74: Pizzo G, Licata ME, Piscopo MR, Coniglio MA, Pignato S, Davis JM. Attitudes of Italian dental and dental hygiene students towards tobacco use cessation. Eur J Dent Educ 2010;14: Ajzen I. The theory of planned behavior. Org Behav Hum Decis Process 1991;50: Stockdale MS, Davis JM, Cropper M. Factors affecting adoption of tobacco education in dental hygiene programs. J Cancer Educ 2006;21: Davis JM, Ramseier CA, Mattheos N, et al. Education of tobacco use prevention and cessation for dental professionals: a paradigm shift. Int Dent J 2010;60: Davis JM. Tobacco cessation. In: Harris NO, Garcia- Godoy F, Nielsen Nathe C, eds. Primary preventive dentistry. Upper Saddle River, NJ: Pearson Education, 2009: Ramseier CA, Warnakulasuriya S, Needleman IG, et al. Consensus report: 2 nd European workshop on tobacco use prevention and cessation for oral health professionals. Int Dent J 2010;60: Roche AM, Eccleston P, Sanson-Fisher R. Teaching smoking cessation skills to senior medical students: a blockrandomized controlled trial of four different approaches. Prev Med 1996;25: O Donnell JA, Hamilton MK, Markovic N, Close J. Overcoming barriers to tobacco cessation counselling in dental students. Oral Health Prev Dent 2010;8: Raupach T, Shahab L, Baetzing S. Medical students lack basic knowledge about smoking: findings from two European medical schools. Nicotine Tob Res 2009;11: Kelly CW, Davis JM, DiCocco M. Assessing the current status of tobacco dependence curricula in U.S. physician assistant programs. J Physician Assist Educ 2011;22: McCartan B, McCreary C, Healy C. Attitudes of Irish dental, dental hygiene, and dental nursing students and newly qualified practitioners to tobacco use cessation: a national survey. Eur J Dent Educ 2008;12: Vanobbergen J, Nuytens P, van Herk M, De Visschere L. Dental students attitude towards anti-smoking programmes: a study in Flanders, Belgium. Eur J Dent Educ 2007;11: Kusma B, Quarcoo D, Vitzthum K, et al. Berlin medical students smoking habits, knowledge about smoking, and attitudes toward smoking cessation counselling. J Occup Med Toxicol 2010;5: Journal of Dental Education Volume 77, Number 8