At first they could not abide it, and now

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1 Nationwide Survey of Fifth-Year Dental Students Perceptions About Tobacco Prevention, Control, and Curriculum in India Aswini Y. Balappanavar, B.D.S., M.D.S.; Varun Sardana, B.D.S., M.D.S.; Puneet Gupta, B.D.S., M.D.S. Abstract: The objective of this study was to assess the tobacco cessation knowledge, attitudes, practices, and perceived barriers of dental interns (students in their last year of the five-year dental curriculum) in India as well as to assess the adequacy of training in tobacco use cessation (TUC) counselling. This was a cross-sectional questionnaire study conducted with 1,521 interns at fiftyone dental colleges of India selected by multistage random sampling. The survey instrument was a fifty-nine-item, self-structured, and self-administered questionnaire. Fifteen questions were about knowledge and attitudes, with twenty-two about practices, fifteen about barriers, and seven about curriculum adequacy; demographic data were also collected. The response rate was 99.7 percent. The results showed that 38.8 percent had knowledge, 30.8 percent had positive attitudes, 19.2 percent practiced TUC, 43 percent experienced barriers, and 85.2 percent agreed on receiving extensive curriculum on tobacco cessation. Only 1 percent were aware of the 5As, the 5Rs protocol, and the motivational interviewing technique of TUC. These respondents knowledge, attitudes, and practices were below normative level, and they took a superficial approach to TUC. The perceived barriers were very high and included curriculum inadequacy. The results of this study help show there is an urgent need to revise the tobacco curriculum in dental schools in India to make students more confident to practice this aspect of dentistry independently. Dr. Balappanavar is Reader, Department of Public Health Dentistry, Jodhpur Dental College and General Hospital, Jodhpur National University, Jodhpur, Rajasthan, India; Dr. Sardana is Reader, Department of Pedodontics and Preventive Dentistry, Jodhpur Dental College and General Hospital, Jodhpur National University, Jodhpur, Rajasthan, India; and Dr. Gupta is Reader, Department of Public Health Dentistry, Government College of Dentistry, Indore, Madhya Pradesh, India. Direct correspondence and requests for reprints to Dr. Aswini Y. Balappanavar, R-5/94, New Raj Nagar, Ghaziabad , Uttar Pradesh, India; aswinicomm@gmail.com. Keywords: tobacco, tobacco counselling, tobacco use cessation, dental students, India Submitted for publication 6/27/12; accepted 9/10/12 At first they could not abide it, and now they cannot be without it. This is exactly what tobacco is. According to estimates by the World Bank, about 5 million people die prematurely every year in the world because of the use of tobacco, mostly cigarette smoking. 1 India is one of the biggest tobacco markets in the world, ranking third in total tobacco consumption behind the markets of China and the United States. 2 Domestic unmanufactured tobacco consumption in India has increased from 483,360 tonnes in to 488,130 tonnes in 2003, and the use of many types of tobacco and its variations have been documented across India, 3 as well as the resulting precancerous lesions and other health effects. 4 The relative risk of death due to tobacco use in cohort studies from rural India is 40 to 80 percent higher for any tobacco use; 50 to 60 percent higher for smoking; 90 percent higher for reverse smoking; 15 and 30 percent higher for tobacco chewing in men and women, respectively; and 40 percent higher for chewing and smoking combined. 5 Overall, smoking was reported in 1998 to cause about 700,000 deaths per year in India. 5 As oral health professionals, we are in a unique position to help our patients who are tobacco users. Multiple oral health problems such as periodontal disease (including poor treatment outcomes and dental implant failures), oral cancer, leukoplakia, stains, halitosis, and tooth loss are related to tobacco use. 5,6 Dentists often see smokers for routine preventive dental care when they are younger and healthier than primary care doctors whose patients are usually older and need management of medical problems. 6 The 2008 U.S. Public Health Service clinical practice guideline, Treating Tobacco Use and Dependence, recognizes dentists among those primary care clinicians most relevant to providing brief interventions for smokers. 7 India is one of the leading contributors of dentists in the world with 302 dental colleges and 23, Journal of Dental Education Volume 77, Number 10

2 B.D.S. students graduating every year. 8 Dental schools in India fall into one of three major categories. Of the 302 dental schools in India in 2009, thirtynine belong to Type A (government dental school as a part of a government university) and 263 to Types B (private dental school affiliated with a government university) and C (private dental school as part of a private university). The five-year dental curriculum in India is devoted to didactic lectures, laboratory, and clinical work. The fifth year focuses on the clinical preparation of students in their last year before going to private practice; these students are called interns or house surgeons. 8 The tobacco curriculum has not undergone any major revisions to meet the present needs. Internship is the period of experimenting, learning new skills, and gaining knowledge as well as attaining confidence to deal with patients independently. Educators have suggested that clinicians in practice are more likely to engage in behaviors they learned during their formal education than behaviors learned in less formal settings. 9 The incorporation of tobacco intervention content into the formal curriculum increases the likelihood that clinicians will practice tobacco intervention behavior and tobacco use counselling (TUC) in the most successful way. 9,10 Some research in health professions curricular studies has considered dentists and dental students 14 in India, but only one study in three colleges in a state in south India was reported of dental interns attitudes about TUC. 14 Since it appears that the formal professional education environment most strongly shapes future clinician behavior, obtaining dental interns perceptions during their formal education will provide valuable input for faculty and administrators who plan curricular content. Hence, our study was designed to assess the knowledge, attitudes, and practices of dental interns across India regarding TUC and also to explore the perceived barriers limiting their involvement in this area of practice. The other objectives were to assess the interns perceptions regarding the presence of tobacco content in their curricula, the adequacy of their preparation to implement tobacco use interventions, and gender differences and to provide recommendations based on the results. Methods This was a cross-sectional questionnaire study conducted with dental interns (in their fifth, clinical year of education) across India. Ethical consent for the study was obtained from the Ethical Committee of Jodhpur Dental College and General Hospital, Jodhpur National University. Informed consent was obtained from all participants. The study was conducted from September 2009 to April All the recognized dental colleges listed in the Dental Council of India (DCI) database in 2009 were considered for the survey. According to the DCI information on dental colleges for admission to the B.D.S. course during academic year , there were 302 dental colleges in India, and 172 of those were recognized dental colleges. A multistage random sampling was used to select colleges to meet our sample size of 1,530 interns obtained from the pilot study. Fifty-one dental colleges were found to be sufficient. India was broadly classified into four zones: North, South, East, and West regions (Figure 1). There were forty recognized dental colleges in the North, forty-three in the West, nine in the East, and eighty in the South. All the states were included in the study for maximum representation and to reduce bias. From each state, the recognized dental colleges were selected randomly (table of random numbers). Depending on the number of dental colleges in each state, the final number of colleges was determined (Figure 1). In total, sixteen postgraduate and thirtyfive undergraduate colleges were selected. Thirty interns of alternate roll numbers from each of the selected colleges were considered for the study. A pilot study was done with 630 students at twentyone dental colleges selected by multistage random sampling. Out of forty colleges each in the North and West zone, five of each were selected; ten colleges out of eighty were selected from the South; and one college out of nine was selected from the East zone. The study used a self-structured, self-administered questionnaire consisting of fifty-nine questions that had been pilot tested. The results obtained from the pilot questionnaires were not included in the data set. The researchers interviewed the pilot test respondents to elicit their understanding of the questions, and suitable revisions were incorporated to ensure content and face validity of the questionnaire. The survey assessed demographic data (age, gender, occupation, education, income, address, etc.), self tobacco use habits, type of practice, and socioeconomic status. 15 Aside from the demographic questions, the questionnaire consisted of fifty-four closed-ended, four open-ended, and one multiplechoice question. Of the fifty-nine questions, fifteen assessed self-perceived knowledge and attitudes, twenty-two assessed practices and opinions about October 2013 Journal of Dental Education 1385

3 Figure 1. Selection of dental colleges in India by multistage random sampling tobacco intervention with patients, fifteen asked about barriers, and seven assessed the respondents perceived adequacy of the curriculum for preparing them for TUC in practice. A five-point scale (limited, moderate, good, excellent, and don t know at all) was used for the self-assessed knowledge and curriculum questions; a five-point scale (never, sometimes, half of the time, usually, and always) was also used for questions on practices or interventions. The attitude- related questions were on two four-point scales (scale 1: not at all, not very, somewhat, and very much; scale 2: agree strongly, agree somewhat, disagree somewhat, and disagree strongly). The barriers were assessed as agree or disagree. Questionnaires were mailed with a letter of introduction, forms, and consent forms. In colleges where a public health dentist was running the functions of the Department of Public Health Dentistry, 1386 Journal of Dental Education Volume 77, Number 10

4 that individual was contacted. In the absence of a public health dentist, the college principal or a known faculty member in the college was contacted. Questionnaires were sent to the fifty-one identified dental colleges. One week later, recipients at all dental colleges were reminded by telephone calls to complete and return the forms, questionnaires, and consent forms. Nonresponding dental colleges received a personalized telephone call three weeks later seeking the completion and return of the questionnaires. Dental colleges asking for more copies of the survey were given extra copies with a reminder letter. The data were entered, tabulated, and analyzed in SPSS version 17. All items were analyzed in the total and by discipline, using frequency distributions. Pearson chi-square, ANOVA, t-test, Cronbach s alpha, and correlation tests were used. For convenience, the data were analyzed in a dichotomous form. The confidence level was set at 95 percent and significance at p<0.05. Results The overall response rate was 99.7 percent (n=1,526). Four questionnaires were not included in the analysis because of extensive missing data. Of the fifty-one total recognized dental colleges that participated, thirty-five (68.6 percent) were undergraduate colleges, and sixteen (31.4 percent) colleges also offered postgraduate programs. The subjects were in the age range of twentytwo to thirty-one years (mean 25±4.1). Out of 1,526 subjects, 68.4 percent (n=1,044) were female, and 31.6 percent (n=482) were male (Table 1). Overall, 1,166 (76.4 percent) subjects did not go for private practice and restricted themselves to college only. Also, 93.7 percent did not have any tobacco-related habits presently as well as in past. However, in a chi-square analysis, 6.3 percent of those who smoked had less knowledge (p<0.001), attitudes (p<0.001), and practices (p=0.861) and perceived more barriers (p<0.001) when compared to nonsmokers. Most subjects (83.2 percent) in our study belonged to the upper middle class. Self-Perceived Knowledge, Attitudes, and Opinions Only 38.8 percent of the total subjects had some knowledge of tobacco use prevention and control, and 30.8 percent had positive attitudes towards TUC. Only 19.2 percent practiced tobacco cessation in their clinics or colleges, and 43.0 percent perceived barriers of some or other form. When self-assessed knowledge, attitudes, practices, and barriers were compared, the difference was found to be statistically significant (p=0.0001). Most respondents agreed that it is their professional responsibility to help smokers and tobacco users quit: 92.0 percent and 94.5 percent, respectively. Table 1. Distribution of study variables Variable Percentage Age (years) % Gender Male 31.6% Female 68.4% Practice type College 76.4% College + private practice 23.6% Smoking/tobacco habits Past Yes 6.3% No 93.7% Present Yes 6.3% No 93.7% Socioeconomic status Upper class 9.8% Upper middle class 83.2% Lower middle class 6.6% Upper lower class 0.5% Type of college Undergraduate 68.6% Postgraduate 31.4% October 2013 Journal of Dental Education 1387

5 Compared with the female interns, the male interns thought they had more knowledge (p<0.001), their attitude was better (p=0.01), they perceived more barriers (p<0.001), and they practiced less TUC (p=1.02). Time spent in counseling showed some association with having more knowledge though it was nonsignificant (p=0.14 ); but there was a definite relation among better attitudes (p<0.01), better practice of TUC (p<0.01), and fewer barriers (p<0.01) (Table 2). Respondents with a low confidence (positive for zero or one question measuring confidence) score were more likely to agree that they did not have enough skills than those with high confidence scores (positive for three questions) (70 percent vs. 25 percent; chi-square=6.77, p=0.005). The interns of postgraduate colleges scored higher in knowledge, attitudes, and practice and lower in barriers when compared to their counterparts in undergraduate colleges (p<0.01). When the four zones were compared, interns in the South zone (29.8±5.7) were far better off in knowledge, attitudes, and practices with fewer barriers followed by the West zone (26.9±5.9) (Table 3). Interns in the upper socioeconomic class (2.74) had better knowledge followed by lower middle class (2.43), upper middle class (2.31), and upper lower class (2.29). The at- titudes seemed to be better with interns belonging to the upper middle class (4.45) followed by upper class (4.27), lower middle class (4.08), and upper lower class (3.86). However, the practices appeared to be more in the upper class (4.01) and lower middle class (4.00) when compared to the upper middle class (3.44) and upper lower class (3.14), though the relation was nonsignificant (F=1.765, p=0.152). The barriers were more in the upper class (6.86) when compared to upper middle class (5.79), lower middle class (5.56), and upper lower class (5.57), which was significant (F=5.424, p=0.01). The confidence bestowed by upper socioeconomic class was more when compared with others (F=11.033, p<0.001). The role of 5As of TUC in practice was very low and not used very much (Figure 2). Ninety-eight percent of the interns were not aware of the 5As and 5Rs protocols of TUC or what they stand for. Curriculum, Practice, and Barriers Eighty-five percent of the interns stated that their dental curriculum had inadequate course content about their role in helping tobacco-using patients to quit. Only 15 percent reported that their program adequately prepared them to help smokers and tobacco users to quit. About 99 percent agreed that their Table 2. Distribution and comparison of gender and time spent in counselling with that of knowledge, attitudes, practice, and barriers of TUC n Knowledge Attitudes Practice Barriers Gender Male ± ± ± ±2.9 Female 1, ± ± ± ±3.8 M vs. F p-value < <0.001 Time spent in counselling per < ± ± ± ±2.4 session (in minutes) ± ± ± ± ± ± ± ±3.5 p-value 0.14 <0.01 <0.01 <0.01 Table 3. Distribution and comparison of type of college with knowledge, attitudes, practice, and barriers of TUC n Knowledge Attitudes Practice Barriers Total College Undergraduate institution ± ± ± ± ±6.2 Postgraduate institution ± ± ± ± ±5.4 Undergraduate vs. postgraduate p-value 0.03 <0.01 < <0.01 Location North ± ± ± ± ±4.7 South ± ± ± ± ±5.7 West ± ± ± ± ±5.9 East 2 3.2± ± ± ± ±1.2 p-value 0.04 <0.01 <0.01 <0.01 < Journal of Dental Education Volume 77, Number 10

6 present curriculum dealt only with the theoretical aspect of tobacco and its ill effects. Only 1 percent had some idea of the 5As and 5Rs protocol as well as the motivational interviewing technique of TUC. In practice, 44 percent of the respondents said they asked their patients if they used tobacco (the first of the 5As), but their responses to their use of the other categories of the 5As were low (Figure 2). There was a comparable pattern for the 5Rs. More interns discussed the risks of smoking with their patients, but very few did so when it came to motivation and relevance (relevance to the patient 15 percent, risks of smoking 32.9 percent, rewards to quitting 12.2 percent, roadblocks to quitting 10.3 percent, repetition 8.2 percent). The main barriers that the interns faced in practicing tobacco cessation were lack of resources and referral centers (of which the subjects were not aware), followed by lack of training during the student or internship period (Figure 3). Almost 46 percent of the subjects blamed the educational staff for not teaching TUC theoretically or clinically. Forty-four percent said they were never taught cessation practices and had never heard of it. The main suggestion of these interns (80 percent) about what would make them confident in practice of TUC was to have a compulsory separate class in lectures as well as clinics. Sixty percent said continuing education programs should be conducted by incorporating the student community on this subject, and 95 percent said they should be provided with a list of referral centers. Seventy percent noted that a certificate course on TUC should be regularly conducted by concerned bodies and this certificate should be made compulsory for registration of dentists by the Dental Council of India. Finally, seventy-five percent of the interns agreed that active involvement of the faculty is necessary for educating students about TUC. Discussion Our study sought to assess the knowledge, attitudes, practices, curriculum adequacy, and barriers related to TUC among dental interns across India. Their knowledge (39 percent) and attitudes (31 percent) were far below the expectations. The interns practices related to TUC were also low (19 percent), and perceived barriers were high (43 percent). Other studies have used dental students (other than interns), dental hygienists, and practicing dentists as their study population, whereas we Figure 2. Percentage of respondents using each step of the 5As in clinical practice October 2013 Journal of Dental Education 1389

7 Figure 3. Percentage distribution of barriers to TUC reported by respondents targeted solely dental interns of India. Focus was placed on the students closest to graduation as they were most likely to have been exposed to tobacco curriculum content. Since these students will soon enter their chosen profession, they were also more likely to have developed a belief about their professional responsibilities. The knowledge of our participants was lower than that reported from other studies (among dental students of different years) in different countries (60-80 percent). The interns who smoked had more barriers and practiced less, which was consistent with other studies The barriers experienced by subjects in our study were more than those reported in other studies (25-30 percent) Our results were similar with the study report of Chowdhury et al. in Bangladesh. 25 Another Indian study with dental surgeons in three dental colleges in north Karnataka in south India showed contrasting results with respect to knowledge and practices. 14 This may be due to the situation of the college being Karnataka, which has the highest number of dental colleges in India and more vigorous postgraduate teaching. However, further comparisons could not be done because of differences in the populations. The protocols of 5As and 5Rs, 27,28 as well as motivational intervention technique and stages of change, 29 which have been proven effective in clinical settings for tobacco cessation, were assessed as practice questions in our study. Our results were low when compared to the Yip et al. study, which reported students providing counselling inconsistently, with 69 percent asking about smoking, 58 percent advising cessation, 24 percent offering support, and 22 percent providing follow-up on a routine basis. 10 Another Indian study also showed a higher response for the 5As (ask 93 percent, advise 94 percent, assess 53 percent, assist 8 to 23 percent, arrange 16.4 percent), but the results were inclusive regarding third- and fourth-year dental students and could not be compared with our study results. 14 None of the students in our study had knowledge of the stages of change model, and knowledge of motivational interviewing technique practices was low. The interns had never heard the words precontemplation, contemplation, planning, and maintenance. None of the other studies in India checked for these variables. Even with the number of dental colleges and postgraduate colleges we have in India, only 2.1 percent of the subjects in our study had attended some 1390 Journal of Dental Education Volume 77, Number 10

8 form of program, workshop, or seminar on tobacco use cessation. These interns also lacked confidence in advising smoking patients to quit, and fewer than half pointed out that they had been taught the necessary skills. The inconsistencies in providing dedicated tobacco-related training in dental curricula reflect a doubt within the dental profession about what is effective In our study the perceived barriers are as shown in Figure 3. This is in contrast to other studies on students and dentists who reported lack of time as the first barrier followed by lack of opportunity for more coursework. 10,20,22,33,34 Additionally, students who graduate without the confidence to provide TUC are less likely to educate their patients about tobacco use in private practice. 9,10,35,36 Studies of medical schools have concluded that comprehensive tobacco cessation education is inadequate in the United States and Europe, which is also observed in India. The DCI curriculum in India for the B.D.S. degree 40 includes lectures on epidemiology of oral cancer as a part of public health dentistry taught in the third or fourth year. Tobacco and its various forms, prevalence of tobacco use in India, harmful contents, and effects on oral and general health are covered in this part of the curriculum. Prevention of oral cancer or premalignant lesions and conditions is taught in terms of primary, secondary, and tertiary levels; however, the coverage is very superficial and theoretical. In clinics, even though students are taught to write levels of prevention, they are not taught to actually practice TUC or deal with tobacco-using patients. There is a lack of psychological and behavioral approach towards patients with a tobacco habit and it is not at all taught to students. In the third year, oral pathology covers precancerous lesions and conditions with oral cancer; in it, tobacco and its contents are dealt with, but much of the emphasis is on histopathological changes. Oral medicine in the third or fourth year deals with the topic of precancerous lesions, conditions, and oral cancer where the emphasis is again on tobacco, its content, effects on oral health, diagnosis, and treatment. Periodontics has a section on tobacco and its effect on periodontal tissues but no mention of cessation guidelines or role of dentists in TUC. Apart from these, no other departments are dealing with tobacco-related issues though they deal with patients daily. There is no mention of TUC education in the curriculum. The 5As, 5Rs, motivational interviewing techniques, and stages of change model about tobacco cessation are not mentioned in the curriculum. In contrast, U.S. dental hygiene curricula have percent of their tobacco curricula dedicated to tobacco-related oral diseases and general diseases, tobacco cessation strategies, and nicotine dependence and percent dedicated to tobacco prevention strategies, historical, social, and economic reasons associated with tobacco use and the tobacco industry and FDA-approved pharmocotherapies to assist with cessation and 5As and 5Rs. 41 Also, they have percent of tobacco curricula related to stages of change and motivational interviewing and percent of comprehensive tobacco cessation program setting at clinics and community-based TUC. Conclusion In India, we need a strong curriculum revision to incorporate TUC. Compulsory training on evidence-based principles in dental school as part of the curriculum and as part of continuing education has to be stressed. Online resources should be made easily available to dental students and faculty. Training initiatives regarding the use and prescription of drugs for cessation have to be taught in continuing education programs/workshops by dental institutions with the help of the pharmaceutical industry. There is evidence that tobacco education should be provided early and diffused throughout the professional sequence. The tobacco use prevention and control guidelines should be incorporated and tested in the dental curriculum as it has been proven to be effective in other countries. 37,41-43 Some of the innovations in tobacco education seen in other countries are the use of active learning methods and standardized patients, the use of competencies, and the involvement of expert faculty members as mentors. 43 Research should be needbased with tailored tobacco policies and strategies in India due to its diverse culture and sociodemographic differences. The mammoth question we face in India is how to involve dental faculty members in TUC activities. Emphasis on promotion, increasing awareness, highlighting the benefits of involvement in terms of patients satisfaction, providing access to high quality courses, and above all motivating the dental team to get involved in TUC through the model of 3Ts (tension, triggers, and training) 36 are some possible suggestions. Our study found a below normative level and superficial approach towards TUC among the dental interns of India. This suggests a broad lacunae in the curriculum as most of the answers for knowledge, at- October 2013 Journal of Dental Education 1391

9 titude, or practices were inadequate. A separate counseling center for TUC should be made compulsory in all the dental institutions of India with postings for faculty members and dental interns. Acknowledgments We thank all the individuals and colleges that participated in the study. Our sincere thanks to Dr. Vaibhav Tandon, PG student (former tutor, Teerthanker Mahaveer Dental College), Kotiwal Dental College, Moradabad, and the faculty members of the participating colleges for their assistance. REFERENCES 1. World Bank. Curbing the epidemic: governments and the economics of tobacco control. Washington, DC: World Bank, Indian Institute of Foreign Trade. Medium term plan for tobacco exports from India and strategies for the next five years. New Delhi: Indian Institute of Foreign Trade, Rani M, Bonu S, Jha P, et al. Tobacco use in India: Prevalence and predictors of smoking and chewing in a national cross-sectional household survey. 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