Tobacco use is described as the single most

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1 Perceptions of Dental Students in India About Smoking Cessation Counseling Prakash 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 from a health professional is an effective method of helping patients quit. The aim of this study was to evaluate the knowledge and attitudes of dental students in Karnataka, India, towards smoking cessation counseling. A questionnaire study was conducted among a convenience sample of 329 dental students comprised of III year and IV year students and interns in three dental colleges in Karnataka, India. Of the 329 students who completed the questionnaire, twenty-two (7 percent) were current smokers, and fifteen (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 for patients. While a majority (95 percent) planned to advise patients about tobacco use in their professional careers, significantly fewer (66 percent) indicated that such counseling would help patients to quit. This study of dental students and interns found that a majority intended to provide smoking cessation counseling in their professional career and agreed it is part of their professional role. Dr. Prakash is a Postgraduate Student, Department of Public Health Dentistry, Coorg Institute of Dental Sciences; Dr. Sequeira is Professor and Principal, Department of Public Health Dentistry, Coorg Institute of Dental Sciences; and Dr. Jithesh Jain is Professor and Head, Department of Public Health Dentistry, Coorg Institute of Dental Sciences. Direct correspondence and requests for reprints to Dr. Prakash Rajasundaram, Department of Public Health Dentistry, Coorg Institute of Dental Sciences, Virajpet , Karnataka, India; phone; kash3648@sify.com. 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 of morbidity and mortality globally, with the World Bank predicting over 450 million tobacco deaths in the next fifty years. 1 Tobacco-related mortality in India is among the highest 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 increasing among young tobacco users. 3 The National Family Health Survey for found that 32.7 percent of males and 1.4 percent of females are smokers in India. 4 Many studies have shown that counseling with a health professional is an effective method of helping smokers quit. A survey of smokers in the United States found that if given a choice, they would prefer to receive smoking cessation counseling from a health professional. 5 Cessation rates of 10 to 20 percent have been found after patients received professional advice and appropriate assistance from their physicians. 6 A recent survey in Hungary found that advice from health care professionals to quit ranked second in effectiveness after requests by the smoker s own family. 7 Cessation rates of up to 18 percent have been seen when dental professionals counseled their patients to quit. 8 The dental office is an ideal setting for tobacco cessation services (TCS) since preventive treatment services, oral screening, and patient education have always been a large part of the dental practice. More than 60 percent of adults and 83 percent of fifteento nineteen-year-olds see their dentist at least once a year. 9 Surveys of Americans and Canadians have found that 58 percent of smokers made regular appointments with their dentists. 10,11 These regular interactions provide dental teams with the opportunity to provide a range of TCS. However, compared to physicians and other health professionals, dentists are less likely to provide tobacco use cessation advice and counseling and feel inadequately prepared to provide tobacco cessation education to their patients. 12 The reasons for not providing it include time and reimbursement issues, poor education and lack of further postgraduate training, and poor coordination of dental and smoking cessation services. 13 Another area of research is the attitudes of dental students, the future dentists, towards tobacco control programs. In a survey of American dental students, those students who adhered best to the four-faceted 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 formal training December 2011 Journal of Dental Education 1603

2 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 of Australian dental students said they planned to advise patients about tobacco use, although their perception of the effectiveness of smoking cessation counseling seems to be low. 15 The same trend was observed in Europe where Greek students considered tobacco cessation counseling a duty for every dentist, although a large part (32 percent) believed it to be ineffective. On the other hand, these students were found to possess significant knowledge about the health effects of tobacco. 16 In 2002, Tobacco Cessation Clinics (TCCs) were set up in India to provide the first formal tobacco cessation intervention. Thirteen clinics were set up in oncology, cardiology, psychiatry, surgery, and NGO settings; coverage was later expanded to nineteen clinics. These were supported by the World Health Organization Country Office and the Ministry of Health and Family Welfare, Government of India. Tobacco cessation services in India are provided through various tools such as behavioral counseling, pharmacotherapy, and a combination therapy after assessing the degree of nicotine dependence of the tobacco user. 17 Smoking cessation counseling is not yet part of routine Indian dental or medical practice, and it is not incorporated into the medical or dental curricula. In India, there is a paucity of information regarding the attitudes of dental students towards smoking cessation counseling. This study was conducted to evaluate the knowledge and attitudes of one group of dental students towards smoking cessation counseling. Materials and Methods A descriptive, questionnaire study was designed to assess the knowledge, attitudes, and views about smoking cessation counseling among clinical dental students. The study population consisted of a convenience sample of III year and IV year students and interns from three dental colleges in Karnataka, India. Those in these groups who were present on the day of the survey were invited to participate. Out of a total of 341 subjects, 329 agreed to complete the survey and twelve declined, yielding a response rate of 96 percent. A pretested, structured survey consisting of twenty-two closed-ended questions was used. Its comprehensibility was tested in a pilot test with a convenience sample of twenty-four students who were not included in the final study. The first set of questions asked for demographic information, including age, gender, year of study, name of the institution where studying, smoking status, marital status, and smoking status of any other family members. The second set of questions was divided into six groups: policies and practices in one s institution; views about smoking cessation counseling; knowledge about smoking cessation counseling relevant to dentistry; strategies for smoking cessation counseling; smoking cessation counseling resources; and barriers to smoking cessation counseling The data were collected in August The surveys were administered during scheduled class times for the III year and IV year students and in clinical courses for the interns. Ethical approval was obtained from the Institutional Ethical Committee of Coorg Institute of Dental Sciences, and permission to conduct the study was obtained from the principals of the respective dental colleges. The students were informed about the study, and only those who consented to participate were included. The collected data were classified and tabulated in Microsoft Office Excel. SPSS for Windows, version 16 (2007), was used for statistical analysis. Responses to the questions were analyzed by calculating percentages based on the number who answered the questions. Chi-square test was used to determine any significant differences among the responses and the respondents demographic variables. A probability value of p<0.05 was set as statistically significant. Results The respondents ages ranged from twenty to twenty-six years (mean=21.86). Of the total population (n=329), 70.3 percent were female. III year and IV year students and interns constituted 34.9 percent, 30.5 percent, and 34.6 percent, respectively, of the total. There were fifteen (4.6 percent) ex-smokers and twenty-two (6.6 percent) current smokers; the remaining 292 (88.8 percent) were never smokers (Table 1). A majority of students were aware that smoking was prohibited in clinical facilities (n=323; 98.2 percent), nonclinical teaching areas (n=313; 95.1 percent), and public areas associated with clinical facilities (n=300; 91.2 percent). Among the total population, only 58.7 percent (n=193) indicated that smoking cessation information was displayed within their teaching institution. In total, 93 percent 1604 Journal of Dental Education Volume 75, Number 12

3 (n=306) said they have taken tobacco usage histories from all patients, and 97.2 percent (n=320) have been taught about the role of tobacco in the etiology of oral cancer (Table 2). Most of the respondents (n=310; 94.2 percent) answered that they gave antismoking advice to patients. About 96 percent of the females said they gave antismoking advice, which was higher than the males (90 percent). This item was significantly associated with respondents smoking status (Table 3) and gender (Figure 1) (p<0.05). However, fewer (n=156; 47.1 percent) indicated they were taught antismoking advice suitable for patients, which was significantly associated with respondents year of training (Figure 2) and smoking status (Table 3) (p<0.05). Only a small number of the respondents (n=51; 15.9 percent) indicated that, during the course of their training, they had helped a smoking patient to quit. Over 95 percent (n=313) said they plan to advise patients about tobacco use in their professional careers, but fewer indicated that such counseling would help patients to quit (n=218; 66.3 percent) (Table 4). This was significantly associated with respondents gender and smoking status (p<0.05). A majority of respondents answered correctly that all patients should be routinely asked about their tobacco use (n=308; 93.6 percent), that a smoking history is relevant for patients considered for implant placement (n=314; 95.4 percent), and that patients about to have oral surgery should be advised to abstain from smoking (n=320; 97.3 percent). When asked about strategies that will be useful for their smoking cessation counseling, a majority (n=173; 52.6 percent) answered that they will counsel smokers about the effects of smoking on their oral Table 1. Distribution of respondents in study with respect to age, gender, year of study, marital status, and smoking status Demographic Variables Number Percentage Age in years % % % % % % % Gender Male % Female % Year of study III Year % IV Year % Internship % Marital status Married % Unmarried % Smoking status Never smoker % Ex-smoker % Current smoker % health. Among other possible strategies, 22.8 percent thought nicotine replacement therapy would be useful, 16.4 percent follow-up visits to discuss smoking cessation, and 8.2 percent providing written information and self-help material. These findings were significantly associated with the year of training of the students (p<0.05) (Table 5). Table 2. Distribution of responses regarding policies and practices in the individual s institution Yes No Don t Know Policies and Practices n % n % n % Is smoking prohibited in nonclinical teaching facilities like lecture % 7 2.1% 9 2.7% halls, basic science labs, preclinical labs, and library? Is smoking prohibited in clinical facilities? % 3 0.9% 3 0.9% Is smoking prohibited in public areas like reception, waiting lobby, % % % and corridors associated with clinical facilities? Do you take tobacco usage histories from all patients? % % 3 0.9% Are you taught the role of tobacco in the etiology of oral cancer? % 8 2.4% 1 0.3% Is smoking cessation information such as posters or pamphlets % % % displayed in your institution? Note: Percentages may not total 100% because of rounding. December 2011 Journal of Dental Education 1605

4 Most of 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 useful resource. Other resources thought to be less useful were teaching audiotapes and videotapes (n=115; 35.0 percent), seminars with experts (n=38; 11.5 percent), and smoking cessation research literature Table 3. Responses regarding practices in the individual s institution according to their smoking status Smoking Status Current Smoker Ex-Smoker Never Smoker Total n (%) 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 for patients.** 13 (59.1%) 12 (80.0%) 131 (45.2%) 156 (47.1%) *Chi square=32.871, df=4, p<0.001 **Chi square=9.848, df=4, p= Figure 1. Respondents agreement that they give antismoking advice to smoking patients, by gender Figure 2. Respondents agreement that they were taught antismoking advice that was suitable for patients, by students year of training 1606 Journal of Dental Education Volume 75, Number 12

5 Table 4. Distribution of responses regarding actions and views about smoking cessation counseling Yes No Unsure n % n % n % In the course of your training, have you ever helped a patient to % % % quit smoking? Do you plan to advise patients about smoking cessation in your % 7 2.1% 9 2.7% professional career? Do you think smoking cessation counseling provided by dentists % % % would help patients to quit smoking? Note: Percentages may not total 100% because of rounding. Table 5. Distribution of responses regarding strategies that respondents think will be useful for smoking cessation counseling, according to year of study Year of Study III IV Interns Total n (%) n (%) n (%) n (%) Counsel smokers about the effects of smoking on 50 (43.5%) 71 (71.0%) 52 (45.6%) 173 (52.6%) their oral health. Provide smoking patients with written information 8 (7.0%) 10 (10.0%) 9 (7.9%) 27 (8.2%) and self-help material to help them to quit. Suggest nicotine replacement therapy for patients 36 (31.3%) 14 (14.0%) 25 (21.9%) 75 (22.8%) who wish to quit. Arrange follow-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, df=6, p<0.001 (n=31; 9.4 percent). These findings were significantly associated with year of training (p<0.05) (Table 6). Finally, the majority of the respondents (n=262; 79.6 percent) agreed that patient motivation was a barrier to students provision of smoking cessation counseling. More than half the students (n=185; 56.2 percent) agreed that smoking cessation counseling may alienate patients. About 72 percent of students agreed that not having sufficient skills is a barrier. This was significantly associated with year of training and smoking status (p<0.05) (Figure 3). Most of the respondents (n=223, 67.8 percent) agreed that smoking cessation counseling is ineffective unless the patient has a related health problem. Only 6.7 percent (n=22) agreed that smoking cessation was not part of dentists professional role, and 15.5 percent agreed that they do not have the time to provide smoking cessation counseling during clinical consultations. About 20 percent agreed that providing good dental care is enough, and 43.5 percent felt that their patients do not expect smoking cessation counseling from a dental student (Table 7). Discussion Dentists play a key role in tobacco use cessation counseling (TUCC) programs directed toward the community as a whole and toward the individual patient. Moreover, the training of dental students in TUCC counseling might lead to higher rates of TUCC intervention in subsequent professional practice. 18 Our study investigated the attitudes and views of clinical dental students from three dental colleges in Karnataka, India. The study sample consisted of 329 respondents, comprised of III year and IV year students and interns. The percentage of current smokers was 6.6 percent, which is less than percentages reported for many other countries, for example, Great Britain (7 percent), Australia (13 percent), Ireland December 2011 Journal of Dental Education 1607

6 Table 6. Distribution of responses regarding smoking cessation counseling resources that respondents think are useful, according to year of study Year III IV Interns Total n (%) 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, df=6, p<0.001 Figure 3. Respondents agreement that they lack skills to provide smoking cessation counseling at this stage of training, by number of respondents in each year of study (20 percent), Bangladesh (22 percent), and Norway (24 percent). 18 On October 2, 2008, Section 4 of India s Cigarette and Other Tobacco Products Act went into effect, prohibiting smoking in all public and work places. This act also stipulated that there should be a visible board at every entrance and every floor of a public place that reads, No Smoking Area. Smoking Is an Offence. As per this legislation, most of the dental colleges in India adopted official policies banning smoking in buildings, clinics, and indoor public and common areas, although it has been reported that less than 10 percent enforce it. 19 This may be the reason only 58.7 percent of the students in our study reported that tobacco cessation information was displayed within their institution. Although 94.2 percent of our respondents said they give antismoking advice to smoking patients, only 47.1 percent said they had been taught antismoking advice suitable for patients; this level is similar to that reported in a study of Australian dental students. 15 The higher rate of advice despite the low levels of instruction is likely attributable to the emphasis placed on the hazardous effects of smoking on oral health in the dental curriculum. These findings underscore the importance of providing training that will encourage dental students to provide more comprehensive smoking cessation services Journal of Dental Education Volume 75, Number 12

7 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 % % Patients do not expect smoking cessation counseling from a dental student % % Smoking cessation counseling is ineffective unless the patient has a related % % health problem. I do not have sufficient skills to provide smoking cessation counseling at this % % stage of my training. I do not have the time to provide smoking cessation counseling during clinical % % consultations. I do not consider smoking counseling part of the dentist s professional role % % I am concerned that the antismoking message may alienate patients who smoke % % Providing good dental care is enough % % Even though 95.2 percent of our respondents planned to advise their patients about smoking cessation in their professional career, only 66.3 percent thought that such counseling would help patients to quit smoking. This rather low perception of effectiveness is consistent with other findings reported in the literature. 15,16,20 These responses suggest that many students remain skeptical about the extent to which tobacco cessation counseling is effective in helping patients to quit. Much remains to be done in dental education to promote awareness of the scientific evidence on both the efficacy and cost-effectiveness of tobacco prevention, including the value of 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 four-pronged cessation approach for dental providers, incorporating Asking patients about tobacco use, Advising them to stop, Assisting them in quitting, and Arranging follow-up. In our study, 93 percent of the respondents took tobacco usage history from all patients (Asking) and 94.2 percent gave antismoking advice (Advising). Although 52.6 percent responded that counseling smokers about the effects of smoking on their oral health is a useful strategy, only 22.8 percent said they suggested nicotine replacement therapy and 8.2 percent written information and self-help material (Assisting). Only 16.4 percent suggested follow-up visits as a useful strategy (Arranging). These findings were similar to a study done in United States. 14 A majority of respondents (93 percent) in our study agreed that smoking cessation counseling is part of a dentist s professional role, which has been reported in other studies ,18 With respect to barriers to smoking cessation counseling, almost 72 percent of our respondents agreed that not having sufficient skills is a barrier for their providing counseling. This lack of skills in turn is perceived as a barrier to incorporating tobacco intervention into clinical practice. In fact, a number of studies conducted amongst health care professionals have found that clinicians who receive formal training in cessation counseling are more likely to provide tobacco intervention for their patients. 18 This study suggests the need to help dental students develop professional competence in smoking cessation by encouraging the development of a prevention mindset, in which smoking counseling is included with other oral disease prevention practices such as brushing and flossing. More emphasis should be placed on conveying information regarding the clinician s potential efficacy in tobacco cessation efforts by focusing on the doubling and tripling of long-term quit rates attributable to clinician efforts compared to self-help methods. This evidence-based teaching should help dispel the undue pessimism with which students tend to view their potential for success. 14 A comprehensive tobacco education curriculum could provide knowledge and clinical experience that would help students expand their concept of a dentist to that of 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 feel more comfortable including tobacco prevention and cessation as a normal part of patient care. December 2011 Journal of Dental Education 1609

8 The design of this study had some limitations that should be considered when interpreting the results. The data were collected by self-report, which could be subject to the respondents recall bias and desire to present their clinical practices in a favorable light. Also, these findings may not be generalizable due to the sample size and sampling procedure. As there have been very few studies of students knowledge and attitudes regarding smoking cessation counseling among Indian students, there is a need for further research to confirm our findings. Conclusion This study found that a majority of these students and interns in three dental schools in India intended to provide smoking cessation counseling in their professional career and saw it as part of their professional role as dentists. However, it also found that lack of smoking cessation training and inadequate knowledge of smoking cessation counseling are barriers to counseling practices. Dental curricula in India include didactic instruction on the oral health impact of tobacco use, but practical training in clinical intervention like cessation counseling is not part of the curriculum. The results of this study indicate that tobacco cessation counseling may be practiced more widely if dental students were given additional training during their undergraduate education. REFERENCES 1. Jha P, Chaloupka FJ. Curbing the epidemic: governments and the economics of tobacco control. Washington, DC: The World Bank, 1999: Jha P, Jacob B, Gajalakshmi V, Gupta PC, Dhingra N, Kumar R, et al. A nationally representative case-control study of smoking and death in India. N Engl J Med 2008; 358: Gajalakshmi V, Peto R, Kanaka TS, Jha P. Smoking and mortality from tuberculosis and other diseases in India: retrospective study of 43,000 adult male deaths and 35,000 controls. Lancet 2003;362: National Family Health Survey 3, At: www. whoindia.org/linkfiles/tobacco_free_lnitiative_nfhs3. pdf. Accessed: January 9, Owen N, Davies MJ. Smokers preferences for assistance with cessation. Prev Med 1990;19: Glynn TJ. Relative effectiveness of physician-initiated smoking cessation programs. Cancer Bull 1988;40: Nagy K, Barabas K, Nari T. Attitudes of Hungarian health care professional students to tobacco and alcohol. Eur J Dent Educ 2004;4: Campbell HS, Sletten M, Petty TL. Patient perceptions of tobacco cessation services in dental offices. J Am Dent Assoc 1999;130(2): Centers for Disease Control and Prevention. Cigarette smoking among adults: United States, MMWR Morb Mortal Wkly Rep 1996;45(27): Tomar SL, Husten CG, Manley MW. Do dentists and physicians advise tobacco users to quit? J Am Dent Assoc 1996; 127: Locker D. Smoking and oral health in older adults. Can J Public Health 1992;83: Cannick GF, Horowitz AM, Reed SG, Drury TF, Day TA. Opinions of South Carolina dental students toward tobacco use interventions. J Public Health Dent 2006;66(1): 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(3): Yip JK, Hay JL, Ostroff JS, Stewart RK, Cruz GD. Dental students attitudes toward smoking cessation guidelines. J Dent Educ 2000;64(9): Rikard-Bell G, Groenlund C, Ward J. Australian dental students views about smoking cessation counseling and their skills as counselors. J Public Health Dent 2003;63: Polychonopoulou A, Gatou T, Athanassouli T. Greek dental students attitudes toward tobacco control programmes. Int Dent J 2004;54: Pratima M, Sadichcha S. Tobacco cessation services in India: recent developments and the need for expansion. Indian J Cancer 2010;47:S69 S Pizzo G, Licata ME, Piscopo MR, Coniglio MA, Pignato S, Davis JM. Attitudes of Italian dental and dental hygiene students toward tobacco-use cessation. Eur J Dent Educ 2010;14(1): Shah M. Health professionals in tobacco control: evidence from Global Health Professional Survey (GHPS) of dental students in India. GHPS Fact Sheet. Geneva: World Health Organization, Victoroff KZ, Dankulich-Huryn T, Haque S. Attitudes of incoming dental students toward tobacco cessation promotion in the dental setting. J Dent Educ 2004;68(5): Journal of Dental Education Volume 75, Number 12