Attitudes, Practices and Perceived Barriers in Smoking Cessation among Dentists of Udaipur City, Rajasthan, India.

BACKGROUND: Tobacco is one of the most important causes of morbidity and mortality. Tobacco toll in India has one-fifth of all worldwide death attributed to tobacco. There are 700000 deaths per year due to smoking and 800000-900000 per year to all forms of tobacco use of exposure in India. The role of dentist in supporting their patients to quit smoking has been recognized. The present study was conducted to know the attitudes, practices and barriers in tobacco cessation among dentists of Udaipur city (Rajasthan, India).
METHODS: A pretested, close-ended, self-administered, coded questionnaire was distributed among all the 262 dental health practitioners and the teaching staff. Out of 262 questionnaires distributed among the dentist, 151 dentists filled out and returned the questionnaire.
FINDINGS: The majority of the dentists (98.7%) agreed that it was their responsibility to provide smoking cessation counseling. 54.3% of dentists agreed that such discussions were too time consuming. 37.1% thought they lacked knowledge regarding this subject. 35.8% feared to an extent about patient leaving their clinic if counseled much.
CONCLUSION: In general, the dentists had a favorable attitude in tobacco cessation counseling for the patients; however, the lack of time and knowledge and to an extent, a fear that the patients would leave their clinic, was the main identified barriers.

Introduction

Tobacco is one of the most important causes of morbidity and mortality. Tobacco toll in India has one-fifth of all worldwide death attributed to tobacco. There are 700000 deaths per year due to smoking and 800000-900000 per year to all forms of tobacco use of exposure in India.1

In addition, tobacco use is also a primary cause of many oral diseases and condition, ranging from mild to life-threatening, such as stained teeth and restoration, taste derangements, halitosis, periodontal diseases, poor wound healing, oral precancerous lesions and oral cancer.2,3

No single healthcare profession can access all smokers; therefore, combined efforts from all health care workers are required in smoking cessation and prevention. The role of dentist in supporting their patients to withdraw smoking has been recognized.4,5

The effectiveness of smoking cessation services provided by dental professionals is well established. Many studies have concluded that the dental office is an appropriate and effective location for the message about stopping tobacco use. The practice of offices that offer tobacco use cessation services is consistent with the current evidence and practices guidelines.6,7

Dental patients who smoke need access to local services to help them stop smoking. A dentist who recognizes a patient to be smoker has a duty to inform the patient of the options available to them. Then, they can refer their patients who wish to stop smoking into smoking cessation services. Not all smokers are ready to quit smoking. Some have not considered quitting. Others may consider stopping but not sure how to take the next step. By enquiring and providing advice, members of the dental team can help patients from pre-contemplation through contemplation towards action.8,9

The 5 A’s model consist of:7

Asking about smoking and desire to stop

Advising the value of quitting

Assessing the motivation to quit

Assisting the patient to stop through access to appropriate support; and

Arranging follow-up support

Barriers that preclude dentist from incorporating tobacco cessation into practice include doubting about knowledge and skills in assisting patients to quit smoking, lack of confidence in their own ability to help their patients to quit, doubting about their effectiveness to give quitting advice, anticipated negative reaction from patients, uncertainty about their role in smoking cessation, lack of educational materials, lack of time and lack of remuneration.2,10-14 The present study was conducted to know the attitudes, practices and barriers in tobacco cessation among dentists of Udaipur city, Rajasthan, India.

Methods

The study population consisted of the following dental hospitals with dental wing and private dental clinics in Udaipur city, Rajasthan, India

Darshan Dental College and Hospital, Loyara, Udaipur

Pacific Dental College and Hospital, Debari, Udaipur

Private dental clinics in Udaipur city.

Inclusive criteria:

All the dental professionals with the B.D.S. designation or higher, working in various schools of dentistry and private dental clinics present at the time of study.

Exclusive criteria:

The dentist who were absent on the day of examination

The dentist who did not give consent and did not respond

The dentist who did not returned the questionnaire

The questionnaire was pre-tested on the dentist not included in the main study and appropriate modifications were made. The performa was tested for reproducibility by test-retest. Reliability of the questionnaire was assessed by using test-retest and the values of measured were kappa = 0.84, weighted kappa = 0.81. Internal consistency of the questionnaire was assessed by applying Cronbach’s alpha = 0.76.

A pretested, close-ended, self-administered, coded questionnaire was distributed among all the 262 dental health practitioners and the teaching staff. Out of 262 questionnaires distributed among the dentist, 151 dentists completely filled out and returned the questionnaire. The study was conducted during the August to October 2012.

The survey questionnaires consisted of two parts:

- The first part consisted of demographic information

- The second part consisted of question pertaining i.e.

Attitudes (6 questionnaires)

Practices (15 questionnaires)

Barrier (5 questionnaires)

Five-point Likert scale (not at all/to some extent/considerable extent/a little bit/great extent) was used to assess attitudinal and practice variables. Three-point Likert scale (totally agree/tend to agree/disagree) was used to assess the barrier variable.

Results

Table 1 shows the socio-demographic profile of the respondents.

Table 1

Demographic characteristics of the participated dentists

Variable	Total = 151
	Number	Percentage
Sex
Male	84	55.7
Female	67	44.3
Age Group (years)
20-30	77	51.0
31-40	59	39.1
41 or above	15	9.9
Qualification
BDS	69	45.7
MDS	82	54.3
Practice type
Academics	107	70.9
Private	44	29.1

BDS: Bachelor of dental surgery; MDS: Master of dental surgery

Table 2 describes the attitudes of dentists towards smoking cessation counseling. The majority of the dentists (98.7%) agreed that it was their responsibility to provide smoking cessation counseling. Most of them (94.7%) reported that they were at least somewhat confident of providing such counseling. Dentists were divided into their views regarding the adequate opportunities available to them for their training in smoking cessation and prevention counseling.

Table 2

Attitudes towards tobacco smoking cessation

Question	Not at all	A little bit	To some extent	Considerable extent	Greater extent
	Number (%)
How much is your responsibility as a dentist in smoking cessation counseling?	2 (1.3)	4 (2.7)	11 (7.3)	78 (51.6)	56 (37.1)
How effective do you think smoking cessation counseling provided by dentist?	2 (1.3)	20 (13.2)	43 (28.5)	63 (41.7)	23 (15.2)
How confident you are in your ability to effectively offer smoking cessation counseling?	2 (1.3)	6 (4.0)	52 (34.4)	73 (48.3)	18 (12.0)
Do you think patients expect smoking cessation advice from dentists?	2 (1.3)	22 (14.6)	78 (51.6)	38 (25.2)	11 (7.3)
How optimistic you are in patient’s ability to change their smoking habits?	2 (1.3)	21 (14.0)	65 (43.0)	52 (34.4)	11 (7.3)
Are there adequate opportunities available to you for training in smoking cessation and prevention counseling?	19 (12.6)	45 (29.8)	50 (33.1)	31 (20.5)	6 (4.0)

Table 3 shows the involvement of the dentists in smoking cessation activity. All the dentists reported to be providing at least some level of smoking cessation counseling to their patients. 45% of the dentists did not provide smoking cessation pamphlets but most of them (81.5%) had posters pertaining to smoking and oral health in their waiting room.

Table 3

Practices in tobacco smoking cessation

Question	Not at all	A little bit	To some extent	Considerable extent	Greater extent
	Number (%)
Do you enquire about your patient’s smoking status?	2 (1.3)	6 (4.0)	42 (27.8)	35 (23.2)	66 (43.7)
Do you offer smoking cessation counseling to your patients?	0 (0.0)	13 (8.6)	53 (35.1)	58 (38.4)	27 (17.9)
Do you provide advice to motivate patient to quit smoking?	0 (0.0)	16 (10.6)	45 (29.8)	69 (45.7)	21 (13.9)
Do you explain patient about the impact of smoking tobacco on general health?	2 (1.3)	0 (0.0)	35 (23.2)	63 (41.7)	51 (33.8)
Do you explain patients about impact of tobacco smoking on oral health?	2 (1.3)	7 (4.6)	38 (25.2)	56 (37.1)	48 (31.8)
Do you inform patients about the benefits of quitting smoking?	5 (3.3)	8 (5.3)	50 (33.1)	59 (39.1)	29 (19.2)
Do you provide smoking cessation pamphlets in waiting room so patients can help themselves?	68 (45.0)	23 (15.2)	28 (18.5)	28 (18.5)	4 (2.7)
Do you provide posters on smoking and health in waiting room?	28 (18.5)	15 (9.9)	56 (37.1)	50 (33.1)	2 (1.3)
Do you assist patient who smoke to give up?	4 (2.7)	28 (18.5)	65 (43.0)	50 (33.1)	4 (2.7)
Do you refer patients to appropriate services to help them stop smoking?	19 (12.6)	15 (9.9)	65 (43.0)	31 (20.5)	21 (13.9)
Do you involve dental team in helping patients with smoking issues?	16 (10.6)	21 (13.9)	69 (45.7)	31 (20.5)	14 (9.3)
Do you discuss Nicotine Replacement Therapy with patients?	6 (4.0)	19 (12.6)	51 (33.8)	70 (46.3)	5 (3.3)
Do you keep record of patient smoking status?	30 (19.9)	28 (18.5)	66 (43.7)	21 (13.9)	6 (4.0)
Do you follow up with the patient and their progress in giving up smoking?	15 (9.9)	27 (17.9)	48 (31.8)	56 (37.1)	5 (3.3)
Do you recommend the use of approved pharmacotherapy accept in special circumstances?	15 (9.9)	18 (11.9)	78 (51.7)	34 (22.5)	6 (4.0)

Table 4 reveals the barriers to dentist to discuss tobacco smoking with the patients and to counsel them for the same. 54.3% of the dentists agreed that such discussions were too time consuming. 37.1% thought they lacked knowledge regarding this subject. 35.8% feared to an extent about patient leaving their clinic if counseled much. Comfort did not prove a barrier as most of them (96.7%) had no difficulty in asking people about their tobacco use.

Table 4

Barriers in smoking cessation activity

Question	Totally agree	Tend to agree	Disagree
	Number (%)
The discussions are too time consuming	17 (11.3)	65 (43.0)	69 (45.7)
You lack knowledge on the subject	6 (4.0)	50 (33.1)	95 (62.9)
You are convinced that smoking is a major health issue	109 (72.2)	40 (26.5)	2 (1.3)
You are comfortable asking people about their tobacco use	91 (60.3)	55 (36.4)	5 (3.3)
You fear that patients may leave practice if counseled to give up smoking	2 (1.3)	52 (34.5)	97 (64.2)

Discussion

The dental profession can play a major role in smoking cessation and prevention.15 The attitude of general dentists in taking responsibility for smoking cessation in the present study was generally encouraging. The results were similar to several other studies previously carried out in different parts of the world2,4,12,13,16 where dentists generally believed that it was their responsibility to help their patients in smoking cessation or to prevent tobacco use in their patients.

A study done by Wyne et al.4 revealed confusion in the dental community regarding the extent of the dentist’s responsibility and role in tobacco intervention. Only a minority thought of tobacco intervention as their responsibility to a “great extent”. Several other studies in other countries have also found similar results and reported dentists were uncertain of their role in smoking cessation, and believed that it was not a part of dentistry.6,17-19 There is a good evidence to support the fact that dentists should provide smoking cessation and prevention counseling.4,20

Along with the encouraging attitude, dentist’s involvement in smoking cessation was also quite good, which was in contrast to some other studies. The study done by Ibrahim and Norkhafizah2 suggested that although most of the dentist had an encouraging attitude in taking responsibility for smoking cessation, their involvement in smoking cessation counseling was limited. The result showed that in general the dentists were quite confident in providing smoking cessation counseling to their patients. On other side the results of similar study done by Wyne et al.4 showed an overall feeling of doubt among general dentists about the effectiveness of their smoking cessation advice and lack of confidence.

Most of the dentists thought that their patients expect them more or a bit of tobacco cessation advice from them. A study done by Ibrahim and Norkhafizah2 showed the differences in opinion among dentists in Kelantan on patients’ expectation of smoking cessation counseling, and quite a number of them (23.0%) felt that patients did not expect smoking cessation advice from their dentists at all. Almost twice as much of dentists in Federal Territory of Kuala Lumpur and Selangor (40.3%) thought the same as well.2,21 Sixty-two percent of dentists in Alberta, Canada also believed that patients did not expect counseling from them.2,22 The present study supports the study done in New South Wales, Australia by Rikard-Bell et al.23 which demonstrated that most patients expected dentists to take interest in their smoking status and to discuss it with them.

Dentists were divided into their views regarding the opportune ties available to them for training in smoking cessation and prevention counseling. Only 24.5% of them believed that enough opportunities were available to get them to train for smoking cessation counseling activity. Similar results have been found by several other researchers in other countries.4,8,12,24-27 However, in general the dentists had an overall favorable attitude towards the smoking cessation counseling.

Many dentists enquired about the tobacco use of their patients and motivated them to quit their habits. Most of them also explained about the impact of the tobacco on the oral and general health so that increase in the knowledge to the patient will per se help them in quitting the tobacco use. Several authors have reported providing preventive advices to patients about smoking, especially information about the impact of smoking on oral hygiene is considered appropriate by most dentists.4,8,14,18 However, 45.0% did not provide any type of reading materials and 18.5% did not have any posters in the waiting room of their clinics which would not encourage patient to quit habits. A small declination was also seen in their matter of keeping records of the patient’s smoking status and their follow-up.

Along with the encouraging attitudes of the dentists, there were some barriers identified to offer the smoking cessation counseling to the patients. Mainly, lack of time, lack of knowledge and fear of patients leaving the clinic were the key identified barriers. Lack of time was a major obstacle for those attempting their implementation. 54.3% of the dentists revealed lack of time as a major barrier in their implementation of the smoking cessation counseling. The finding is disturbing as it is widely accepted among dental professionals that tobacco use has a direct impact on oral cavity, including the link between tobacco use and oral cancer, oral lesions and periodontal disease and the association with an increased incidence of dental caries. Many of the studies have found lack of time as a major barrier for the dentists unable to implement them into the tobacco cessation activity.2,10-13,21

Lack of knowledge proved to be another barrier for the dentists. A study conducted among the Kelantan dentists (Malaysia) stated that the lack of confidence could be attributed to inadequate knowledge among the dentists in smoking intervention.2 37.1% of the dentists agreed to some degree that they lacked knowledge on the subject. The findings of the study were in accordance with studies which identified insufficient knowledge as a major barrier that discouraged dentists from helping their patients to quit.2,13,14,21,28

Fear of patient leaving the clinic was detected as another obstacle in seeking smoking cessation advice to the patient. 35.8% of the dentist feared that the patient would leave the ongoing treatment or before treatment if counseled much for tobacco withdrawal. A similar study done by Ibrahim and Norkhafizah2 showed that 52.4% of the dentists feared that patient may leave the clinical set if counseled to give up smoking.

The hazardous effects of smoking on general and oral health are well known.4 There has been rising trend of smoking and use of tobacco in the adults, youngsters as well as school children. Dentist is one of the role models for children and adolescents. So, children and adolescents are more likely to receive efforts of the dental community positively.4 The inclusion of smoking cessation training in the dental curriculum also would become paramount if smoking cessation behavior in dental practice is to be improved.29 Curriculum in schools of dentistry needs to incorporate not just didactic instructions on the oral health impact of tobacco use, but also clinical training in smoking cessation activities so that the next generation of dentists would graduate with competency in assessing and treating tobacco use.18 The U.S. Department of Health and Human Services, in 2000 guideline on Treating Tobacco Use and Dependence, recommended a counseling protocol known as the “5A’s” to identify smokers who want to quit and how best to support them in their attempt.7 The “5A’s” protocol which consists of; asking about the smoking status, advising the benefits of quitting, assessing the motivation to quit, assisting in the quit attempt, and arranging for supportive follow up, was developed based on comprehensive review of up to 6000 articles on tobacco addiction published from 1975 to 1999. The protocol was designed to brief such that minimal counseling time is required, which was estimated to be only 3 minutes or less of direct clinician time.2

Studies have shown that dentists trained in smoking cessation counseling were able to contribute to smoking cessation programs in the community with good success rates, comparable to the rates reported in general medical practice settings.30-32

Information obtained through the self-administered questionnaire has to be interpreted with caution due to bias created through favorable responses. Most of the questions were of a sensitive nature for a healthcare professional, so possibility of a bias created by favorable responses cannot be ruled out. It is possible that dentists who agreed to participate and returned the questionnaire were more interested in the issue as compared to those who did not participate, resulting in possible overestimation of positive responses. Nevertheless, it is hoped that the study has provided useful information about the approach of the dentists towards the smoking cessation counseling. The information would also help to enhance the utilization of general dentists in smoking cessation and prevention and provide further training facilities to general dentists. To conclude, In general the dentists had a favorable attitude in smoking cessation counseling for the patients; however, lack of time and knowledge -and to an extent- a fear that the patients would leave their clinic were the main identified barriers.