Kadanakuppe ORIGINAL andARTICLE Aradhya
Survey of Patient Opinion on Tobacco Cessation Counseling and Services in a Dental Teaching Institution and Hospital Sushi Kadanakuppea/Shankar Aradhyab Purpose: The objective of this study was to assess the opinion of dental patients who use tobacco towards receiving tobacco cessation counseling and services in a dental college and hospital setting. Materials and Methods: A cross-sectional descriptive survey method using a structured questionnaire was used in this study. Participants were patients attending The Oxford Dental College, Hospital, and Research Center, Bengaluru, India. Each patient in the clinic waiting room was asked by the investigator to complete a 29-item self-administered questionnaire. Descriptive statistics and bivariate analysis using Fisher’s exact tests were used for statistical analysis of the data. Results: Ninety-six percent (n = 770) of tobacco users had previously attempted to quit tobacco and 95.7% were willing to quit. Sixteen percent (n = 132) of respondents reported that they currently used tobacco. About 83% of tobacco users agreed that the student dentist should ask patients whether or not they use tobacco, 79.4% agreed that the student dentist should advise tobacco users to quit, and 81.4% agreed that student dentists should offer information on quitting tobacco to patients who want to quit. Only 12.5% (n = 100) of the patients who use tobacco were aware of the community resources available to quit tobacco. Conclusion: This study shows that patients expect and felt comfortable with receiving tobacco cessation counseling services by oral health professionals in a dental hospital setting. Key words: oral health, patient opinion, student dentist, tobacco cessation Oral Health Prev Dent 2013;11:175-180 Submitted for publication: 31.03.10; accepted for publication: 21.06.12 doi: 10.3290/j.ohpd.a29733 This paper was presented at the XII National Conference of Indian Association of Public Health Dentistry (28–30 November 2007), Kanpur, Uttar Pradesh, India.
T
he hazards associated with cigarette smoking and smokeless tobacco use have been well documented. It is estimated that 30% of all cancers are caused by tobacco usage. The oral use of smokeless tobacco could cause cancer, as well as lead to nicotine addiction and dependence (Gordon et al, 2006). As oral health professionals, we are aware that tobacco use also plays a role in the etiology of a number of oral morbidities. Because tobacco use is such a detrimental health problem, it a
Senior Lecturer, Department of Public Health Dentistry, Vokkaligara Sangha Dental College and Hospital, Bangalore, India.
b
Professor and Head of Department, Department of Public Health Dentistry, The Oxford Dental College, Hospital and Research Center, Bangalore, India.
Correspondence: Dr. Sushi Kadanakuppe, #1256 ‘Nesara’, 4th Cross, Paduvana Road, Kuvempunagar, Mysore, Karnataka, India 570023. Tel: +91-95-3520-5012. Email:
[email protected],
[email protected]
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is imperative that those in the health professions do all they can to deter its use. Health-care settings, including dental hospital settings, have become increasingly attractive as an avenue for promoting tobacco cessation. Most studies focus on the oral health professional’s attitudes toward Tobacco Cessation Counseling (TCC), not the patients’ perspective (Fried and Rubinstein, 1989; Gerbert et al, 1989; Telivuo et al, 1991; Fried and Cohen, 1992; Logan et al, 1992; Jones et al, 1993; Mullins, 1994; Secker-Walker RH et al, 1994; Chestnutt and Binnie, 1995; Albert et al, 2002; Warnakulasuriya, 2002; Helgason et al, 2003; Needleman, 2006; Stacey et al, 2006; Vanobbergen et al, 2007). Hence, it is imperative to first know the receptiveness of patients who use tobacco towards tobacco cessation counseling in order to emphasise the fact that oral health professionals need to put a concerted organised effort to
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help reduce tobacco consumption. The objective of the study was to assess the opinion of dental patients who use tobacco towards receiving tobacco cessation counseling and services in a dental teaching institution and hospital setting.
MATERIALS AND METHODS A cross-sectional descriptive survey method using a structured questionnaire was used in this study. Participants were patients attending The Oxford Dental College, Hospital, and Research Center, Bengaluru, India, during a period of four weeks. Each patient in the clinic waiting room was asked by the investigator to complete a 29-item anonymous self-administered questionnaire. The survey questionnaire was prepared based on the survey items used in previous studies (Victoroff et al, 2006). The questionnaire was designed to determine patient’s opinion towards the provision of tobacco cessation counseling and services in the dental setting. In addition, questions were included to determine each respondent’s demographic characteristics, current and past tobacco use status, quitting history, readiness to quit (precontemplation, contemplation and preparation stage), awareness of community resources, whether or not the respondent has a family physician and if and when the family physician had discussed tobacco use with the respondent, whether they had seen a dentist or physician in the preceding year and whether that health care provider had advised them to stop smoking. The current and former tobacco users were considered as continual tobacco users for analysis. The patients participating in the study gave informed consent. Ethical clearance for the study was obtained from the Institutional Ethics Clearance committee. A pilot study was conducted to pretest the questionnaire. The Cronbach’s alpha reliability coefficient was 0.78. The SPSS statistical software (version 11.0) was used to analyze data. Descriptive statistics and bivariate analysis using Fisher’s exact test were used for statistical analysis of the data with significance level set at 5%.
RESULTS A total of 802 patients (age range = 18–75 years) who were tobacco users attending the Oxford Dental College and Hospital during a period of four
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weeks were included in the study. The response rate was 80.2%. Sixty-one percent (n = 489) of the respondents reported that they were continual (both current and former tobacco users) users of tobacco, 22.6% (n = 181) were former tobacco users and 16.5% (n = 132) were current tobacco users. Tobacco quitting willingness and attempts by the patients showed that 96.1% (n = 770) of tobacco users had previously attempted to quit tobacco and 95.7% were willing to quit. 8.9% (n = 64) were willing to quit tobacco within six months (Contemplation stage); 34.1% (n = 245) were willing to quit tobacco but not within six months (Pre-contemplation stage) and 57.1% (n = 410) of tobacco users were willing to quit within a one-month period (Preparation stage). Only 12.5% (n = 100) of the patients who use tobacco were aware of the community resources available to quit tobacco. Tobacco cessation promotion activities of a provider (Table 1) revealed that 23.3% (n = 183) of the tobacco users had a family physician but only 73.2% (n = 134) of family physicians had actually discussed the ill effects of tobacco on health and advised them to quit. Out of 81.5% (n = 654) who had visited a medical doctor in the past one year, only 25.1% (n = 164) of the medical doctors had discussed the ill effects of tobacco use and advised them to quit. 66.4% (n = 521) of tobacco users had visited this dental college and hospital in the past one-year and only 9.5% (n = 49) of student dentists had discussed the ill effects of tobacco and advised them to quit. Participant’s opinion regarding tobacco cessation promotion activities of the provider is depicted in Table 2. A majority of the patients (83.4%) agreed that student dentists should ask them about their tobacco use routinely. Student dentists were expected to inform patients on the ill effects of tobacco use on oral health as well as provide information on quitting tobacco, assistance and services by 81.3% and 81.4% of patients surveyed, respectively. Patients also expected the student dentists to advise patients who use tobacco to quit. It was an interesting and important observation that 93.8% of patients surveyed felt comfortable in receiving advice on quitting tobacco by the student dentist. Male patients (94.4%, n = 554; P = 0.002) and younger patients 21 to 30 years of age (42.2%, n = 248; P = 0.001) were more likely to believe that oral health professionals should provide tobacco cessation counseling than were female patients (5.6%) and older patients (49.5%) >31 years of age. Those who were married were found to be pos-
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Table 1 Tobacco cessation promotion activities of provider Provider and tobacco cessation promotion activities
Number
%
Table 2 Participants’ opinion regarding tobacco cessation promotion activities of provider in a dental college and hospital setting Participants’ opinion
Family physician
785
100.0
Yes
183
23.3
No
602
76.7
If yes, has your doctor ever discussed the ill effects of tobacco on health and advised you to stop using tobacco products?
183
Yes
134
73.2
No
49
26.8
Have you visited a medical doctor within the past year?
802
100.0
100.0
Number
%
Should the student dentist ask you whether or not you use tobacco?
802
100.0
Yes/routinely
669
83.4
Not sure/sometimes
100
12.5
33
4.1
Should the student dentist tell patients who use tobacco that tobacco use can affect oral health (mouth, gums, and teeth)?
802
100.0
Yes/routinely
652
81.3
Not sure/sometimes
84
10.5
66
8.2
No/not at all
Yes
654
81.5
No/not at all
No
148
18.5
Should the student dentist advise patients who use tobacco to quit? (Question no. 26)
802
100.0
Yes/routinely
637
79.4
Not sure/sometimes
99
12.4
No/not at all
66
8.2
If yes, has the doctor ever discussed the ill effects of tobacco on health and advised you to stop using tobacco products?
654
100.0
Yes
164
25.1
No
490
74.9
Have you visited this dental college and hospital in the past year?
785
100.0
Yes
521
66.4
Yes/routinely
653
81.4
No
264
33.6
Not sure/sometimes
133
16.6
If yes, has the student dentist ever discussed the ill effects of tobacco on general health and oral health and advised you to stop using tobacco products?
Should the student dentist offer tobacco cessation information to patients who use 802 tobacco and want to quit? (Question no. 27)
No/not at all 521
100.0
Yes
49
9.5
No
472
90.5
16
2.0
Should the student dentist offer tobacco cessation assistance and services to patients who use tobacco and want to quit? (Question no. 28)
802
100.0
Yes/routinely
653
81.4
Not sure/sometimes
116
14.5
33
4.1
How comfortable do you feel about receiving advice about quitting from the student dentist?
802
100.0
Comfortable
752
93.8
50
6.2
-
-
No/not at all
Neutral Not comfortable
itive about receiving tobacco cessation advice and services than those who were single and divorced (60.6% vs 39.4% and 0%, respectively, with P < 0.001). It was also found that patients who had an interest in quitting were more likely to feel comfortable receiving tobacco cessation counseling from student dentists than were those patients who were not interested in quitting (85% vs 25%, P < 0.01). Former tobacco users were more affirm-
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100.0
ative toward receive tobacco cessation counseling from student dentists than were the current users (72.4% vs. 23%, P < 0.001; Table 3). Also those who had higher education (more than school education) were more interested in quitting and also more likely to believe that oral health professionals should offer tobacco cessation assistance and services than those with less than school education (88.9% vs 11.1%, P < 0.001).
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Table 3 Association of tobacco use status with participants’ opinion regarding receiving tobacco cessation counseling from student dentist Tobacco use status
No/not at all
Not sure/sometimes
Yes/routinely
No
%
No
%
No
%
Current user
132
13
9.8
89
67.4
30
23
Former user
181
33
18.2
17
9.4
131
72.4
Continual user
489
34
6.9
98
20
357
73
Inference: Tobacco use status is significantly associated with opinion regarding tobacco cessation counseling (P < 0.001).
DISCUSSION Tobacco use is a major cause of oral diseases and health professionals have been urged to take a more active role in tobacco cessation (Brewster et al, 2007). Oral health professionals are beginning to respond. Oral health professionals report routinely asking patients about tobacco use, but significantly fewer report that they provide tobacco cessation counseling (TCC) (Campbell et al, 1997; Albert et al, 2002; Warnakulasuriya, 2002; RikardBell et al, 2003). Perceptions of how patients will react to the provision of TCC can affect oral health professionals’ motivation for offering such programs. Most studies focus on the oral health professional’s attitudes toward TCC, not the patients’ perspective (Campbell et al, 1997; Albert et al, 2002; Warnakulasuriya, 2002; Helgason et al, 2003; Needleman, 2006; Stacey et al, 2006; Brewster et al, 2007; Vanobbergen et al, 2007). There are a few studies reporting patient attitudes about receiving cessation advice from dental college and hospital and dental clinics (Campbell et al, 1997; Rikard-Bell et al, 2003; Victoroff et al, 2006). In this study 83.4% of tobacco users agreed that student dentists should ask patients whether or not they use tobacco, which, when compared to the study conducted by Victoroff et al (2006), was similar (72%). The results indicate that a majority of tobacco users were positive about receiving cessation advice as well as tobacco cessation assistance and services from a student dentist. The majority of tobacco users were also positive about expecting student dentists to discuss the ill effects of tobacco on oral health. This study found that 73.2% of tobacco users thought that tobacco cessation counseling (TCC) and services should be provided by oral health pro-
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fessionals in a hospital setting routinely as compared to 58.5% of those in a study by Campbell et al (1997) and 89% of those in a study conducted by Victoroff et al (2006). In this study about 99.2% of former tobacco users who were no longer using tobacco also believed that TCC and cessation services should be provided in a dental college and hospital setting. It is critical for oral health professionals to realise that patients who use tobacco, including former users, see TCC as a legitimate oral service. These findings and the receptive opinions of patients towards tobacco cessation counseling and services found in this study should clearly motivate the oral health professionals to provide TCC services to their patients. The present study found that a majority of tobacco users had not visited their physician in the previous one year and among those who visited only 25.1% of the physicians had actually discussed the ill effects of tobacco on health and advised their patients to quit. This was found to be similar to physician studies conducted by Kviz et al (1997) and Goldstein et al (1997). These findings emphasise the importance of tobacco cessation efforts by oral health professionals as a part of the team of health care providers in providing public health service. The patients seen in a dental college and hospital setting may not have had previous access to cessation resources and assistance. Although they may have been ready to quit for some time, they may have lacked the resources and support to do so. As was found in this study, only 12.5% of tobacco users were aware of the community resources to help them quit as compared to 31% of those in a study conducted by Victoroff et al (2006). Patients with low socioeconomic status are associated with high rates of smoking (Jindal et al, 2006),
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yet they might have the fewest opportunities to avail themselves of treatment. It also is possible that these patients had not been educated previously about the oral health effects of tobacco use by their dentists as was glaringly demonstrated in this study. As the results indicate only 9.5% of student dentists had actually discussed the ill effects of tobacco on health and advised their patients to quit. Interest in quitting is a critical factor. Tobacco users interested in quitting were much more likely to feel comfortable in receiving advice to quit, as found in this study. In the present study 93.8% of tobacco users felt they would be comfortable about receiving TCC. Particularly those patients who had an interest in quitting were more likely to feel comfortable receiving TCC than were those patients who were not interested in quitting (95.7% vs 4.3%, P < 0.05) which was similar to the findings of the study conducted by Campbell et al (1997) (59.7% percent vs 39.4%, P < 0.01). Campbell et al (1999) propose that identifying patients’ interest is essential and with one simple question, ‘Are you interested in quitting?’ oral health professionals can determine which patients may be offended by or resistant to cessation advice. Asking this type of screening question could help increase the efficiency of the practice. The findings regarding opinions of patients towards TCC and services in a dental teaching institute and hospital in this study invoke organised dentistry to make a commitment to integrating tobacco cessation activities into routine care. Implementation of more than the first two ‘A’s (ask and advise) has lagged. Two avenues may be used to speed the adoption of comprehensive tobacco cessation services: (1) education to increase ‘intrinsic motivation’ of oral health care professionals; and (2) insurance coverage to provide monetary or ‘extrinsic’ motivation. In addition to policy statements, ‘intrinsic motivation’ in the form of inclusion of extensive tobacco cessation training in oral and dental health education curricula is needed in order to effect a change in dental culture. Although it is difficult to define reimbursable, behavioural interventions, insurance carriers and governmental programmes that fund oral care must promote and reimburse more extensive tobacco cessation activities. In addition to requiring practitioners to ask and advise, insurance providers may need to stipulate provision of some form of cessation assistance and reimburse practitioners adequately for these services.
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The limitations of this study lie in the generalisability of these results to tobacco users who visit private dental clinics. A larger section of tobacco users visit private clinics and TCC services and assistance in a private clinical set-up might differ from the hospital setting surveyed in this study. This study also did not include patients less than 15 years of age – an important age group, as tobacco use habits are initiated at young ages. Adolescents and young adults may be more receptive to dental advice as oral health and cosmetic effects are important at that age. They are also more likely to quit than are older, more addicted tobacco users. Therefore, frequent professional advice may be effective. The oral health professional’s role in adolescent tobacco use cessation needs further investigation.
CONCLUSION This study shows that patients expected and felt comfortable with receiving tobacco cessation counseling services by oral health professionals and a dental teaching institution and hospital setting offers an appropriate avenue to provide these services. It is now up to oral health professionals to show their concerns about patients’ receptive opinions and provide these services. Consistent advice and assistance can make a difference in reducing the harmful effects of tobacco.
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