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ORIGINAL ARTICLE

Health professional’s perception toward tobacco cessation:

A cross-sectional study
Vikram Pal Aggarwal, Anmol Mathur, C. L. Dileep, Manu Batra, Diljot Kaur Makkar
Department of Public Health Dentistry, Surendera Dental College and Research Institute, Sri Ganganagar, Rajasthan, India

Address for correspondence:

Dr. Vikram Pal Aggarwal, Department of Public Health Dentistry, Surendera Dental College and Research Institute, Sri Ganganagar, Rajasthan, India.
E‑mail: drvikramaggarwal@yahoo.com

ABSTRACT:
Introduction: Tobacco smoking is a major cause of preventable morbidity and mortality. The prevention and control of adverse health
effects associated with tobacco consumption is an emerging issue of public health significance. Aim: To assess the knowledge,
attitude, and practices among health professionals (HPs) toward tobacco cessation (TC). Materials and Methods: A cross‑sectional
study, using pretested structured questionnaire was conducted among 422 medical and dental practitioners, to obtain information
on the TC. The data were descriptively analyzed and Chi‑square tests and multivariate analysis was applied using SPSS
version 20. Results: Dental professionals had better knowledge about various preventive measures regarding TC as compared
to medical professionals. Nonsmoker professionals advised patients to quit tobacco 10 times more than the smokers. Most of the
HPs (91.9%) had a similar belief that TC counseling is not effective due to lack of formal training (P < 0.001). Conclusion: This
study suggests a need and a desire for HPs to improve knowledge, attitudes, and practices in dealing with tobacco smoking
cessation in their practice.
Key words:
Attitude, dentists, knowledge, practices

INTRODUCTION developing countries.[3] Current statistics indicate that

Tobacco consumption is the leading cause of preventable
illness and death in the developing world. The promotion
of adverse effects accompanying tobacco consumption
is an evolving issue of public health significance.[1]
Tobacco usage in any form is the second major etiological
factor responsible for the death, and nearly 1 out of 10
deaths worldwide is due to tobacco. By 2030, tobacco
is expected to rise and become the forerunner among
causes of death worldwide. Every 6.5 s, one tobacco
user dies from a tobacco‑related disease somewhere in
the world.[2] It is assumed to account for more than 10
million deaths/year by 2030, 70% of which will be from
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it will not be possible to reduce tobacco‑related deaths
over the next 30–50 years, unless tobacco users are
encouraged to quit.[4]
More than one‑third (35%) of adults in India use tobacco
in some form or the other.[5] According to the Global
Adult Tobacco Survey,[5] 26% of adults in India consume
smokeless tobacco ‑ 33% of men and 18.4% of women.
As per the World Health Organization (WHO), Global
Report[6] on “Tobacco Attributable Mortality 2012” 7% of
all deaths (for age’s ≥ 30) in India are attributed to tobacco.
This is an open access article distributed under the terms of the Creative
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How to cite this article: Aggarwal VP, Mathur A, Dileep CL, Batra M,
DOI: Makkar DK. Health professional's perception toward tobacco cessation:
10.4103/2319-5932.171161 A cross-sectional study. J Indian Assoc Public Health Dent 2015;13:438-43.

© 2015 Journal of Indian Association of Public Health Dentistry | Published by Wolters Kluwer - Medknow 438
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Aggarwal, et al.: Tobacco habits and its cessation
While taxation and prohibition of advertising have been
effective, nonlegislative and cost‑effective approaches
for cessation should be utilized as well. One of the
strategies to reduce morbidity and the number of
smoking‑related deaths is to encourage the involvement
of health professionals (HPs) in tobacco use prevention
and cessation counseling. HPs (medical and dental)
have a key role to play by working through the health
care system to motivate and advise users to quit. Since
doctors are well regarded and their advice well‑accepted,
they form the most likely persons from whom advice on
quitting would be taken seriously and accepted by the
users.[4]
Tobacco cessation counseling (TCC) in dentistry is critical
to reduce the effect of a major risk factor for both oral
and systematic diseases. Randomized clinical trials have
found that even brief dental office‑based interventions
can be effective in motivating and assisting tobacco users
to quit.[7] Dentists play an important role in educating
patients about health risks of tobacco use and TC
because of the regular contact many patients have with
their dentists.
Even a brief advice from HPs to tobacco consumers can
significantly increase the quit rate. One‑way to make
HPs’ involvement even more effective in tackling tobacco
use is a multi‑professional approach which has been
advocated by the WHO. Despite the potential, not many
HPs are involved in TCC activities. Barriers that have
been associated with provision of TCC include lack of
time, no monetary benefits, lack of professional training
in TCC activities along with anticipated negative feedback
from patients, lack of confidence in their ability, and skills
to provide effective counseling.[8‑10]
To be able to effectively participate in the anti‑tobacco
effort, HPs’ knowledge, attitudes, and practices toward
tobacco use cessation are important. In the light of
currently available guidelines and little that is known
about the extent to which the dentists engage themselves
in performing TCC, the study explored the factors
associated with their performance. The objective was to
assess and compare knowledge, attitudes and practices
of medical and dental professionals’ role in TC.
MATERIALS AND METHODS
A cross‑sectional study was conducted among medical
and dental practitioners in Sri Ganganagar city from
September to December 2014. The study was approved by
the Institutional Ethical Committee. The sampling frame
comprised of 491 medical and dental practitioners from
Sri Ganganagar city registered with the state medical
and dental council. The inclusion criteria were that
doctor must be a registered practitioner and must be
having clinical/patient interaction. Those who did not
give consent and failed to return the questionnaire or
439
incomplete questionnaire were excluded from the study.
The final sample was 422 medical and dental doctors
with a response rate of 85.7%.
A questionnaire in English language was used to
record the knowledge, attitude, and practice of medical
and dental surgeons regarding TC. The present
questionnaire was based on previous WHO[11] guidelines
to conduct tobacco smoking surveys among HPs. The
questionnaire was viewed by three experts in Public
Health Dentistry to ensure its suitability for the present
study. The questionnaire was pretested on a group of
20 professionals to check the feasibility of the study. Six
out of twenty‑nine questions of the initial questionnaire
were removed and appropriate modifications were
made. The reliability of the questionnaire was evaluated
by:  (1) Cronbach’s coefficient alpha to measure the
internal consistency; (2) test‑retest method to examine
the stability of the questionnaire. The alpha coefficient
of 0.7 was considered adequate. Test‑retest reliability
was measured by having the same set of respondents to
complete a questionnaire at two different points of time
within which there was no change of the constructs of
interest. Intra‑class correlation coefficient  (ICC) with
95% confidence interval  (CI) was used for assessing
this reliability. The value of the ICC was 0.70. The
questionnaire included sections on demographic data
and questions on knowledge, attitudes, awareness of
smoking cessation, willingness to provide cessation
services, and barriers to smoking cessation advice
in the dental setting. All the attitude and some
knowledge questions[1,4,5] responses was based on a
Likert scale where the respondents were asked to
indicate their agreement with the statement on a scale
of 1–5, (strongly agree strongly disagree) and for the
remaining questions, where appropriate, the answers
were dichotomized.
The questionnaire was personally administered, and
the professionals were explained regarding the motive
of the study and how to complete the questionnaire.
It was emphasized that the confidentiality of the
responses made by them would be strictly maintained.
Strengthening the Reporting of Observational Studies in
Epidemiology guidelines were followed while conducting
the research.
Statistical analysis
Data were examined, and the responses were coded. The
data were then descriptively analyzed and Chi‑square
tests and multivariate analysis was applied using SPSS
version 20 (IBM SPSS. Statistics Windows, Version
20.0. (Armonk, NY: IBM Corp)). The Chi‑square test of
association was used to assess differences among HPs
in all variables. Bivariate and multivariate analyses were
conducted for two outcomes. Odds ratio were calculated
with 95% CIs, and two‑tailed significance was set at
5% (P < 0.05) in all analyses.
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Aggarwal, et al.: Tobacco habits and its cessation

RESULTS professionals (81.2%) recommend nicotine replacement

The sample comprised of 70.1% and 29.9% males
and females, respectively. The participants comprised
medical (54.74%) and dental professionals (45.26%).
More than 50% of the dentists and medical professionals
were aged 20–29 years and 40–49 years respectively.
Most of the medical professionals (87.9%) had done
postgraduation when compared to the dentist (46.6%).
Approximately, all the medical professionals (90.5%) had
at least 5 years of practicing experience, while 61.8%
of dental professionals had < 5 years of experience.
Altogether, 23.2% of participants reported being
smokers [Table 1].
therapy when helping smokers to quit tobacco, whereas
only 71.9% medical professionals recommend nicotine
replacement therapy (P < 0.05) [Table 2].
Multivariate analysis showed that asking about smoking
and advising patients to quit was significantly associated
with health providers being female, age more than
40 years and nonsmokers [Table 3]. The probability of
counseling patients to quit tobacco was 10 times more
among the nonsmokers HPs as compare to smokers HPs.
DISCUSSION

When knowledge was assessed regarding tobacco HPs, due to their position in society, have a unique role
smoking effects on general health among medical and in tobacco control. Whether HPs personal tobacco use
dental professional, it was found that medical professional behavior affects their professional attitude and clinical
has better knowledge than dental professionals. When behavior is unknown, yet it represents a critical issue
knowledge about various preventive measures regarding in public health policy, as they are usually the primary
TC was assessed among HPs, it was found that dental health care providers. The study revealed several lacunae
professionals had better knowledge as compared to in the knowledge, attitudes and practices among the HPs.
medical professionals [Table 2].
In the present study, 61.8% of dentists reported that
A total of 38.5% and 28.3% medical and dental they enquired the patients regarding their tobacco
professional respectively had a view that enquiring habits which are comparatively higher than that was
about tobacco habits has a negative impact on clinical reported by Sahoo et al.[4] (52%), but less as compared
practice (P < 0.05). Most of the HPs (91.9%) had a similar Parakh et al.[12] (83%) and Khalaf[13] (72.1%). In the
belief that TCC is not effective due to lack of formal present study, 57.1% of the dentists were engaged in
training (P < 0.001). A total of 61.8% HPs enquired from TC practices actively whereas Khalaf[13] reported that
their patients regarding tobacco habits. Among the dental most of the dentist never got engage in TC practices.
However, Chandrashekar et al.[14] reported that 60% of
the dentists enquired regarding TC from the patients
Table 1: Demographic characteristics and smoking in their practices. The reason cited with this finding is
status of the study sample that negative impact may incur on their practice due
Characteristic Total Medical Dental to TC practices among the patients. However, as per a
(n=422) (n=231) (n=191) study,[15] patients who had tobacco habit in any form were
n (%) n (%) n (%) quite positive in their attitude toward reception of TCC
Gender in the dental setting. Saud et al.[16] reported that 95% of
Male 296 (70.1) 188 (81.4) 108 (56.5) physicians asked patients about their smoking status
Female 126 (29.9) 43 (18.6) 83 (43.5) compared to 61.9% of physicians in the present study
Age (in years) which is similar to the study conducted by Thankappan
20-29 112 (26.5) 1 (0.4) 111 (58.1) et al.[17] (57%) and Klink et al.[1] (57.6%).
30-39 139 (32.9) 84 (36.4) 55 (28.8)
40-49 128 (30.3) 117 (50.6) 11 (5.8) In the current study, 26.8% of the physicians smoked
50-59 36 (8.5) 27 (11.7) 9 (4.7) in office in the presence of a patient while in contrary
≥60 7 (1.7) 5 (2.2) 2 (1.0) Jiang et al.[18] reported only 8.5% but in case of dental
Qualification professionals only 18.5% smoke in office in the presence
Graduate 130 (30.8) 28 (12.1) 102 (53.4) of a patient. This may be due to longer working hours
Postgraduate 292 (69.2) 203 (87.9) 89 (46.6) and getting adapted to such habits among medical
Professional experience (in years) professionals.
<5 140 (33.2) 22 (9.5) 118 (61.8)
5-9 111 (26.3) 77 (33.3) 34 (17.8) Parakh et al. [12] reported that 93% of the dental
10-19 135 (32.0) 106 (45.9) 29 (15.2)
professional explained to the patients about the health
≥20 36 (8.5) 26 (11.3) 10 (5.2)
risks associated with tobacco use whether in smoke
Smoking
or smokeless form compared to 63.9% of the dental
Smoker 98 (23.2) 62 (26.8) 36 (18.8)
professional in this study. This difference may be due
Nonsmoker 324 (76.8) 169 (73.3) 155 (81.2)
to lack of interest among the dental professionals

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Aggarwal, et al.: Tobacco habits and its cessation

Table 2: Health provider’s knowledge, attitudes, and practices regarding smoking cessation
Particulars Total (n=422) Medical Dental P
n (%) (n=231) n (%) (n=191) n (%)
Knowledge
Bladder cancer associated with TC 272 (64.5) 165 (71.4) 107 (56.0) 0.001*
Lung cancer associated with TC 413 (97.9) 229 (99.1) 184 (96.3) 0.101
Oral cancer associated with TC 417 (98.8) 230 (99.6) 187 (97.9) 0.26
Chronic bronchitis associated with TC 370 (87.7) 207 (89.6) 163 (85.3) 0.24
Pulmonary emphysema associated with TC 342 (81.0) 204 (88.3) 138 (72.3) <0.0001†
Laryngeal cancer associated with TC 353 (83.6) 218 (94.4) 135 (70.7) <0.0001†
Peripheral vascular disease associated with TC 297 (70.4) 213 (92.2) 84 (44.0) <0.0001†
Neonatal death associated with TC 173 (41.0) 112 (48.5) 61 (31.9) 0.0008†
Passive smoking linked to lung disease 336 (79.6) 189 (81.8) 147 (77.0) 0.07
Heard of nicotine patches 332 (78.7) 159 (68.8) 173 (90.6) <0.0001†
Heard of nicotine gums 362 (85.8) 186 (80.5) 176 (92.1) 0.0011*
Heard of behavioral methods 305 (72.3) 143 (61.9) 162 (84.8) <0.0001†
Heard of pharmacotherapy 197 (46.7) 112 (48.5) 85 (44.5) 0.47
Attitudes
Enquiring about tobacco habits has negative impact on clinical practice 143 (33.9) 89 (38.5) 54 (28.3) 0.034*
TCC is not effective due to lack of formal training 388 (91.9) 223 (96.5) 165 (86.4) 0.0003†
Proper counseling will lead to patient quitting the habit 377 (89.3) 202 (87.4) 175 (91.6) 0.220
TCC should be the part of regular treatment modalities 403 (95.5) 221 (95.7) 182 (95.3) 0.963
Media and celebrities promote tobacco 35 (8.3) 13 (5.6) 22 (11.5) 0.08
Support strict legislation on tobacco use 376 (89.1) 205 (88.7) 171 (89.5) 0.92
Increase in tax of tobacco products 320 (75.8) 178 (77.1) 142 (74.3) 0.594
Practices
Smoke in your office in the presence of a patient 98 (23.2) 62 (26.8) 36 (18.5) 0.069
Enquire from patients regarding tobacco habits 261 (61.8) 143 (61.9) 118 (61.8) 0.941
Explain the risk associated with tobacco use and counsel the patients 259 (61.4) 158 (68.4) 122 (63.9) 0.381
Advocate TC practices actively 226 (53.6) 117 (50.6) 109 (57.1) 0.223
No‑smoking sign in your waiting room 191 (45.3) 119 (51.5) 72 (37.7) 0.006*
Recommended nicotine replacement therapy when helping smokers quit 321 (76.1) 166 (71.9) 155 (81.2) 0.035*
Provision of TCC center in hospitals and institution 375 (88.9) 198 (85.7) 177 (92.7) 0.565
P values derived from Chi‑square test (*Statistically significant, †Highly statistically significant). TC – Tobacco cessation, TCC – Tobacco cessation counseling

to understand their role and importance in TC need to sensitize medical professionals on the different
interventions. modalities of TC.

Standard smoking cessation practices like nicotine
replacement therapy was used by 71.9% of the
physician in the current study but a study conducted
by Jiang et al.[18] and Abdullah et al.[19] reported only
approximately 7% of the physicians use nicotine
replacement therapy. In case of dentist, 81.2%
recommend nicotine replacement therapy when helping
smokers to quit tobacco.
Regarding the knowledge about preventive measures,
more than 90% of the dentists were aware about different
forms of nicotine replacement therapy in the current
study which is high as compared to study done by
Sahoo et al.[4] (approximately 50%). Twenty‑six percent
of the dentists were aware of the pharmacotherapy
reported by Sahoo et al. [4] in their study, whereas
present study stated 44.5%. Medical professional’s
knowledge regarding preventive measures was low as
compared to dental professionals, reflecting the urgent
Medical professional 87.4% have the belief that proper
counseling will lead to patient quitting the habit in
the present study, whereas only 49.4% of the medical
professional reported the same in a study by Klink
et al.[1] In the present study, both medical and dental
professionals (approximately 90%) favored strict
legislation on tobacco use. More than two‑third of the
HPs also felt that the media and celebrities promoted
tobacco, either directly or indirectly, calling for measures
to control such surrogate promotion of tobacco use. This
is similar to the earlier studies on dental students who
support the same.[20]
Ehizele[21] and Uti[22] et al. reported that 74.1% of the
dentists feel lack of training as a barrier in providing
cessation services which is low as compared to the
present study with (86.4%). The reasoning for such poor
attitudes among the HPs may be due to lack of formal
training in TCC.

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Aggarwal, et al.: Tobacco habits and its cessation
Table 3: Multiple logistic regression analyzing the odds
of engaging in cessation counseling practices among HPs
Characteristic Ask about smoking Advise patients to quit
OR  (95% CI)
a
P ORa (95% CI)
Sex
Female 1.3 (0.8-2.2) 0.05* 1.07 (0.53-1.7)
Male 1 1 (reference)
Age in years
>40 1.5 (1.1-2.9) 0.04* 1.2 (0.7-2.3)
≤40 1 1
Smoking status
Nonsmokers 1.7 (1.0-3.0) 0.05* 10.46 (9.8-21.7) <0.0001†
Smokers 1 1
Qualification
Postgraduate 1.1 (0.6-1.8) 0.06 1.09 (0.55-1.6)
Undergraduate 1 1
Experience in years
>10 1.4 (0.8-2.5) 0.23 1.24 (0.77-2.6)
≤10 1 1
a
Adjusted ORs for age and each characteristic. Ask about smoking: Nagelkerke
R2=0.11, Advise patients to quit: Nagelkerke R2=0.24 (*Statistically significant,
†
Highly statistically significant). ORs – Odds ratios, CI – Confidence interval,
HPs – Health professionals
Rajasthan government has taken substantial efforts
toward TC such as to make mandatory for all persons
seeking government jobs to give an undertaking that they
are not tobacco users (both smoking and smokeless).
Rajasthan has the highest value added tax on tobacco
products in the country. Significant improvements
were observed in compliance with Cigarettes and Other
Tobacco Products Act Section 4, in terms of curtailing
smoking in public places, provisions of sale, and
placement of no smoking signs.[23]
This is the first study to assess and compare the
knowledge, attitudes, and practices among medical and
dental professionals, according to which strategies can be
formulated in this region. The limitations of the present
study are that in spite of anonymous questionnaire, there
are chances of social desirability bias among respondents
toward tobacco consumption. The authors recommend
a change in curriculum toward practical, skill‑based
training, and education on TC among HPs by Government
Organizations in India.
Recommendation
There is an urgent need to sensitize and train HPs at
the community level toward the treatment of nicotine
dependence as most people in India cannot afford to go
to a specialist TC clinic nor can the government afford
to operate them at mass level. Such sensitization on the
preventive measures would certainly benefit patients by
improving cessation rates among them. We, therefore,
believe that HPs can and should ascertain and record
tobacco use status of their patients on a routine
basis; deliver brief TC advice at every opportunity; and
Journal of Indian Association of Public Health Dentistry
Vol. 13, Issue 4, | October-December 2015
advocate for the inclusion of training of TC methods in
medical school curricula of their respective professional
bodies.
P
CONCLUSION
0.01* In the present study, it is concluded that HPs lacked the
necessary knowledge of smoking cessation. They showed
positive attitudes toward their role in smoking cessation,
0.02* prohibition of tobacco promotion, its advertisement, and
to provide smoking cessation intervention.
Financial support and sponsorship
Nil.
0.06
Conflicts of interest
There are no conflicts of interest.
0.11
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