Abstract
Introduction:
Oral health problems arising from tobacco use have been reported and some of these conditions can be prevented through Tobacco Cessation (TC). Dentists are well positioned to provide tobacco cessation services to patients. In Nigeria, little is documented on the provision of cessation services among dentists and the challenges. This study was conducted to assess the cessation practices of dentists and their related challenges in Southwest Nigeria.
Methods:
A cross sectional study was carried out in all the tertiary healthcare facilities within the six states of the Southwest geopolitical zone. A total population survey involving dentists below the cadre of Consultant/Chief Dental Officers undergoing postgraduate training and/or providing services in the tertiary hospitals was conducted using a pretested semi structured self-administered questionnaire. This included questions on challenges experienced in the provision of TC services in their respective facilities.
Results:
A total of 224 eligible dentists were approached to participate in this study with a response rate of 91.5%. Mean age and completed years of working experience were 33.8±5.2 and 6.1±4.4 respectively. In reporting challenges to implementing tobacco cessation services, 60% of respondents reported 'lack of perceived efficacy and training' as the major barriers.
Conclusion:
From this study, incorporation of tobacco cessation into the dental curriculum will increase the knowledge and competence of dentists. Provision of systems support to dentists willing to help patients quit smoking may be important in ensuring the health system is responsive to the tobacco control needs of patients in Southwest Nigeria.
Keywords: Tobacco cessation, Dentists, Challenges, Nigeria
INTRODUCTION
The use of tobacco is a common global event with over one billion smokers, though its prevalence varies from continent to continent as well as from country to country. Its use is reported to kill 6 million people on a yearly basis and this includes approximately six hundred thousand non-smokers.1 Tobacco smoking in its various forms (cigars, cigarettes, pipes) is an important risk factor in many non-communicable diseases (NCDs) which include but are not limited to cardiovascular disease, lung disease, low birth weight and premature birth. Tobacco smoking with its attendant thermo-cycling effects is also associated with dental conditions such as, teeth abrasion and staining, implant failure, halitosis and oral cancer.2,3
Tobacco control effects have gained grounds in recent decades and as part of the solution to the problem in May 2003, the World Health Organization (WHO) World Health Assembly unanimously adopted the WHO Framework Convention on Tobacco Control.4 In 2008, WHO also introduced the MPOWER package of six evidence-based tobacco control measures that are proven to reduce tobacco use and save lives.5 M - Monitor tobacco use and prevention policies, P - Protect people from Tobacco smoke, O - Offer help to quit tobacco use, W - Warn about the dangers of tobacco, E - Enforce bans on tobacco advertising, promotion and sponsorship, and R - Raise taxes on tobacco.
A thrust of the O component of MPOWER is dependent on healthcare personnel integrating tobacco cessation into primary health care and other routine medical visits which provides the health-care system with opportunities to remind users that tobacco harms their health and that of others around them.5
This intervention can be particularly effective because it is provided by a well-respected health professional with whom tobacco users may have a good relationship.6 Dentists are strategically placed in tobacco prevention and cessation as they provide preventive services to a basically healthy population and therapeutic services when needed, on a regular basis. By expanding the dental examination, diagnosis, and treatment to include tobacco cessation, a potentially life-saving element of care is added to an established service.
Nigeria has an estimated 4000 licensed dentists to an estimated population of 170 million.7 As oral health professionals, dentists have the unique opportunity as they interface with the main portal of tobacco entry into the body and as part of the natural consequences of their oral health care efforts, can educate patients in a bid to make informed decisions and behavioral changes as regards smoking. Tobacco cessation is a viable method of achieving this. Despite the strength and the tenacity of the tobacco companies, tobacco control bill was recently enacted and it becomes important to carry out studies like this within the health sector which will provide important baseline information on dentists' perceived competence and preparedness to undertake tobacco cessation.
Furthermore, periodontal disease and the potential for oral cancer mandate the inclusion of tobacco cessation services into dental care. There is a dearth of information on the knowledge, perceived roles of dentists, and the challenges to carrying out these roles as regards tobacco cessation in Nigeria. This study (which is a part of a larger study), therefore was aimed at determining the various challenges faces by Nigerian dentists in implementing tobacco cessation services.
MATERIALS AND METHODS
This was a cross sectional study carried out in the Southwest geopolitical zone of Nigeria which comprises six states namely- Lagos, Ogun, Oyo, Osun, Ondo and Ekiti. Three of these states are home to the largest teaching hospitals which cover both undergraduate and post graduate training. These are the Lagos University Teaching Hospital (LUTH) which was the first dental school established in Nigeria. The University College Hospital (UCH), Ibadan, Oyo State and the Obafemi Awolowo University Teaching Hospital (OAUTH), Ile-Ife, Osun State. Other state tertiary healthcare facilities in which dental services and training are being provided e.g. Lagos and Ekiti States, as well as Federal Medical Centre, Abeokuta in Ogun state were used.
The study population was made up of all dentists undergoing training or service provision in a tertiary health institution under the supervision of a dental consultant in the six states. Sampling frame was obtained from each institution used in the study. A pre-tested, semi structures, self-administered questionnaire was used for data collection. The questionnaire contained sections on socio-demographics, tobacco history taking, knowledge of tobacco cessation methods, willingness to offer tobacco cessation services as well as challenges posed which were listed from most to least important.
The data collected was collated, cleaned and analyzed using the Statistical Package for Social Sciences (SPSS) version 20. Descriptive statistics was generated and associations tested using the Chi Square test at p=0.05. Only consenting individuals participated in this study and the UI/UCH Ethical Review Board approved this study.
RESULTS
A total of two hundred and twenty four eligible dentists were approached to participate in this study with a response rate of 91.5%. Mean age and completed years of working experience were 33.8±5.2 and 6.1±4.4 respectively. The respondents consisted of 57.1% males with the highest number of respondents from Osun State. Junior residents made up the largest bloc of respondents (40.5%) while dental officers made up the smallest bloc (3.4%). Table 1 shows the socio-demographic characteristics of the participants.
Table 1:
Socio-demographic characteristics of participants
| Variable (N=205) | N | Percentage |
|---|---|---|
|
| ||
| Age range (years) | ||
| 20-29 | 44 | 21.5 |
| 30-39 | 141 | 68.8 |
| 40 and above | 20 | 9.8 |
| Mean age | 33.8±5.2 | |
| Sex | ||
| Male | 117 | 57.1 |
| Female | 88 | 42.9 |
| Highest Level of education | ||
| First degree | 179 | 87.3 |
| Masters' degree | 26 | 12.7 |
| Professional qualification | ||
| None | 139 | 67.8 |
| Part 1 | 66 | 32.2 |
| State of employment | ||
| Lagos | 57 | 27.8 |
| Ogun | 10 | 4.9 |
| Oyo | 65 | 31.7 |
| Osun | 66 | 32.2 |
| Ondo | 3 | 1.5 |
| Ekiti | 4 | 2.2 |
| Subspecialty ? (N=158) | ||
| Restorative dentistry | 25 | 15.8 |
| Community dentistry | 12 | 7.6 |
| Periodontology | 11 | 7.0 |
| Child dental health | 30 | 19.0 |
| General dental practice | 20 | 12.7 |
| Oral pathology | 16 | 10.1 |
| Oral medicine | 8 | 5.1 |
| Oral surgery | 36 | 22.8 |
| Designation | ||
| House officer (junior dentist) | 39 | 19.0 |
| Dental officer (junior dentist) | 7 | 3.4 |
| Registrar (junior dentist) | 83 | 40.5 |
| Senior dental officer (senior dentist) | 8 | 3.9 |
| Senior registrar (senior dentist) | 60 | 29.3 |
| Principal dental officer^ (senior dentist) | 8 | 3.9 |
| Completed Years of Work Experience (CYWE) | ||
| 0-4 | 73 | 35.6 |
| 5-9 | 85 | 41.5 |
| 10-14 | 42 | 20.5 |
| 15 and above | 5 | 2.5 |
| Mean CYWE | 6.1±4.4 | |
With regards to tobacco use history as shown in Table 2, majority (86.3%) of respondents reported frequently asking their patients if they smoked though fewer asked how long patients had been smoking for and about 60% asked the number of sticks smoked. Despite asking about patients' smoking history, less than 10% assisted patients to quit smoking.
Table 2:
Participants' tobacco use history taking practice
| Questions | Response | ||
|---|---|---|---|
| Frequently | Infrequently | Never | |
| n (%) | n (%) | n (%) | |
|
| |||
| *Ask if patient smokes | 177 (86.3) | 20 (9.8) | 8 (3.9) |
| Ask how long patient has been smoking | 149 (72.7) | 25 (12.2) | 31 (15.1) |
| Ask number of sticks patients smokes | 126 (61.5) | 27 (13.2) | 52 (25.4) |
| *Advises patients to quit smoking | 117 (57.1) | 53 (25.9) | 35 (17.1) |
| *Assesses patient's willingness to quit | 41 (20.0) | 28 (13.7) | 136 (66.3) |
| *Assists patients to quit smoking | 16 (7.8) | 15 (7.3) | 174 (84.9) |
| *Arranges follow up to quitting | 7 (3.4) | 3 (1.5) | 195 (95.1) |
The 5 A's of smoking cessation
When asked about challenges to implementing tobacco cessation services, 60% of respondents reported 'lack of perceived efficacy and training' as the major barrier while 'lack of reimbursement' was regarded as the least important. Table 3 shows the challenges listed by respondents.
Table 3:
Challenges of provision of tobacco cessation services
| Challenges (N=205) | n (%) |
|---|---|
|
| |
| Lack of perceived efficacy and training | 118 (60.2) |
| Lack of system support | 106 (54.1) |
| Lack of time | 90 (43.9) |
| Low patient acceptance | 76 (38.8) |
| Lack of personal interest of the provider | 72 (35.1) |
| Possibility of offending the patient | 58 (28.3) |
| Little chance of success with intervention | 42 (20.5) |
| Lack of reimbursement | 38 (18.5) |
Multiple responses allowed
Results show that age and prior formal training on tobacco cessation both influenced significantly the practice of tobacco cessation in the clinical setting (p=0.03 and 0.02 respectively). Other factors like designation, and completed years of work experience did not significantly influence cessation practice as shown in Table 4.
Table 4:
Factors influencing cessation practice
| Influencing factors | Cessation practice category | P value | |
|---|---|---|---|
| Age range | Poor n (%) | Good n (%) | |
|
| |||
| 20-29 | 34 (77.3) | 10 (22.7) | |
| 30-39 | 125 (88.7) | 16 (11.3) | |
| >40 | 14 (70.0) | 6 (30.0) | 6.781, 0.03 |
| Sex | |||
| Male | 97 (82.9) | 20 (17.1) | |
| Female | 76 (86.9) | 12 (13.6) | 0.456, 0.32 |
| Completed years of work experience | |||
| 0-4 | 61 (83.6) | 12 (16.4) | |
| 5-9 | 73 (85.9) | 12 (14.1) | |
| >10 | 39 (83.0) | 8 (17.0) | 0.23, 0.88 |
| Professional qualification | |||
| None | 119 (85.6) | 20 (14.4) | |
| Part 1 of West Africa/National PG College) | 54 (81.8) | 12 (12.2) | 0.489. 0.62 |
| Educational qualification | |||
| First degree | 151 (84.4) | 28 (15.6) | |
| Masters' degree | 22 (84.6) | 4 (15.4) | 0.07, 0.6 |
| Prior formal training on TC methods | |||
| Yes | 14 (67.7) | 7 (33.3) | |
| No | 158 (86.3) | 25 (13.7) | 5.51, 0.02 |
| Knowledge of tobacco cessation methods | |||
| Poor | 38 (84.4) | 7 (15.6) | |
| Fair | 61 (78.2) | 17 (21.8) | |
| Good | 64 (88.9) | 8 (11.1) | 3.14, 0.21 |
| Designation | |||
| Junior dentist | 108 (83.7) | 21 (16.3) | |
| Senior dentist | 65 (85.5) | 11 (14.5) | 0.119, 0.73 |
DISCUSSION
This study was made up of more males (57.1%) than females which is similar to another Nigerian study8, which also reported slightly more males among dentist and dental students in their study. Similarly, other global studies have made the same observations.9-13 However, a study from Tanzania had predominantly male respondents14 in comparison to this study. The reason for this is not quite clear but may be due to gender disparity within the profession. In this study, most of the respondents reported routinely asking patients if they smoke. This was significantly higher than the 65% reported in another Nigerian study, 60% reported in the United States8,15, as well as 75% reported in a Kuwaiti study.16 This result is however lower than 94% reported in another Nigerian study17 and that reported in a study in California.11 In this study, 86% of participants reported frequently asking patients if they smoke, 72% asked how long they smoked for but very few arranged for follow up.
The barriers to implementation identified in this study include the following: a lack of perceived efficacy and training, system support, time, personal interest of the provider and reimbursement. In addition, possibility of offending the patient and little chance of success with the intervention were also identified. These are in keeping with the reports from some other studies.18,20 In this study, lack of perceived efficacy and training was regarded as the most important barrier to implementation of TC activities by a large proportion of respondents which is similar to results of other Nigerian studies.8,21
Slightly more than half of respondents regarded a lack of systems support as an important barrier while less than half thought lack of time was an important barrier. Only about a fifth of respondents indicated that reimbursement and the possibility of the intervention succeeding being low were important barriers to implementation of TC activities which is markedly similar to other studies in the United States and United Kingdom.22,23 Some of these barriers are expressed in other studies though the level of importance attached differs.24-26
'Possibility of offending the patient' was ranked as most important, followed by 'lack of training' in a study in Hong Kong.27 A study conducted among periodontologists by Patel et al, in 2011, reported that low patient acceptance, lack of time and lack of training were the most important barriers to implementing TC services.22 Another study out of Iowa, reported that 'resistance to intervention', 'inadequate time' and 'forgetting to ask' as the important barriers to implementation.10 Gender was reported as being the main barrier to implementation of TC services in Pakistan28 possibly because it is an Islamic nation; however, this was not perceived as a challenge in this study. Other barriers include 'lack of necessary patient education materials', 'availability of referral services', 'non availability of NRT' and 'resistance by members of staff '.29 The differences above are possibly as a result of social and cultural differences as well as differences in modes of training/curriculum of dental professionals.
In Nigeria, the majority of dentists do not provide TC services in stark contrast to many other countries as there are no operational clinical guidelines to follow in helping a patient who is willing to stop smoking, non-availability of NRTs and neither are there referral centres.
CONCLUSION
This study shows that most dentist frequently ask about their patients' tobacco use history but very few actually go ahead to render assistance in stopping the use of tobacco. Also, various barriers to implementation of tobacco cessation activities were enumerated and the major ones were 'lack of perceived competence and training', 'lack of systems support' and 'lack of time'. Incorporating tobacco cessation into both undergraduate and postgraduate curricula will positively improve the knowledge base and increase the competence of dentists. IN addition, provision of systems support to the majority of dentists who are willing to help patients quit smoking may be important in ensuring that the health system is responsive to the tobacco control needs of patients in Southwest Nigeria.
REFERENCES
- 1.World Health Organization. WHO REPORT on the global TOBACCO epidemic; Warning about the dangers of tobacco. Geneva: WHO Press; 2011. pp. 1–264. [Google Scholar]
- 2.Collins F. Tobacco cessation and the impact of tobacco use on oral health. 2009. Nov, pp. 1–13. Available from www.ineedce.com .
- 3.Rad M, Kakoie S. Effect of Long-term Smoking on Whole-mouth salivary flow rate and oral health. [cited 2015 Jan 7];J Dent Reserch [Internet] 2010 4(4):110–114. doi: 10.5681/joddd.2010.028. Available from http://w w w. n c b i . n l m . n i h . g o v / p m c / a r t i c l e s /PMC3429961/ [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.World Health Organization. WHO framework convention on tobacco control. Third. Geneva: 2005. pp. 1–42. [Google Scholar]
- 5.World Health Organization. MPOWER/ :Six policies to reverse the tobacco epidemic. WHO Report on the Global Tobacco Epidemic. Geneva. 2008.
- 6.Fiore M, Jaen C, Baker T, et al. Treating tobacco use and dependence; 2008 update guideline panel. clinical practice guidelines. Rockville. 2008.
- 7.Nigerian Dental Association. Dentistry in Nigeria. J Niger Dent Assoc [Internet]. Lagos. 2014;4:1–5. Available from www.nigdentalasso.org . [Google Scholar]
- 8.Uti O, Sofola O. Smoking cessation counseling in dentistry; attitudes of Nigerian dentists and dental students. [cited 2014 Nov 18];J Dent Educ [Internet] 2011 75(3):406–12. Available from http://www.jdentaled.org/content/75/3/406.short . [PubMed] [Google Scholar]
- 9.Rodrigues GA, Galvao V, de Assis Viegas CA. Prevalence of smoking among dentists in the Federal District of Brasilia, Brazil. J Bras Pneumol. 2008;34((July 2007)):288–93. doi: 10.1590/s1806-37132008000500007. [DOI] [PubMed] [Google Scholar]
- 10.Pendharkar B. Fourth-year dental students perceived barriers to providing tobacco intervention services. [cited 2014 Nov 19];J Dent Educ [Internet] 2010 74(10):1074–85. Available from: http://www.jdentaled.org/content/74/10/1074.short . [PubMed] [Google Scholar]
- 11.Prakash P, Belek MGM, Grimes B, et al. Dentists' attitudes, behaviors, and barriers related to tobacco-use cessation in the dental setting. [cited 2015 Jan 5];J Public Health Dent [Internet] 2013 Jan;73(2):94–102. doi: 10.1111/j.1752-7325.2012.00347.x. Available from http://www.mendeley.com/research/dentists-attitudesbehaviors-barriers-related-tobaccouse-cessationdental-setting/ [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Anjum M, Reddy P, Monica M, et al. Dental Students attitude towards tobacco cessation in and around the dental colleges of Hyderabad - A cross sectional survey. WebmedicalCentral Dent [Internet] 2014;5(11):1–11. Available from http://www.webmedcentral.com/article_view/4730 . [Google Scholar]
- 13.Wang J, Li C, Jia C, et al. Smoking, smoking cessation and tobacco control in rural China; a qualitative study in Shandong Province. BMC Public Health [Internet] 2014 Jan;14:916. doi: 10.1186/1471-2458-14-916. Available from : http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4169812&tool=pmcentrez&rendertype=abstract . [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Amemori M, Korhonen T, Kinnunen T, et al. Enhancing implementation of tobacco use prevention and cessation counselling guideline among dental providers: a cluster randomised controlled trial. [cited 2014 Nov 7];Implement Sci [Internet]. BioMed Central Ltd. 2011 Jan;6(1):13. doi: 10.1186/1748-5908-6-13. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3055178&tool=pmcentrez& rendertype=abstract . [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Tomar SL. Dentistry s role in tobacco control. J Am Dent Assoc. 2001;132 (November):30s–36s. doi: 10.14219/jada.archive.2001.0386. [DOI] [PubMed] [Google Scholar]
- 16.Khalaf M. Smoking cessation practices in Kuwaiti general dental clinics. [cited 2014 Nov 19];Med Princ Pract [Internet] 2013 Jan;22:576–82. doi: 10.1159/000351560. Available from : http://www.ncbi.nlm.nih.gov/pubmed/24021780. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Ehizele A, Azodo CC, Ezeja EB, Ehigiator O. Nigerian dental students' compliance with the 4As approach to tobacco cessation. J Prev Med Hygeine. 2011;52(52):12–26. [PubMed] [Google Scholar]
- 18.Fotedar S, Sogi GM, Fotedar V, et al. Knowledge of, attitude towards, and prevalence of tobacco use among dental students in Himachal Pradesh State, India. Oral Health Dent Manag [Internet] 2013;12(2):73–9. Available from http://www.ncbi.nlm.nih.gov/pubmed/23756422 . [PubMed] [Google Scholar]
- 19.Sychareun V, Hansana V, Choummanivong M, et al. Cross-sectional survey; smoking among medical, pharmacy, dental and nursing students, University of Health Sciences, Lao PDR. BMJ Open [Internet] 2013;3(8):e003042. doi: 10.1136/bmjopen-2013-003042. Available from : http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3758981&tool=pmcentrez&rendertype=abstract . [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Tam -Maury I, Aigner CJ, Hong J, et al. Perception of tobacco use prevention and cessation among faculty members in Latin American and Caribbean Dental Schools. [cited 2014 Nov 9];J Cancer Educ [Internet] 2014 Dec;29(4):634–41. doi: 10.1007/s13187-013-0597-3. Available from http://www.ncbi.nlm.nih.gov/pubmed/24385339 . [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Ehizele A, Azodo C, Umoh A, Akinboboye B. Attitude of dental students to tobacco cessation services. Internet J Dent Sci [Internet] 2008;7(1):1–10. Available from https://ispub.com/IJDS/7/1/12864 . [Google Scholar]
- 22.Patel AM, Blanchard SB, Christen AG, Bandy RW, Romito LM. A survey of United States periodontists' knowledge, attitudes, and behaviors related to tobacco-cessation interventions. [cited 2014 Nov 9];J Periodontol [Internet] 2011 Mar;82(3):367–76. doi: 10.1902/jop.2010.100405. Available from http://www.ncbi.nlm.nih.gov/pubmed/20809858 . [DOI] [PubMed] [Google Scholar]
- 23.Jannat-khah DP, Mcneely J, Pereyra MR, et al. Dentists' self-perceived role in offering tobacco cessation services: Results from a nationally representative survey, United. Prev Chronic Dis. 2014;11:1–12. doi: 10.5888/pcd11.140186. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Gordon J, Severson H. Tobacco cessation through dental office settings. [cited 2014 Nov 21];J Dent Educ [Internet] 2001 65(4):354–363. Available from: http://www.jdentaled.org/content/65/4/354.short. [PubMed] [Google Scholar]
- 25.Desalu OO, Adekoya AO, Elegbede AO, et al. Knowledge of and practice related to smoking cessation among physicians in Nigeria. J Bras Pneumol. 2009;35(May):1198–203. doi: 10.1590/s1806-37132009001200006. [DOI] [PubMed] [Google Scholar]
- 26.Amemori M, Korhonen T, Michie S, Murtomaa H, Kinnunen TH. Implementation of tobacco use cessation counseling among oral health professionals in Finland. [cited 2015 Feb 11]; J Public Health Dent [Internet] 2013 Jan ;73(3):230–6. doi: 10.1111/jphd.12019. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23594270 . [DOI] [PubMed] [Google Scholar]
- 27.Li KWK, Chao DVK. Current practices, attitudes, and perceived barriers for treating smokers by Hong Kong dentists. [cited 2014 Nov 19];Hong Kong Med J [Internet] 2014 Apr;20(2):94–101. doi: 10.12809/hkmj134027. Available from http://www.ncbi.nlm.nih.gov/pubmed/24625385 . [DOI] [PubMed] [Google Scholar]
- 28.Mumtaz R, Khan AA, Moeen F, Noor N, Humayun S. The role of Pakistani dentists in tobacco cessation. Int Dent J. 2008;58:356–62. doi: 10.1111/j.1875-595x.2008.tb00357.x. [DOI] [PubMed] [Google Scholar]
- 29.Johnson NW, Lowe JC, Warnakulasuriya KS. Tobacco cessation activities of UK dentists in primary care; signs of improvement. [cited 2014 Nov 18];Br Dent J [Internet] 2006 Jan 28;200(2):85–9. doi: 10.1038/sj.bdj.4813148. Available from http://www.ncbi.nlm.nih.gov/pubmed/16444223 . [DOI] [PubMed] [Google Scholar]