European Journal of Dental Education ISSN 1396-5883
Attitudes of Irish dental, dental hygiene and dental nursing students and newly qualified practitioners to tobacco use cessation: a national survey B. McCartan, C. McCreary and C. Healy Anatomy Department, Royal College of Surgeons, Dublin, Ireland
Keyword attitudes; knowledge; mouth disease; smoking; tobacco; tobacco cessation. Correspondence Prof. Bernard McCartan Anatomy Department Royal College of Surgeons 123 St Stephen’s Green Dublin 2 Ireland Tel: +353 1 402 2239 Fax: +353 1 402 2753 e-mail:
[email protected]
Abstract Background: Ireland has some of the strictest smoking regulations in the world. Little is known of the attitudes of student Irish dental healthcare workers towards tobacco control and tobacco use cessation. This study aimed at determining the knowledge and attitudes of these students towards the deleterious effects of tobacco in the mouth and towards tobacco use cessation in dental practice. Method: A questionnaire survey was distributed to 654 students (including newly qualified) on dentistry, dental hygiene and dental nursing programmes in Irish dental schools. Information sought included college, course, year of study, sex, age, nationality, smoking status, knowledge of effects of tobacco in the mouth and attitudes towards tobacco use cessation in dental practice and towards the Irish smoking bans.
Accepted: 9 July 2007 doi:10.1111/j.1600-0579.2007.00466.x
Main findings: There was a 90% response rate. In all, 12% of dental students, 25% of dental hygiene students and 31% of dental nursing students were current smokers. Newly qualified dental hygienists were as knowledgeable about tobacco effects in the mouth as newly qualified dentists. Overall, the majority in each student category believed that all three groups could be effective tobacco counsellors and should provide tobacco use cessation counselling to patients, although less than half of evening course dental nursing students felt that dental nurses could be effective counsellors or should provide counselling. There was overwhelming support for the Irish smoking ban. Only a minority of dental students and dental nursing students had received instruction in tobacco use cessation counselling. Conclusions: There are strong positive attitudes to tobacco use cessation counselling in dental practice among these young dental healthcare students. This is true even amongst those who have not received specific instruction in tobacco use cessation counselling.
Introduction Ireland has had a comprehensive ban on smoking in enclosed public places since 1995 (1). This ban includes, for example, government buildings and offices, cinemas, theatres, indoor sports centres, buses, schools and colleges and health facilities including hospitals and doctors’ waiting rooms. More recently, smoking has been banned in all enclosed places of employment (2). These bans, which have given Ireland some of the strictest smoking regulations in the World, seem to enjoy significant public support. Little is known about the knowledge and attitudes of Irish dental health professionals to smoking and tobacco use cessation (TUC) in dental practice. A study in 1993 showed that
14% of Irish dentists and 20% of dental students were current smokers (3). However, the response rate from the dentists surveyed was relatively low (43%). In general, both dentists and students expressed positive attitudes to higher taxes on tobacco, stricter control of advertising and sponsorship, and government intervention to reduce smoking prevalence. The role of the dental team in tobacco use cessation (TUC) is well established (4, 5); one recent suggestion that dentists are not effective as tobacco use counsellors (6) is, perhaps, better interpreted as evidence for the need for appropriate training, which has a significant effect both on the likelihood of healthcare workers’ counselling patients and the tobacco quit rates achieved by their patients (7).
Eur J Dent Educ 12 (2008) 17–22 ª 2008 The Authors. Journal compilation ª 2008 Blackwell Munksgaard
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Irish dental attitudes to tobacco use cessation
McCartan et al.
A recent study of 149 European dental schools showed that 76% expected students to take tobacco histories from all patients, while 67% and 70%, respectively, gave instruction to students in TUC and expected them to counsel their patients (8). This was an improvement from a similar study in 1993 when the figures were 58%, 49% and 48% respectively (9). Schools taught the role of tobacco in oral cancer aetiology (93%), periodontal disease (94%) and in osseointegrated implant failure (92%). There was considerable regional variation between northern, southern and eastern Europe. This study showed Europe lagging behind North America where 83% of a sample of 54 US dental schools provided instruction in tobacco prevention, 81% provided instruction in TUC and 96% expected students to take tobacco use histories (10). Students in a US dental school, in another recent study (11), generally felt that they had a role in tobacco use counselling. Seventy-one per cent agreed that it is the dentist’s responsibility to convince patients to quit and 74% felt that dentists should set an example by not using tobacco. However, 39% felt that their time would be better spent on other activities; these students were less likely to adopt smoking cessation procedures with their patients. The students’ own current smoking practices were not reflected in their attitudes and practices in smoking cessation for their patients. Two recent Scandinavian studies have shown that about 60% of Norwegian dental hygienists give TUC advice to patients (12) while 73% of Swedish dental hygienists see TUC advice as a part of their work (13). In contrast, >90% of dental hygiene students in a US college saw TUC counselling as a duty (14) while 88% of recent dental hygiene graduates in the US believed strongly that they could be effective in helping patients to quit tobacco use (15). A random survey of US dental hygienists showed that 77% asked patients about current and former tobacco use while 80% agreed that dental hygienists should be trained to provide TUC advice (16). Apart from one Scandinavian paper in 1995 (17), there appears to be no literature on the attitudes and practices of dental nurses and dental nursing students. This paper reported that 54% of dental assistants felt that ‘tobacco prevention work’ was important. A recent study of UK general dentists (18) showed that 87% ask patients about current use of tobacco. In all, 68% of UK primary care dentists feel that offering TUC advice is a duty and 64% give advice to their patients always or fairly regularly (19). Seventy-five per cent of a group of Northern Irish general dental practitioners claimed to provide information on smoking cessation when they felt it appropriate to their patients’ needs (20). However, no attempt was made to define what was meant by the qualifying statement. The aim of the present study was to determine the knowledge and attitudes of student dental healthcare workers and newly qualified dental healthcare workers in Ireland towards the deleterious effects of tobacco in the mouth and towards TUC in dental practice.
Materials and subjects A questionnaire was distributed to students of dentistry, dental hygiene and dental nursing in the dental schools in Trinity College Dublin (University of Dublin) and University College Cork 18
(National University of Ireland Cork). For each course, the qualifying class was also surveyed at or about the time of completion of course. For convenience, all participants, whether newly qualified or not, are referred to here as ‘students’. Dental nursing students fell into two groups; a full-time course in Trinity College Dublin and a national part-time evening course. For the dental, dental hygiene and full-time dental nursing courses, all students were surveyed. For the evening course in dental nursing, students from three centres only (Cork, Waterford and Tralee) were included; as their replies were collated through Cork, they are listed as Cork students for convenience. The questionnaire sought details of college, course, year, age, nationality and smoking status. Students were also asked to agree or disagree with the following seven statements on the possible effects of tobacco in the mouth: smoking is associated with oral cancer; smoking is associated with chronic periodontitis; smoking is associated with pyogenic granuloma; smoking is associated with necrotising ulcerative gingivitis; smoking is associated with ameloblastoma; smoking is associated with dental implant failure; smoking is associated with desquamative gingivitis. Three of these statements were deliberately chosen as distracters where there is no valid evidence for an aetiological role for tobacco. The questionnaire also contained the following statement, ‘Depending on your course and your year of study, you may not have studied some of the items. Please only answer what you know; do not guess.’ Provision was made for ‘Don’t know’ responses. Students were also asked to agree or disagree with statements concerning the ability of dentists, dental hygienists and dental nurses to provide TUC counselling and whether they agreed that these three groups of dental clinical workers should provide such counselling. Students were asked if they had received instruction in TUC counselling and whether they agreed with the recent Irish ban on smoking in enclosed places of employment. To maximise returns the questionnaire was kept as short as possible (two sides of a sheet of paper). Returned questionnaires were entered in Epi Info ver 6 (Centers for Disease Control, Atlanta, GA, USA) and analysed in both Epi Info and JMP6 (SAS Institute, Inc., Cary, NC, USA). Statistical testing was by chi-squared or Fisher’s exact test, as appropriate; P-values 1% are expressed to the nearest percentage point.
Results Completed questionnaires were returned from 586 students. This represents 90% of all dental, dental hygiene and dental nursing students surveyed. Detailed response rates are shown in Table 1. As students from Northern Ireland were known to form a reasonably large proportion of the students surveyed, and as
Eur J Dent Educ 12 (2008) 17–22 ª 2008 The Authors. Journal compilation ª 2008 Blackwell Munksgaard
McCartan et al.
Irish dental attitudes to tobacco use cessation
TABLE 3. Mean knowledge scores of dental and dental hygiene students, by year of study
these students may variously describe themselves as Irish, British or Northern Irish, students recording any of these three national descriptions were placed in one group. Of the remaining students, those from the Middle East were grouped together as were those from other parts of Asia. African students were another group while the remainder were placed together in a miscellaneous group, which included students from the Americas, elsewhere in Europe and Australasia. Table 2 shows the distribution of respondents by course, sex and nationality.
1
2
3
4
5
6
All
Mean score Dentistry Dental hygiene
1.4 2.6
1.5 5.4
2.6 5.4
3.6 –
4.7 –
5.4 –
3.2 4.4
Dentistry year 6 and dental hygiene year 3 are newly qualified.
The questions on the effectiveness of members of the dental team as TUC counsellors produced mixed results. In all, 82% felt that dentists could be effective. This proportion was highest (95%) in the newly qualified dentists. Eighty-three per cent agreed that dental hygienists could be effective counsellors. Again this was highest (92%) among newly qualified dentists. Only 58% felt that dental nurses could be effective counsellors. There was no statistically significant increase in this figure over the years of the course as students gain more exposure to dental nurses. For all three of these views on effectiveness as TUC counsellors, the number expressing no opinion dropped over the years. These attitudes are shown in more detail in Table 4. As dental nursing is an overwhelmingly female profession, the views of the dental students were further analysed to look for a sex bias. While the proportion in men was lower than that in women (54% vs. 61%), there was no statistically significant difference between the opinions of the sexes. In all, 80% of dental students and newly qualified dentists felt that dentists should give TUC advice. Again this proportion was highest in the newly qualified dentists (95%). Eighty-three
Dental students There were 418 replies from dental students and newly qualified dentists, a response rate of 90%. The median age was 22 years (range 17—42); 62% were female. The proportion of dental students currently smoking was 12% (females 10%, males 15%). These figures were heavily dependent on nationality. No African dental student smoked while the rate in Middle Eastern dental students ranged from 0% in females to 35% in males. The mean score for knowledge of the oral effects of tobacco was 3.2; this score increased steadily over the years of study, from 1.4 in first year to 5.4 among newly qualified dentists (Table 3). Support for the Irish smoking ban was overwhelming, 97%. This figure was heavily influenced by the fact that only 10 male Middle Eastern students of 20 supported the ban. When they are excluded from the total, support was 98%. Only 10% of dental students reported having been instructed in TUC counselling. This percentage was highest among fifth year students (17%) and newly qualified dentists (21%). TABLE 1. Number of respondents (and percentage response), by school, course and year of study
Year
Cork
Dublin
Dental Year Dentistry hygiene 1 2 3 4 5 6 All
40 36 30 28 27 35 196
(90) (86) (81) (85) (79) (92) (86)
Dental nursing
11 (85) 46 (79) 13 (93) 27 (100) 10 (100)
34 (92)
73 (86)
Both
Dentistry
Dental hygiene
36 (90) 7 36 (100) 7 37 (93) 5 35 (97) 38 (97) 40 (98) 222 (94) 19
Dental nursing
(100) 15 (100) (100) 13 (87) (63) 14 (93)
(86)
42 (93)
Dental Dental Dentistry hygiene nursing 76 72 67 63 65 75 418
(90) (92) (87) (91) (89) (95) (90)
18 (90) 20 (95) 15 (83)
61 (84) 40 (95) 14 (93)
53 (90)
115 (88)
In each column, the last entry represents the newly qualified. Values are expressed in n (%). TABLE 2. Distribution of respondents by course, sex and nationality Dentistry Nationality
Men
Irish/UK Middle Eastern Asian African Miscellaneous Not stated Total
114 20 5 13 5 0 157
(19) (3) (1) (2) (1) (0) (27)
Dental hygiene
Dental nursing
All
Women
Both
Men
Women
Both
Men
Women
Both
Men
221 13 10 8 6 3 261
335 33 15 21 11 3 418
1 0 0 0 0 0 1
50 0 0 1 1 0 52
51 0 0 1 1 0 53
0 0 0 0 0 0 0
111 0 0 0 3 1 115
111 0 0 0 3 1 115
115 20 5 13 5 0 158
(38) (2) (2) (1) (1) (1) (46)
(57) (6) (3) (4) (2) (1) (71)
(
