Prevalence of Smoking among Dental Students in Bangalore - A Questionnaire Based Cross Sectional Study

Introduction

Tobacco smoking claims about eight million lives annually, making it one of the leading causes of mortality worldwide.¹ In long-term smokers, the toxic compounds in tobacco results in serious health hazards. In terms of oral diseases like periodontitis, oral cancers, and systemic diseases like lung cancer and cardiovascular disease, tobacco smoking, specifically cigarette smoking is recognized as the most significant environmental risk factor.²

In addition, smoking increases the risk of developing periodontal disease, which is characterized by deepened periodontal pockets, increased attachment loss and consequent tooth mobility, increased tooth loss, gingival recession, a higher risk of dental implant failure, a higher risk of peri-implantitis, and unsatisfactory outcomes from both surgical and nonsurgical periodontal therapy.³

Further evidence links tobacco use to a higher risk of alveolar osteitis following tooth extraction and delayed healing following oral surgery.⁴ Additionally, tobacco use has been linked to gingival pigmentation, diminished taste sensitivity, halitosis, and discoloration of teeth and dental restorations.⁵

Smokers have been observed to benefit from specific drugs, including nicotine replacement therapy (NRT) products like nicotine gum or patches and antidepressants like Zyban and Bupropion. Conversely, non-nicotine medications are rarely used and have not shown long-term efficiency. However, the treatment of tobacco dependency with nicotine replacement therapy has been repeatedly proven effective.⁶

Despite the well-established negative effects of smoking, research indicates that a significant proportion of healthcare workers are smokers.⁷ Dentists play a major role in tobacco cessation programs by educating patients about the adverse effects of smoking, particularly with regards to oral health. Considering that dental students belong to the younger and future generations, it is possible to effectively reduce smoking in India by demonstrating comprehensive knowledge and a positive attitude towards smoking cessation.⁸ Thus the aim of the present study was to determine the prevalence of cigarette smoking among dental students and interns and to assess their level of knowledge and awareness about the negative effects of smoking on oral health.

Materials and Methods

A cross sectional survey was conducted from March 2022 to April 2022 (two months) among 268 3rd year, 4th year dental students and interns of two dental colleges in Bangalore, affiliated to Rajiv Gandhi University of Health Sciences. A questionnaire was prepared based on the global health professional students survey (GHPSS) by WHO and few additional questions from another study were also added to meet the objectives of the study.⁹ The questionnaire included socio demographic data (gender, age & academic level), as well as questions on smoking behaviour, attitudes and awareness regarding the oral health effects. Before data collection, official written ethical approval was obtained from the Institutional Research Ethics Committee (Reference Number- VIDS-IEC/ PG/APP/2022/011). In order to maximize the number of respondents, the survey was carried out during class periods and no personal information was gathered and to ensure confidentiality, surveys were collected using a drop box.

Results

A total of 268 students participated in the study. The age range of the students was 19–26 years. Female students constituted the majority of the respondents in the survey. The distribution of respondents based on demographic data is shown in Table 1.

Prevalence of smokers and smoking behaviour

Figure 1 depicts the prevalence of smokers. Among the 268 consented respondents, 107 (39.9%) were found to be smokers.

Exposure to environmental tobacco smoke and chewing tobacco

Table 2 depicts the age at which the respondents were first exposed to tobacco smoke. Among the respondents, 60.1% (n=161) had never smoked. A statistically significant proportion of students (P <0.001) started smoking between the ages of 11 and 16 years (5.2%; n = 14), whereas 34% (n = 91) started smoking after the age of 17 years.

Attitude towards cessation of tobacco products

As depicted in Table 3, majority of students responded that advertising for tobacco products should be completely banned and that they preferred receiving specific training on cessation techniques. These findings were found to be statistically significant.

Attitude towards cessation advise for smoking patients

Although research participants were aware of NRT, those who smoked were less likely to quit. Additionally, professionals who smoked were less likely to counsel patients to quit, with a statistically significant P value <0.001 (Table 4).

Awareness regarding the effects of smoking on oral health

The study population were aware of the negative effects of smoking on dental health, which was found to be statistically significant. Table 5 shows that although 51.1% of participants were unaware, 48.9% of participants were well informed that smoking does not cause bleeding gums.

Discussion

In this study, the prevalence of smoking among dental students was investigated, along with their knowledge and awareness regarding the negative effects of tobacco smoking on oral health. Research has revealed that despite their awareness of the negative health impacts of smoking, many students pursuing careers in the medical field still smoke.⁹

Prevalence of smoking among dental students was approximately 39.9% in this study (Figure 1), which was lower than 50% prevalence among medical professionals in Bangalore reported in a study conducted five years ago.¹⁰ The age of initiation of smoking among dental students was found to be between 11 and 15 years (Table 2), which was comparable to the study conducted by Jayachandra et al. in the year 2018.¹⁰ Another research investigation conducted in Saudi Arabia found a higher prevalence of smoking, at approximately 21.1% among medical students in the year 2019.⁹ Our findings show that 39.9% of dental students in Bangalore smoke, while around 60.1% have never smoked. Approximately 68.3% of health professionals who were smokers were less likely to advise patients to quit smoking, regardless of information and experience regarding tobacco use and nicotine replacement therapy (Table 4). Dental professionals must be aware of this shortcoming and incorporate oral health promotion into their clinical practice.

The majority of participants (11.9%) demonstrated willingness to quit smoking. Also currently, 22% of participants did not smoke, and roughly around 2.6% were not ready to quit (Table 4). In a study conducted in the year 2019 by Alkhalifah et al. in Saudi Arabia, medical students were less conscious of knowledge regarding staining, halitosis, and oral cancer (90.2%, 89.2%, and 85.6%, respectively).⁹ Dental students in our study were better informed about the impact of cigarette smoking on oral health, including staining, halitosis, and oral cancers (100%, 98.5% and 99.3%, respectively) and also awareness about periodontitis, delayed wound healing, oral ulcers ( 98.1%, 97%, 94.4%, respectively) (Table 5). At the same time, knowledge and awareness regarding hairy tongue and dental caries were comparatively lower (79.9% and 68.7%, respectively), while awareness about bleeding was found to be at 51.1%. According to a systematic review conducted in Denmark in the year 2018, quitting smoking reduces the incidence of periodontitis and enhances the results of non-surgical treatment.¹¹ Dentists have a significant influence on the patients' decision to avoid smoking. Additionally, the patient and dentist communicate frequently, which facilitates the dentist's ability to constantly motivate individuals. However, evidence indicates that dentists encounter plenty of challenges while providing care, including lack of time, inadequate training, and concern of breaking the patient-dentist connection.¹²

Limitations

This study has certain shortcomings. It was limited to interns and third- and fourth-year undergraduate dentistry students from two dental colleges in Bangalore. The majority of respondents were females, and the sample size was modest. Therefore, it is possible that the results fail to adequately reflect the perspective of all Bangalore dental students. Moreover, it is possible that the results may not apply to populations in other geographical regions.

Conclusion

Significantly large number of dental students demonstrated good overall knowledge about the effects of smoking, but were unwilling to quit despite knowing the effects of smoking on specific oral health conditions, indicating the need for additional education. Dentists are in an exceptional position to raise awareness regarding smoking cessation and offer helpful guidance. Further research with a larger and more diverse sample may be necessary.

Conflict of Interest

Nil