Smoking is mostly associated with respiratory and cardiovascular diseases including lung cancer whereas SLT causes oral ill effects including development of oral and oropharyngeal cancer. Tobacco cessation counseling has been identified as an effective method of promoting the users to give up the habit and it is considered as part of the routine work of health care professionals. There are multiple interventions for tobacco cessation. There had been extensive work on smoking cessation but research on smokeless tobacco cessation is scarce [21]. Most of the interventions appear to be effective against both smoking and smokeless tobacco use. Behavioural interventions are highly efficient in SLT cessation but regular telephone support/quit-lines also appeared to be beneficial in addition to some pharmacological interventions [21].
There are multiple action plans in practice to minimize the use of tobacco in Sri Lanka, but most of these initiatives are targeted on smoking. With the initiatives of the Smokeless Tobacco Project Committee of the National Authority of Tobacco and Alcohol (NATA), a gazette notification has been issued banning the production, distribution and sale of SLT products in the year 2016. However, this important legislation has not being implemented effectively in the country. Awareness among both public and health care professionals appears to be inadequate, and supporting this fact 48% of the dental surgeons who participated in this survey were not aware on this regulation.
To the best of our knowledge, this study is the first of this nature to identify knowledge, attitudes and practices regarding TCC among dental surgeons in Sri Lanka. We will be using the findings of this study to improve the tobacco cessation counseling in the country by introducing appropriate programs. Our sample size was 663 which is more than 25% of the dental surgeon strength in Sri Lanka. Therefore, the findings of this study can be considered as a representation of the situation in the country. Limitations of the study include some incompletely answered questions in questionnaires which may lead to non-response bias. In addition, effectiveness of the workshops was only assed immediately after the workshop and therefore long term effectiveness was not assessed. Similar to any questionnaire-based study, we have collected self-reported data form the participants and therefore the answers to some of the questions might not be accurate specially the attitude and practice component of the questionnaire. In order to minimize this bias, de-identified questionnaires were used.
As SLT usage is common in Sri Lanka and also on the rise, it’s important to promote SLT cessation. Dental surgeons are identified as an ideal group of health professionals to carry out SLT cessation activities. Brief intervention at dental office is very effective in preventing SLT use among general population [22]. Brief interventions or behavioral change interventions are useful in both smoking and smokeless tobacco cessation [21, 23]. Formal training is mandatory to initiate tobacco cessation. Binnal et al (2012) in their study conducted in India with house surgeons in one dental institute have reported that 97% of the participants in their study were willing to undertake tobacco cessation activities but 93% of them were lacking adequate training [16]. We have observed that only 27.1% of the dental surgeons in this study have received any formal training in tobacco cessation highlighting the importance of organizing more and more such programs for the dental surgeons and other health care professionals. Findings of the pre work shop questionnaire evaluation demonstrated that a significant percentage of dental surgeons are not having sufficient knowledge especially on some aspects of SLT cessation. Analysis of post workshop questionnaire showed that the dental surgeons improved their knowledge significantly demonstrating the effectiveness of the workshops conducted. However, as the assessment was done immediately after the workshop, this will not indicate along term effectiveness. A separate study is being planned to identify the long term success of the workshop.
Dental surgeons are in an ideal position to advice their patients regarding the ill effects of tobacco and it must be considered as part of their routine work. Having proper attitudes towards tobacco cessation is an essential requirement for successful implementation of such programs, similar to many other studies conducted around the world [16, 24, 25]. Sri Lankan dental surgeons had a satisfactory level of good attitudes towards tobacco cessation. This aspect has shown a statistically significant improvement after the workshop highlighting that properly planned workshops can be used to improve not only knowledge but also attitudes of dental surgeons towards tobacco cessation. We have observed that only 42.7% of the respondents had the habit of inquiring regarding tobacco usage from all of their patients routinely. This is much less than the reported numbers in the literature [25]. Giving up the SLT habit early will definitely benefit the patient as the chances of developing adverse effects increase with the duration of SLT use. In this regard, it is encouraging to observe that 35.1% of the dental surgeons provide advice against SLT use for SLT users in their clinics even when they are without any oral mucosal lesions. However, there is room for further improvement as compared to literature this good practice is less often implemented by Sri Lankan dental surgeons [25]. Furthermore, 5.7% of the respondents provide tobacco cessation advice only when the patient is having a lesion due to SLT use, which is unacceptable as each and every person with SLT/AN use should receive TCC.
Maintain a tobacco free environment in the health care institution is important to motivate the patients to give up the habit. Ministry of Health as well as Ministry of Public Administration of Sri Lanka has issued relevant circulars banning the use of tobacco in government institutions in Sri Lanka. Dental surgeons must play a leading role in implementing these circulars in their institutions. According to our findings, only 50% of the participants enforce a tobacco product free environment in their clinics.
There are multiple methods of providing knowledge on tobacco cessation to the patient. Behavioural interventions by health care professionals alone have shown a high efficacy in SLT cessation and it has been identified as the most suitable tobacco cessation intervention for countries with low-resources but high SLT burden [21]. Information on SLT cessation interventions are minimal and therefore, research in this area must be encouraged to identify the most appropriate intervention. Al-Maweri et al reported that around half of the Yemeni dental surgeons in their study believed that tobacco cessation intervention may affect their clinical practice and reduce their income and they also believed that provision of dental treatment is more important than providing TCC [25]. Similar findings were reported by others as well [26]. In contrast, only a small minority of Sri Lankan dental surgeons in the present study thought that it can affect their income and clinical practice whereas majority believed that providing TCC is equally important as any routine dental treatment.
In addition to the tobacco cessation counseling by a trained dental surgeon, extra educational material is very helpful. Some of the dental surgeons who participated in this study practice tobacco cessation counselling in their clinics together with patient education using audio, video materials and by giving leaflets to all patients. Around 40% of the respondents have identified lack of educational materials as a main barrier in implementing tobacco cessation counseling. Therefore, this fact has to be taken seriously by the relevant authorities and necessary steps have to be taken to develop educational materials to the patients in their languages.
Most of the dental surgeons have tried to carry out tobacco cessation counselling. However, 19.2% of them claim that they were unsuccessful in their efforts. Lack of experience was considered as an important barrier by 30.8% of the participants in this study highlighting the importance of having regular formal training on tobacco cessation.
Self use of tobacco by health care professionals has been identified as a main barrier in controlling tobacco use among people. It has a direct impact on the attitude of the dental surgeon towards TCC where non users were showing better attitudes [25]. Most of the dental surgeons believe that they must refrain from using tobacco products and must act as role models [26]. Past users of tobacco in the present study was as high as 15.2% with 2.1% had used SLT. There are only a very few dental surgeons who are current tobacco and/ or areca nut users. This is completely different from most of the studies reported where a significant percentage of dental surgeons use tobacco, specially smoking [25].