Knowledge, Attitudes and Practices Related to Smokeless Tobacco and Areca Nut Cessation Among Dental Surgeons in Sri Lanka

Background: Prevalence of smoking in Sri Lanka shows a gradual reduction whilst the use of smokeless tobacco and areca nut shows an increasing trend. At present adequate numbers of smokeless tobacco / areca nut cessation counseling programs are not being carried out in Sri Lanka. As the Dental surgeons could play a signicant role in smokeless tobacco / areca nut cessation activities, capacity building programmes for dental surgeons on smokeless tobacco/ areca nut control were carried out. The study was planned to evaluate the knowledge, attitude and practices related to smokeless tobacco/ areca nut control among dental surgeons. Methods: A cross sectional study was conducted. Two questionnaires were used to assess the improvement of knowledge and change of attitudes following programmes on smokeless tobacco / areca nut control. Results: There were 663 participants in the study. 27.1% of them had received formal tobacco cessation training in the past. Majority had a good knowledge on harmful effects of smokeless tobacco but not on areca nut. Their knowledge on the current legislation on smokeless tobacco control in Sri Lanka and carcinogenicity of areca nut was not satisfactory. Almost all agreed that proper counseling leads to patient quitting the habit, a formal training is necessary to conduct tobacco control activities and it should be the part of the regular treatment modalities. More than 80% of the Dental surgeons believed that they should support strict legislation. Almost 50% agreed on tobacco and areca nut free environment in their dental clinics. Most important factors leading to poor involvement in tobacco cessation activities were lack of expertise and inadequate educational material, not breach of patient privacy and lack of nancial incentives. Surprisingly, 20.1% of the dental surgeons had consumed smokeless tobacco / areca nut products in the past and only a few were current users of tobacco and/or areca nut. Conclusions: Well planned workshops are ecient and cost effective in improving knowledge, practices and attitudes of Dental surgeons towards smokeless tobacco / areca nut cessation.

areca nut. Their knowledge on the current legislation on smokeless tobacco control in Sri Lanka and carcinogenicity of areca nut was not satisfactory. Almost all agreed that proper counseling leads to patient quitting the habit, a formal training is necessary to conduct tobacco control activities and it should be the part of the regular treatment modalities. More than 80% of the Dental surgeons believed that they should support strict legislation. Almost 50% agreed on tobacco and areca nut free environment in their dental clinics. Most important factors leading to poor involvement in tobacco cessation activities were lack of expertise and inadequate educational material, not breach of patient privacy and lack of nancial incentives. Surprisingly, 20.1% of the dental surgeons had consumed smokeless tobacco / areca nut products in the past and only a few were current users of tobacco and/or areca nut.
Conclusions: Well planned workshops are e cient and cost effective in improving knowledge, practices and attitudes of Dental surgeons towards smokeless tobacco / areca nut cessation.

Background
According to the World Health Organization (WHO), tobacco kills up to half of its users, more than 8 million people die each year out of which more than 7 million due to direct tobacco use and the rest as a result of exposure to second-hand smoke. Use of tobacco is a major problem in low and middle-income countries where around 80% of the tobacco users live [1]. Alarmingly, smokeless tobacco is also associated with serious health consequences. In India, it has been estimated to have around 370,000 deaths due to smokeless tobacco use and out of which 60% are females [2]. According to the 2018 WHO factsheet on Sri Lanka [1], tobacco is responsible for 12,351 deaths and it represents 10% of all deaths. It has estimated to have 2.1 million current tobacco users in the country.
Tobacco is a common addictive substance used by many individuals all over the world for centuries. In a survey conducted in 2012, 15.8% of Sri Lankans which includes 8.6% of the youth have been estimated to be smokeless tobacco (SLT) users [4]. However, in contrast to smoking, SLT use is gaining popularity especially among the youth. SLT products used by these individuals include betel quid and other commercially available tobacco products such as pan masala, mawa, red tooth powder, khaini, tobacco powder, zarda and many others [4]. In addition, use of areca nut with traditional betel quid is a frequent habit. Areca nut has been identi ed as a group I carcinogen by IARC. In most instances, it has been used as a part of the betel quid but there is a trend especially among youth to use commercially prepared areca nut packets [5]. The harmful effects of SLT use has been well documented and includes high prevalence of oral potentially malignant disorders (OPMD) and oral squamous cell carcinoma (OSCC). It is the number one ranked cancer with a high mortality out of all cancers among Sri Lankan males [6]. Most devastating oral health effect of areca nut is occurrence of oral submucous brosis (OSF). Public awareness on oral cancer and OPMD as well the risk habits contributing to those lesions appear to be not satisfactory. [7,8].
There had been several attempts to develop a successful SLT cessation model [9]. However, it is unfortunate that successful SLT cessation programs are yet to be developed. Most people are unaware of the harmful effects of areca nut (AN). Social values and beliefs lead to the notion that areca nut is harmless. In addition, addiction to areca nut further complicates the issues. Therefore, these factors have been identi ed as some barriers for people not to quit areca nut chewing habit. From the patients point of view, lack of time, lack of rapport with the individuals who conduct SLT/AN control programs and accessibility to cessation centers have been identi ed as signi cant shortcomings [10].
Dental patient visits the dental clinic multiple times per year as part of their routine examination. As such dental surgeon is in an ideal position to identify oral effects of tobacco. These visits provide an ideal opportunity for the dental surgeons' to offer tobacco cessation advices and counseling. According to the management protocols of OPMD established in Sri Lanka [11], low risk OPMDs is managed at primary care level by dental surgeons with education on habit intervention with 6-month review appointments. Therefore, tobacco and areca nut cessation advice has to be considered as an important duty of a dental surgeon. Thus, dental surgeons are well suited and can play a major role in tobacco cessation activity and dental clinic is an ideal place to implement it [12,13,14,15]. Lack of knowledge and experience has been identi ed as an important barrier in carrying out tobacco cessation activities by dental surgeons [16]. With these shortcomings in mind, island-wide capacity building workshops to train healthcare workers on tobacco and areca nut cessation activities were planned by the Centre for Research in Oral Cancer, Faculty of Dental Sciences, University of Peradeniya in collaboration with Presidential Task Force for Drug Prevention and Ministry of Health, Sri Lanka. The present study targeted the participants of these programmes to evaluate the successfulness of the programme with reference to change in their knowledge, attitudes and practices towards tobacco and areca nut cessation. In addition to assessment of the application of imparted knowledge and attitudes towards conducting successful SLT/ areca nut cessation programmes in their dental clinics.
Majority of tobacco cessation protocols have been developed for smoking cessation [17,18]. However, though the same protocols can be applied for SLT cessation as well, successful implementation may require at least some modi cations. SLT is used together with areca nut in betel quid especially in South and South East Asian countries. Areca nut is also a known powerful addictive substance. Therefore, tobacco cessation should be targeted together with areca nut cessation. Dependency and withdrawal symptoms of SLT use as well as areca nut use show differences when compared with smoking [19,20].
Thus, a training programme on SLT and areca nut cessation was developed to improve the knowledge and skills of dental surgeons targeting the situation and needs of the country.
The impact of the training programme was evaluated by knowledge that they have gained and/or a change of attitude towards tobacco cessation using a pre-tested questionnaire. The ndings will be useful to improve the quality of the training programs to be developed in the future.

Methods
This study was conducted with the general objective of evaluating the improvement of knowledge, change of attitude and practices related to smokeless tobacco and areca nut cessation among dental surgeons following a workshop.
A cross sectional study was conducted among the participants attending a series of workshops conducted to train dental surgeons on SLT and areca nut cessation practices. Two questionnaires were developed to assess dental surgeons' knowledge and attitudes towards tobacco cessation practices. The rst questionnaire was given prior to the workshop and consisted of ve components including demographic pro le of the participants: age, gender, number of years in service and designation, knowledge related to effects of SLT and areca nut with tobacco cessation practices, attitudes regarding smokeless tobacco cessation counseling (TCC) and ways to reduce SLT use, tobacco control measures undertaken by dental surgeons and barriers to implement tobacco cessation counseling in dental clinics. Cancer together with Ministry of Health and Presidential Task Force on Drug Prevention to educate and train health care workers on SLT and areca nut cessation. These workshops were conducted in all provinces of the country with more than one program for larger provinces by experienced and well trained specialists in the elds of Oral Medicine, Oral Pathology and Community Dentistry. Questionnaires were pretested using the dental surgeons working in the University Dental Hospital Peradeniya whose responses were excluded from the main study. Workshops were composed of lectures on SLT and areca nut related disease burden of the country, health effects of SLT and areca nut, legislation on tobacco and areca nut in Sri Lanka, tobacco cessation methods with a demonstration followed by a group work and open discussion. All the dental surgeons who were participating in these training workshops were recruited for the study after obtaining their informed consent. Dental surgeons who submitted an incomplete questionnaire with less than 70% responses were excluded from the study.

Data analysis
The SPSS (version 22) software package was used for the data analysis. Data obtained from the questionnaire were entered in SPSS software and were expressed as frequencies (percentages)

Results
A total of 663 questionnaires were considered in the analysis. This study group had a female preponderance, with the age ranges from 28 to 60 years with majority belonging to above 35 years. Out of the participants 490 (73.9%) had never consumed tobacco in any form in their lifetime and 133 (20.1%) had past habit of tobacco consumption.
It was interesting to note that 14 (2.1%) and 15 (2.3%) had consumed only SLT and areca nut respectively. Majority (2.7%) of them has initiated the habit between the ages of 16-20 years and practiced the habit for 1-5 years (22%). The popular reasons for tobacco consumption were recorded as part of the culture and to keep the company with friends. It was surprising to see that only 180 (27.1%) dental surgeons had received formal training in tobacco cessation methods.
Analysis of the knowledge related to Smokeless tobacco, its effects and cessation practices There were ten questions to assess the knowledge of dental surgeons and, eight questions demonstrated a statistically signi cant increase in knowledge (P < 0.05) following the workshop when compared to the pre workshop knowledge. Interestingly, none of the questions had at least 80% correct response and six questions had less than 50% correct responses prior to the workshop. Therefore, majority didn't know the facts, that "Red tooth powder is a SLT popular among children" (16.1%), "Manufacturing and selling of SLT products is banned in Sri Lanka" (48%), "Four persons die each day in Sri Lanka due to SLT use" (36.8%), "Withdrawal symptoms may prevent SLT users from quitting the habit" (42.5%), "SLT users can be given existing drugs prescribed to combat cigarette craving" (21.3%), and "Five "R" concept can be used in counseling a client who is unwilling to quit SLT use" (33.2%). Pre and post assessment, a highly signi cant difference was observed (P < 0.001) for all ten questions (Table 1).  (14)(15)(16)(17)(18)(19)(20) with the mean of 18.7 (SD 1.56). These total scores were converted to Z scores. The total Z scores were dichotomized: Less than zero as 'unsatisfactory attitudes' and above zero as 'satisfactory' attitude. McNemar test was carried to test the signi cance of the differences of pre and post workshop assessment. Table 2 shows the pre and post dichotomized attitude scores. With these two correlated samples, change of attitude in pre and post assessment was highly signi cant (P < 0.001).

Tobacco control measures undertaken by Dental surgeons
There were six different questions to assess this section and only 283 (42.7%) had the habit of routinely inquiring regarding tobacco use from all patients. Almost 50% enforced a tobacco product free environment in their clinics. It was encouraging to note that 233 (35.1%) dental surgeons provide advice against SLT use when they identify a patient to be a SLT user even without any lesion present in the oral cavity due to SLT use. In contrast, 5.7% of the dental surgeons only provided any advice if the patient has a lesion due to SLT use. Further, 34.2% of the dental surgeons practice tobacco cessation counselling in their clinics using patient education via audio and video materials, providing lea ets to all patients to read followed by discussing with them the consequences and motivation to cease SLT/AN use in detail.
Only 127 (19.2%) claim that they were unsuccessful in their tobacco cessation counselling.

Barriers encountered to implement tobacco cessation counseling
Out of the six reasons given, the two most popular reasons were lack of educational materials (39.7%) and lack of expertise (30.8%) (Table 3).

Discussion
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 identi ed 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 e cient in SLT cessation but regular telephone support/quit-lines also appeared to be bene cial 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 noti cation 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 rst of this nature to identify knowledge, attitudes and practices regarding TCC among dental surgeons in Sri Lanka. We will be using the ndings 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 ndings 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 nonresponse 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-identi ed 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 identi ed as an ideal group of health professionals to carry out SLT cessation activities. Brief intervention at dental o ce 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 signi cant percentage of dental surgeons are not having su cient knowledge especially on some aspects of SLT cessation. Analysis of post workshop questionnaire showed that the dental surgeons improved their knowledge signi cantly 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 signi cant 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 de nitely bene t 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 ndings, 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 e cacy in SLT cessation and it has been identi ed 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 ndings 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 lea ets to all patients. Around 40% of the respondents have identi ed 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 identi ed 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 signi cant percentage of dental surgeons use tobacco, specially smoking [25].

Conclusions
Smokeless tobacco cessation intervention in the dental clinic is a simple, cost effective method of promoting people to give up the risk habit. Tobacco cessation counseling should be part of routine dental care. Present study highlights the importance of having proper training programs for dental surgeons on tobacco cessation with a special attention on smokeless tobacco and areca nut cessation.

Declarations
Ethics approval and consent to participate RDJ conducted literature searches and provided summaries of previous research studies, involved in conceptualization, Project administration and wrote the rst draft of the manuscript. PJ designed the study and wrote the protocol. HA conducted the formal statistical analysis. SS and KH involved with initial protocol development, data collection and editing of the rst draft. DW involved with data acquisition and curation. SK involved in fund acquisition and data collection. WMT involved with project administration. Apart from each speci c role all the authors contributed to and have approved the nal manuscript.