Effectiveness of an Educational Smoke Cessation Counseling Intervention on Knowledge, Attitude, and Skills of Undergraduate Dental Students in IranABSTRACT
Objective: To investigate the impact of an educational intervention on the knowledge, attitude, and skills of dental students regarding smoking cessation.
Material and Methods: The participants were dental students in their 7th (Intervention group) and 8th semester (Control group) between February and July 2022. The intervention group received an educational package consisting of a lecture, a podcast, a seminar, and role-playing on smoking cessation, while the control group only received a lecture. The students' knowledge, attitudes, and skills were assessed using a questionnaire. The questionnaire included statements regarding the importance of learning about smoking cessation, the level of students' knowledge of and attitudes towards treating tobacco addiction, and skills related to quitting smoking. Moreover, students' knowledge about the physiology of addiction, non-nicotine drugs for smoking cessation, and electronic cigarettes was evaluated.
Results: In total, information from 55 students was used. In the intervention group, an increase was found in the willingness to advise patients from 56% to 92% (p=0.003), the mean score of knowledge regarding electronic cigarettes (3.11±1.65 to 4.19±1.33, p=0.001), agreement with "I can get information about the patient's smoking" from 22% to 90%, "I am able to advise for quitting smoking" from 38% to 81%, "I can provide recommendations for smoking cessation" from 22% to 58%, and "In my opinion, smoking addiction is a chronic disease" from 56% to 77%.
Conclusion: Training dental students in smoking cessation counseling can enhance their understanding and motivation to assist patients in quitting smoking.
Keywords:
Smoking Cessation; Students, Dental; Education, Medical, Undergraduate
Introduction
The epidemic of tobacco use is one of the most significant threats to public health. It is also a controllable risk factor for cardiovascular diseases and mortality. Smoking is the second leading cause of years of life lost due to death or disability. In 2019, smoking accounted for about nine million deaths, making tobacco the leading cause of death globally. It is worth noting that nearly two-thirds of these deaths occur in developing countries. Smoking is responsible for approximately 8% of all DALYs (disability-adjusted life years) worldwide [1].
Studies have shown that counseling by healthcare professionals can increase the rate of smoking cessation [2]. Specifically, dental professionals have been found to be effective [3]. Since dental treatments require multiple treatment sessions and considering that the effects of smoking appear very quickly on the teeth, periodontal tissue, and oral mucosa, dentists can play a crucial role in smoking cessation counseling and encouraging their patients to quit.
It is essential to incorporate basic knowledge and skills in smoking cessation counseling into the undergraduate education of dental students. By instilling these principles during their training, students will be better equipped to address smoking cessation in their future practice. Dental schools should focus on creating a belief system that emphasizes the importance of smoking cessation counseling. The curriculum should include comprehensive and continuous education on smoking cessation to ensure that students have a positive perspective on their role as consultants in this field. This approach will help develop their expertise and facilitate its application in their future practice.
Several studies have investigated the effectiveness of such an intervention among dental students. For example, Vollath et al. [4] investigated the effect of a program that consisted of a podcast, an interactive lecture, a seminar, and a small group with role playing. In this study, 28 dental students participated in the educational program, and their knowledge, skills, and communication attitudes were measured using a written test and a structured clinical examination (OSCE) at the end of the program and 6 months later. The results were compared with a control group of 27 dental students who received standard training. Students in the intervention group scored higher in knowledge, OSCE, and skill compared to the control group. Ahmadian et al. [5] assessed the effectiveness of two educational methods (role-playing and problem-based learning) of smoking cessation counseling for dental students. They found improvement in students' scores on knowledge, attitude, and skill when compared to scores before training, without any difference between the two educational methods. Maharani et al. [6] explored the intention of Indonesian dental students to provide tobacco cessation counseling using the theory of planned behavior (TPB). They found positive attitudes and intentions towards providing counseling, influenced by subjective norms and perceived behavioral control among the students. The TPB was found to be a useful framework for understanding the factors influencing dental students' intention to offer tobacco cessation counseling.
Dental practitioners, as key healthcare providers, have a unique opportunity to engage with patients on tobacco cessation interventions during routine dental visits. However, studies have shown that dental professionals may lack the necessary knowledge, skills, and confidence to effectively address smoking cessation with their patients [7]. To address this gap, educational interventions targeting dental students have been proposed to enhance their competency in providing smoking cessation support. This research, therefore, aimed to assess the effectiveness of a comprehensive smoking cessation counseling program on dental students’ knowledge, attitude, and skills regarding the provision of this service.
Material and Methods
Study Design and Ethical Clearance
The present interventional study was conducted among undergraduate dental students of Shahid Beheshti University of Medical Sciences (SBUMS) in Tehran, Iran, and it was approved by the institution's Ethics Committee (ethic code: IR.SBMU.DRC.REC.1401.048). Participation in the study was voluntary, and the students' acceptance to fill out the questionnaires was regarded as informed consent to enter the research.
Sample
The target population comprised all dental students in the 7th semester (intervention group) who took the course "Practical Community Oral Health II" and the 8th semester (control group) who had passed the course in the previous semester.
Data Collection
During February-July 2022, one of the authors (FA) explained the aim of the study in one of the classes of the students separately for each group at the beginning of the semester in the school of dentistry and asked them to participate in the study by completing a questionnaire as a pre-test. Afterward, students in the intervention group received the educational package on smoking cessation in the format of a lecture, a podcast, a seminar, and role playing during the semester, while students in the control group did not receive any education on this subject. Students of both groups completed the questionnaire as a post-test at the end of the semester.
The instrument for data collection in this study was the translation of the questionnaire that was conducted at the University of Gottingen, Germany [4]. The questionnaire was requested from the researchers at the University of Gottingen, and after translation and minor modifications for adaptation to the Iranian culture, its validity has been assured by revisions based on the advice of a group of professors in the department of dental public health of Shahid Beheshti School of Dentistry. To assess the reliability of the questionnaire, a test-retest process on 20 students with a two-week time period was conducted, which resulted in a Kappa statistic of >0.9.
The questionnaire included the assessment of learning counseling skills for smokers to quit addiction, the level of knowledge of students in addiction treatment methods and their mechanisms, students' attitudes towards the chronic nature of addiction, students' skills in gathering information from patients about tobacco use, and providing useful recommendations for smoking cessation to patients seeking help. Also, in this questionnaire, students' knowledge about the physiology of addiction and electronic cigarettes was evaluated.
The educational package for the intervention group in this research consisted of four parts as follows:
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Podcast: Based on the book “Guidelines for Smoking Cessation” published by the Tobacco Prevention and Control Research Center (SBUMS), a 20-minute podcast was produced by FA and made available to the students. The content of the podcast included epidemiology of smoking, the basic principles of counseling, 5A and 5R strategies, first-line drugs in nicotine replacement therapy and non-nicotine drugs.
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Lecture: In this 60-minute session, one of the authors (GH, Head of the Tobacco Prevention and Control Research Center, SBUMS), presented the following subjects for the students: the epidemiology of tobacco use in developing and developed countries, history and the trend of the tobacco epidemic, the mechanisms of nicotine addiction, the side effects of hookah consumption in comparison to cigarette, the symptoms and cycle of change in smoking cessation, barriers for implementing smoke cessation, the way of dealing with smokers, behavioral therapy in smoking cessation, nicotine replacement therapy and non-nicotine drugs, and available services of the Tobacco Prevention and Control Research Center, SBUMS. At the end of the session, the presenter answered and discussed the questions raised by the students regarding the lecture.
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Seminar: In this session, the students' questions related to the podcast and the lecture were answered and explained by GH. Moreover, some tips about smoke cessation counseling strategies (5A and 5R), indications and contraindications of smoke cessation drugs (such as nicotine replacement therapy, bupropion, and varenicline) were presented and discussed.
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Role-playing: the students engaged in a simulation of a smoking cessation counseling session, actively applying their knowledge from the preceding three interventions. Throughout these brief five-minute sessions, overseen by HG, each student took turns embodying the role of a dentist providing counseling on smoking cessation to another student acting as the patient. Prior to each session, the duo randomly selected one scenario from a variety of predefined scenarios for the patient's role, which covered topics such as tooth removal, smoking during pregnancy, oral lesions, gum health, discoloration on the tongue and teeth, as well as guidance on dental implants.
Data Analysis
Descriptive statistics involved the calculation of the frequency and percentage of students within each category. To compare the frequencies of students before and after the test, the McNemar test was applied. Additionally, the T-test was used to evaluate differences in mean scores related to knowledge or attitude. Statistical analyses were performed with SPSS software, version 21 (IBM Corp., Armonk, NY, USA), using a significance level of p<0.05.
Results
Fifty-five out of the 77 invited students completed the questionnaire, with 32 in the intervention group and 23 in the control group. Female students and those students with no smoking history were included in both intervention and control groups (Table 1).
Table 2 presents students' feedback on two questions and six statements regarding smoking and smoking cessation in the pre-test and post-test. The majority of the students in both groups reported that they usually ask patients about their smoking status, with no statistically significant difference between the two groups or between the two test times. Initially, 68% of the control group and 59% of the intervention group stated they advised smoking patients to quit. Post-intervention, the intervention group saw a significant increase to 86% (p=0.01), whereas the control group showed no significant change.
Distribution of the participants based on their feedback to 8 statements about smoking cessation.
Significant improvements were observed between pre-test and post-test in the knowledge and skills of the students in intervention group related to tobacco addiction treatment in terms of the proportion of students: reporting knowledge of how tobacco addiction is treated from 19% to 88% (p<0.001), able to explain the mechanism of addiction progression from 25% to 69% (p=0.003), confident in obtaining comprehensive information about patients' tobacco use 22% to 90% (p<0.001), able to provide useful recommendations for quitting smoking from 38% to 81% (p=0.002), and students who could offer recommendations for smoking cessation based on the individual's smoking history from 22% to 58% (p=0.006). The control group remained relatively unchanged.
In Table 3, the students' correct answers for each statement, in addition to their mean knowledge scores regarding the physiology of smoking, were presented. Mean knowledge scores were assessed in two groups at two different time points using an independent t-test. The comparison between the pre-test (p=0.37) and post-test (p=0.72) revealed no significant difference in knowledge among the students in both groups. Although the average knowledge of students in both groups increased in the post-test compared to the pre-test, the results of the paired t-test indicated no statistically significant difference.
Distribution of the participants based on their responses to 6 statements about the physiology of smoking.
Table 4 displays the number of accurate responses from the students regarding electronic cigarettes. It is evident that the intervention group exhibited a slight rise in correct responses post-test compared to pre-test, with statistically significant results based on the paired t-test (p= 0.001). The control group did not show statistically significant changes (p=0.72).
Distribution of the participants based on their responses to 6 statements about electronic cigarettes.
Discussion
Overall, the intervention effectively enhanced students' understanding regarding treatment methods, providing recommendations for smoking cessation, and knowledge on electronic cigarettes. Moreover, the intervention increased the students’ practice related to smoking cessation in terms of advice to quit smoking, highlighting its positive impact on education in this area.
The results of this study revealed that about 60% of dental students were willing to provide guidance on smoking cessation to their smoking patients initially. This figure is slightly lower than those reported in comparable studies among dental students (69%) [8] and dentists (64%) [9] in Iran. However, following the educational intervention, the percentage of students expressing willingness increased to 90%, underscoring the effectiveness of the intervention. This highlights the impact of education and awareness on changing perceptions. It can be inferred that the lack of adequate information and training may contribute to dentists' reluctance to counsel smoking patients to quit smoking. According to the theory of planned behavior, dentists' attitudes and beliefs play a crucial role in their ability to effectively advise and assist patients for optimal oral health behaviours [10].
The intervention resulted in a marked increase in knowledge related to tobacco addiction and smoking cessation methods. These findings align with those of Ghorbani et al. [11] who reported that smoking cessation counseling based on the Stages of Change Model in a dental school setting led to substantial knowledge gains. Moreover, these findings are consistent with previous research demonstrating the effectiveness of educational interventions in improving knowledge about smoking cessation among healthcare students [12] and community pharmacists [13].
The intervention also positively influenced the students' attitudes toward smoking cessation. This shift is essential for fostering a more empathetic and effective approach to patient counseling. Similar attitudinal improvements were reported by da Silva Leonel et al. [14], who found that educational interventions significantly improved Brazilian dental students' attitudes towards smoking cessation counseling. Additionally, Martínez et al. [12] highlighted that structured educational programs enhance nursing students' attitudes toward tobacco dependence and cessation.
The skills of dental students in conducting smoking cessation counseling also showed significant improvement. These findings are supported by Liu et al. [15], who found that dental students' preparedness to manage tobacco-using patients improved significantly following targeted educational interventions. Similarly, Myers Virtue et al. [16] reported that interprofessional tobacco cessation education programs for dental and pharmacy students led to improved patient outcomes in smoking cessation.
Educational interventions are effective in enhancing the knowledge, attitudes, and practical skills necessary for smoking cessation counseling. Maharani et al. [6] found that Indonesian dental students' intention to provide tobacco cessation counseling improved significantly when educational interventions were aligned with the Theory of Planned Behavior. Additionally, Rajesh et al. [17] reported that counseling as a tool for tobacco cessation in a dental institution in India led to notable improvements in students' counseling skills.
Our study suggests that integrating structured smoking cessation education into the dental curriculum is crucial for improving the competencies of future dental professionals. Dental professionals play a significant role in public health and equipping them with the right knowledge and skills can effectively contribute to reducing tobacco use among patients. This supports the broader trends in health education, which emphasize comprehensive training to adequately prepare future healthcare providers. Sadhu et al. [18] further support this notion by demonstrating that interactive educational methods significantly enhance dental students' counseling skills.
In this study, a range of teaching methods were employed to enhance students' understanding. The researchers attempted to combine traditional teaching methods, such as lectures, with active methods that involved student participation, such as discussions and role-playing. This was done because certain content, such as the mechanism of action of tobacco, its effects on the body, and strategies for overcoming addiction, can be better presented in a theoretical manner. Theoretical frameworks also serve to accumulate knowledge in empirical studies, thus forming the foundation for the development of more effective interventions. Previous studies have indicated that both active learning methods and traditional approaches are beneficial in teaching smoking cessation counseling to medical students.
In the study of Park and his colleagues, the effectiveness of a training program using 41 smoking patients (Standardized Patient) was compared with a role-playing training program (Role Play). In this study, it was shown that both methods are effective in increasing students' information, and no significant difference was observed between the two groups. However, the level of students' self-confidence was higher in the group that was helped by a smoking patient for students' practice [19].
Vollath et al. [4], like our current study, utilized a combination of seminars, lectures, podcasts, and role-playing exercises to instruct dental students in smoking cessation counseling. Their findings demonstrated a significant increase in the knowledge and skills of students both immediately following the training and six months later, compared to a control group. Evaluation methods included a written questionnaire and an Objective Structured Clinical Examination (OSCE). The questionnaire results revealed an increase in students' knowledge from 7.37% to 11.67%, which was later adjusted to 7.52% after six months, likely due to the theoretical nature of the content and the lack of continuous practice. Further analysis indicated that the most substantial improvement was in "how to counsel a smoking patient," with control group students lacking this information entirely. Additionally, students' knowledge about non-nicotine smoking cessation medications showed a significant increase compared to the control group, mirroring the results of our study. Moreover, they assessed students' attitudes towards smoking addiction by asking them to agree or disagree with the statement "I think smoking addiction is a chronic disease." In our study, students' attitudes regarding the concept of addiction improved from 3.56% to 9.76%, whereas Vollath et al. [4] reported an increase from 3.39% to 4.46%.
E-cigarettes have emerged as a novel tool for smoking cessation, yet their use and potential health risks remain subjects of debate. The intervention group showed significant improvements in knowledge and perceptions about electronic cigarettes. For instance, the belief that electronic cigarettes are effective in quitting smoking increased from 44% to 69% post-intervention. This aligns with the findings of Alhajj et al., who reported that educational programs significantly improve dental students' knowledge and beliefs about e-cigarettes [20]. Additionally, the understanding that nicotine consumption from electronic cigarettes can lead to malignancies increased from 63% to 77%, reflecting similar concerns raised in the literature by Briggs et al. [21] and Natto [22] about the potential health risks of e-cigarettes.
Both our study and Alhajj et al. [20] highlighted concerns about electronic cigarettes being used by non-smoking youth, which could potentially lead to tobacco use. However, our intervention group's belief in this risk decreased post-test (from 69% to 62%), indicating that the intervention might have provided a more nuanced understanding. Alhajj et al. [20] found that dental students were aware of this risk but did not delve into how educational interventions might alter these perceptions. Briggs et al. [21] also noted this concern, stressing the importance of awareness among dental professionals about the gateway potential of electronic cigarettes.
The significant improvement in the mean knowledge scores in the intervention group in our study (from 3.11 to 4.19) highlights the effectiveness of targeted educational interventions. This finding resonates with Alhajj et al. [20] and Natto [22], both of which called for enhanced educational programs to improve dental students' knowledge about electronic cigarettes. Briggs et al. [21] also advocated for comprehensive training for dental professionals, emphasizing the importance of accurate and up-to-date knowledge.
Despite the positive outcomes, some limitations exist regarding the present study. The sample size was relatively small, and the follow-up period was short. Future research should include larger sample sizes and longer follow-up periods to assess the long-term impact of such interventions. Additionally, the study was conducted at a single institution, which may limit the generalizability of the findings.
Despite its contributions, this study has several limitations. The sample size and composition may not be representative of all medical students, and findings may not generalize to other populations or healthcare professionals. Additionally, the study relied on self-reported data, which may be subject to biases and social desirability effects.
Conclusion
The educational intervention significantly improved the knowledge, attitudes, and skills of undergraduate dental students regarding smoking cessation. These findings underscore the importance of incorporating comprehensive smoking cessation training into the dental curriculum to better equip future dental professionals to contribute to public health efforts in reducing tobacco use. By addressing these areas, dental education can play a pivotal role in the broader healthcare strategy to combat tobacco addiction, ultimately improving patient outcomes and public health. Future studies should continue to explore and refine these educational interventions to maximize their effectiveness and reach.
Financial Support
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None.
Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.
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Edited by
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Academic Editor:
Alessandro Leite Cavalcanti
