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Archives of Orofacial Sciences (2008), 3(1): 11-16


Attitudes and practices in smoking cessation

counselling among dentists in Kelantan
H. Ibrahim, S. Norkhafizah *
School of Dental Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.
(Received 17 March 2008, revised manuscript accepted 10 June 2008)
smoking cessation.

Abstract This is a cross sectional study to determine the attitudes

and practices in smoking cessation counselling among dentists in
Kelantan and to identify the barriers that prevent them from doing so.
Self-administered questionnaires were distributed to 152 dentists
practising in Kelantan. A total of 84 (55.2%) questionnaires were
completed and returned. Although majority of the dentists (98.8%)
agreed that they have a role in smoking cessation counselling, only few
of them (17.9%) were actually involved in a considerable extent. The
main barriers cited were lack of training and time in their practice. In
conclusion, dentists in Kelantan believed that they have a role in
smoking cessation counselling but their involvement was rather limited.


further to 16.9%, which is comparable to the rates

reported in general medical practices (Cohen et
al., 1989).
potential, not many dentists routinely offer
smoking cessation counselling to their patients
although the majority of them have positive
attitudes towards the idea (John et al., 1997,
Stacey et al., 2006). A study by Dolan et al.
(1997) found that tobacco control activities, such
as asking about tobacco use and documenting
tobacco use status in patients record, were not
a routine part of dental practice. Similarly, a
study by Trotter and Worcester (2003)
suggested that even though dentists were
willing to participate in smoking cessation, their
activities were neither comprehensive nor
systematic and there was a need for education
and training in this area.
Barriers that preclude dentists from
incorporating tobacco cessation into practice
include doubt about knowledge and skills in
assisting patients to quit smoking, lack of
confidence in their own ability to help their
patients to quit, doubts about their effectiveness
to give quit advice, anticipated negative reaction
from patients, uncertainty about their role in
smoking cessation, lack of educational
materials, lack of time and lack of remuneration
(Albert et al., 2002; Chestnutt and Binnie, 1995;
Clover et al., 1999; Stacey et al., 2006; Trotter
and Worcester, 2003).
The purpose of this study was to
determine the attitudes and practice in smoking
cessation counselling among dentists in
Kelantan, as well as barriers that prevent them
from doing so.

Smoking remains a significant public health

problem worldwide. The adverse health effects
from cigarette smoking are undisputable.
Besides reducing the health of smokers in
general, smoking harms nearly every organ of
the body, causing many serious illnesses such
as cancer, cardiovascular diseases, and
pulmonary diseases. In addition, tobacco use is
also a primary cause of many oral diseases and
conditions, ranging from mild to life-threatening,
such as stained teeth and restorations, taste
derangement, halitosis, periodontal diseases,
poor wound healing, oral precancerous lesions,
and oral cancers (Sham et al., 2003).
The prevention and control of tobacco
use is an emerging issue of global significance
and the important links between smoking and
oral health provide a unique opportunity for
dentists to become involved in smoking
cessation activities (Watt et al., 2000). Smoking
cessation advice provided by dentists has been
shown to be effective (Warnakulasuriya, 2002).
Dental treatment that often necessitates multiple
visits provides the mechanisms for initiation,
reinforcement, and support of tobacco cessation
activities. Cessation advice can also be
associated with readily visible changes in oral
status. Cessation rate of 8.6% after one year of
counselling alone has been reported, and when
combined with prescription of nicotine
replacement therapies, the quit rate increased
* Corresponding author. Dr. Norkhafizah Saddki, School of
Dental Sciences, Universiti Sains Malaysia, 16150 Kubang
Kerian, Kelantan, Malaysia. Fax: +609-764 2026.
E-mail address: fizah@kb.usm.my


Ibrahim and Norkhafizah

Table 1

Materials and Methods

Socio-demographic profile of respondents


This was a cross sectional study. Period of data

collection was from 5th June until 3rd July 2007.
Ethical approval to conduct the study was
obtained from the Research Ethics Committee
(Human), Universiti Sains Malaysia.
A self-administered questionnaire used by
Aza Fazura (2004) previously in a similar study
was adapted and utilized. The questionnaire
consisted of 4 sections; socio-demographic
profile, attitudes in smoking cessation, practices
in smoking cessation, and barriers to smoking
cessation. A 5-point Likert scale of not at all, a
little bit, to some extent, considerable extent,
and great extent was used to indicate their
degree of agreement and involvement in
smoking cessation attitudes and practices
respectively. Four main barriers to smoking
cessation as identified in previous studies; lack
of training, lack of remuneration, lack of time,
and fear of losing patients; were listed and the
dentists were asked whether they agreed or
disagreed. The dentists were also asked to
specify other barriers that they perceived in their
All 152 registered dentists practising in
Kelantan, both in the government, either in
Ministry of Health (MOH) premises or Universiti
Sains Malaysia (USM), and the private sectors
were included to meet the prior determined
sample size. The questionnaires were
distributed together with a cover letter explaining
the purpose of the study, as well as specific
instructions on how to answer and return the
filled forms. The letter also emphasised that the
study was anonymous, thus confidentiality of
respondents was assured.
Questionnaires to dentists in the School
of Dental Sciences, USM, were placed in their
personal mailbox. The private dentists were
contacted through mail together with stamped
returned envelope, while kind assistance from
the Kelantan Deputy Director of Health (Dental)
was obtained to distribute the questionnaire to
all MOH dentists in the state. A total of 84
(55.2%) questionnaires were completed and
returned. No attempt was undertaken to
increase the response rates following the first
mailing. The highest response rate was from the
MOH (82.2%). Data entries and analyses of
results were done using the SPSS for Windows
(version 12.0, SPSS Inc., Chicago) statistical
software package.

Frequency (%)
22 (26.2)
62 (73.8)

Ethnic group

78 (92.8)
3 (3.6)
2 (2.4)
1 (1.2)

Type of practice
Ministry of Health
Universiti Sains Malaysia

60 (71.4)
15 (17.9)
9 (10.7)

Results on dentists attitudes towards

smoking cessation counselling are shown in
Table 2. Most of the dentists agreed that they
have the responsibility in smoking cessation
counselling (98.8%), and more than half of them
(72.7%) were at least somewhat confident in
giving such counselling. However, not many of
them (4.8%) viewed that counselling given by
dentists would be very effective, and even fewer
(2.4%) were very optimistic in patients ability to
change their smoking habit.
Table 2

Attitudes on smoking cessation

Frequency (%)
How much is your responsibility as a
dentist to provide in smoking cessation
Not at all
1 (1.2)
A little bit
8 (9.5)
To some extent
26 (31.0)
Considerable extent
28 (33.3)
Great extent
21 (25.0)

Table 1 shows the socio-demographic profile of
the respondents. Majority of them were female.
Malay was the majority ethnic group compared
to others. Most of the dentists were in the
government sector, either in the Ministry of
Health (71.4%) or in USM (17.9%). Of all
subjects, only 20.2% had ever attended a formal
course in smoking cessation.


How effective do you think smoking

cessation counselling provided by
Not at all
A little bit
To some extent
Considerable extent
Great extent

1 (1.2)
26 (30.9)
32 (38.1)
21 (25.0)
4 (4.8)

How confident you are in your ability to

effectively offer smoking cessation
Not at all
A little bit
To some extent
Considerable extent
Great extent

7 (8.3)
16 (19.0)
33 (39.3)
23 (27.4)
5 (6.0)

Do you think patients expect smoking

cessation advice from dentist?
Not at all
A little bit
To some extent
Considerable extent
Great extent

19 (22.6)
20 (23.8)
29 (34.5)
14 (16.7)
2 (2.4)

How optimistic you are in patients

ability to change their smoking habit?
Not at all
A little bit
To some extent
Considerable extent
Great extent

5 (6.0)
29 (34.5)
37 (44.0)
11 (13.1)
2 (2.4)

Attitudes and practices in smoking cessation counselling among dentists in Kelantan

Table 3

Practices on smoking cessation


Frequency (%)

Do you enquire about your patients

smoking status?
Not at all
A little bit
To some extent
Considerable extent
Great extent

26 (31.0)
21 (25.0)
22 (26.2)
9 (10.7)
6 (7.1)

Do you offer smoking cessation

counselling to your patients?
Not at all
A little bit
To some extent
Considerable extent
Great extent

15 (17.8)
24 (28.6)
30 (35.7)
14 (16.7)
1 (1.2)

Do you explain to patients regarding

the health risks due to smoking?
Not at all
A little bit
To some extent
Considerable extent
Great extent

17 (20.2)
18 (21.4)
23 (27.4)
21 (25.0)
5 (6.0)

Do you provide advice or helpful

hints to motivate patients to quit
Not at all
A little bit
To some extent
Considerable extent
Great extent

18 (21.4)
21 (25.0)
27 (32.1)
17 (20.2)
1 (1.2)

Do you provide reading materials

on smoking cessation in your
waiting area?
Not at all
A little bit
To some extent
Considerable extent
Great extent

36 (42.8)
25 (29.8)
13 (15.5)
7 (8.3)
3 (3.6)


smoking cessation
counselling among dentists in Kelantan was
rather limited (Table 3). Surprisingly, many of
the dentists (31.0%) did not at all enquire about
their patients smoking status. Not to mention,
quite a number of them also never provided
smoking cessation counselling (17.8%) or
explained on the health risks of smoking
(20.2%) or offered any advices and motivation
for their patients to stop smoking (21.4%).
Majority of the dentists cited the lack of training
and time as the main reasons for their low
involvement in such activities (Table 4). Apart
from the ones listed in the questionnaire, no
other forms of barrier were identified.
Table 4

Perceived barriers to smoking cessation

Frequency (%)
I feel constrained because of lack
73 (86.9)
of training in smoking cessation
I dont provide smoking cessation
due to lack of remuneration

26 (30.1)

Lack of time in my practice

prevents me from being involved in
smoking cessation

73 (86.9)

I fear that patients may leave the

practice if counselled to give up

44 (52.4)


Almost all dentists in Kelantan (98.8%) agreed

about their role in smoking cessation
counselling although opinions on the degree of
responsibility varied. A similar study done in
Malaysia by Aza Fazura (2004) among dentists
in Federal Territory of Kuala Lumpur and
Selangor also found that most dentists (69.1%)
considered their role in smoking cessation as
important. It was noted that the attitudes in
smoking cessation counselling among dentists
in Kelantan was more favourable than dentists
in Kuala Lumpur and Selangor. However this
was not an issue as ones attitudes depend on
many background factors such as knowledge,
training, past experiences as well as interests
and rewards in practices, which were not
explored in this study. Nevertheless, there is an
agreement with results of other studies done in
the United States (Logan et al., 1992), the
United Kingdom (John et al., 1997; Stacey et al.,
2006), Australia (Clover et al., 1999), and Saudi
Arabia (Wyne et al., 2006) that dentists
generally believed that it was part of their
responsibility to help patients in smoking
In contrast to the encouraging attitude,
the dentists involvement in smoking cessation
counselling was limited. Although most of the
dentists (82.1%) did offer smoking cessation
counselling to their patients, only fifteen dentists
(17.9%) were actually involved to a considerable
extent. The results are in agreement with
several other studies that in spite of having
positive attitudes towards smoking cessation,
relatively few dentists really did provide smoking
advice for their patients (John et al., 1997,
Stacey et al., 2006).
There were differences in opinion among
dentists in Kelantan on patients expectation of
smoking cessation counselling, and quite a
number of them (23%) felt that patients did not
at all expect smoking cessation advice from
their dentists. Almost twice as much of dentists
in Federal Territory of Kuala Lumpur and
Selangor (40.3%) thought so too (Aza Fazura,
2004). Sixty-two percent of dentists in Alberta,
Canada also believed that patients did not
expect counselling from them (Campbell et al.,
1999). Nearly a quarter of dentists surveyed in
Victoria, Australia even viewed that it was not
appropriate to ask patients about their smoking
status and to assist patients to quit smoking
(Trotter and Worcester, 2003). In contrast to
what the dentists believed, results of a study
done in New South Wales, Australia by RikardBell et al. (2003) on 1,160 dental patients
revealed that most patients expected dentists to
be interested in their smoking status (73%) and
to discuss smoking with them (61%). Another
study done in Alberta, Canada also found a
discrepancy between dentists and patients
views on smoking cessation counselling. While
61.5% of dentists thought patients did not
expect smoking cessation counselling, 58.8% of

Ibrahim and Norkhafizah

Dentists are responsible to educate the

community about the health effects of tobacco
use to oral health as well as general health.
Thus dentists are in an ideal position to reach
out to smoking patients. Studies have shown
that dentists trained in smoking cessation
counselling were able to contribute to smoking
cessation programs in the community with good
success rates, comparable to the rates reported
in general medical practice settings (Cohen et
al., 1989; Wood et al., 1997; Smith et al., 1998).
However, consistent with previous
research, our study showed that, dentists were
not active in this area. In attempt to encourage
health care providers to become more involved
in smoking cessation, a simple yet effective
protocol that can be used in a busy practice was
introduced. The U.S. Department of Health and
Human Services, in the 2000 guideline on
Treating Tobacco Use and Dependence,
recommended a counselling protocol known as
the 5As to identify smokers who want to quit
and how best to support them in their attempt
(Fiore et al., 2000).
The 5As protocol which consists of;
asking about the smoking status, advising the
benefits of quitting, assessing the motivation to
quit, assisting in the quit attempt, and arranging
for supportive follow up, was developed based
on comprehensive review of up to 6,000 articles
on tobacco addiction published from 1975 to
1999. The protocol was designed to be brief
such that minimal counselling time is required,
which was estimated to be only 3 minutes or
less of direct clinician time.
In the year 2003, the Ministry of Health
Malaysia published its first clinical practice
guideline on Treatment of Tobacco Use and
Dependence adapting the 5As protocol to
assist all health care providers in smoking
cessation (Ministry of Health Malaysia, 2003).
Nevertheless, there has been a considerable
concern that the expanding body of research
may make it difficult for any health care
providers to be aware of every applicable
guideline and critically apply it into practice
(Cabana et al., 1999). Thus, there is an issue of
whether the local doctors, dentists, or other
health care providers are even aware of the
existence of the guideline to make full use of it.
Lack of awareness as a possible reason for
non-adherence is supported by results of a
study done in Texas that found an
overwhelming majority of dentists (89%) were
unaware of the U.S. 2000 guideline on Treating
Tobacco Use and Dependence despite the fact
that it was published almost a decade ago (Hu
et al., 2006). The study also showed that
dentists who were familiar with the guideline
were significantly more likely to engage in
smoking cessation counselling with their
patients compared to those who were not.
Hence, besides the training sessions, strategies
to improve smoking cessation counselling
among dentists should also address issues
related to distribution of the guideline.

patients responded otherwise (Campbell et al.,

Only a small number of dentists in
Kelantan (2.4%) have great optimism in
patients ability to change their smoking habit.
Correspondingly, very few of our respondents
(4.8%) believed that counselling provided by
dentists would be very effective. Perceptions of
how patients will react to smoking cessation
counselling can affect dentists motivation and
confidence in offering such advice. Our results
also showed that there was an overall feeling of
doubtfulness among dentists in Kelantan about
their ability to offer effective smoking cessation
counselling. Only very few of them (6%) have
great confidence in handling the situation.
Clover et al. (1999) reported similar results for
dentists in New South Wales, Australia and so
did Wyne et al. (2006) in Riyadh. The lack of
confidence could be attributed to inadequate
knowledge and training in smoking intervention.
The results are consistent with studies that
identified insufficient knowledge and counselling
skills in smoking cessation as major barriers that
discouraged dentists from helping their patients
to quit (Trotter and Worcester, 2003; Aza
Fazura, 2004; Hu et al., 2006; Stacey et al.,
Lack of time and training were seen as
important barriers for conducting smoking
cessation counselling by dentists in Kelantan. It
was commented by few respondents that too
much time were spent on providing dental
treatments such that it was almost impossible to
give smoking cessation counselling to patients.
This was proven in quite a number studies
(Chestnutt and Binnie, 1995; Clover et al., 1999;
Albert et al., 2002; Aza Fazura, 2004; Stacey et
al., 2006). For this reason, majority of dentists
thought it was better to refer smokers to a
smoking cessation expert or quit-smoking clinics
(Trotter and Worcester, 2003; Wyne et al.,
2006). In Malaysia, there are almost 300 quitsmoking clinics under the Ministry of Health
services available to assist and support the
smokers who want to quit. The chain of quitsmoking clinics, established as part of the
ministry's National Tobacco Control Programme,
were set up in various health clinics in almost all
districts and also in big hospitals nationwide.
These clinics were run by trained health
personnel who offer counselling services and
nicotine-replacement therapy when necessary.
In Kelantan, quit-smoking clinics were
initiated in 1999, and there are now 33 quit
smoking clinics throughout the state. In the year
2006, 510 clients registered, slightly decreased
from 617 clients in year 2005 (Jabatan
Kesihatan Negeri Kelantan, 2005; Jabatan
Nevertheless, the referral sources of patients
seen in the clinics were not reported. Hence,
utilisation of quit smoking clinics by dentists in
Kelantan, as far as patient referral is concerned,
is not known, and further investigation is called


Attitudes and practices in smoking cessation counselling among dentists in Kelantan

The inclusion of smoking cessation

training in the dental curriculum also becomes
paramount if smoking cessation behaviour in
dental practice is to be improved (Christen,
2001). Although the record keeping systems of
many dental clinics have incorporated the
critical question about tobacco use of patients,
the dental students should be trained to go
beyond the first two steps of the 5As protocol.
Curriculum in dental schools needs to
incorporate not just didactic instructions on the
oral health impact of tobacco use, but also
clinical training in smoking cessation activities
so that the next generation of dentists would
graduate with competency in assessing and
treating tobacco use (Tomar, 2001).
The present study provided an
interesting insight into the attitudes and
practices of dentists in Kelantan towards
smoking cessation. Although the response rate
was only 55.2%, we consider it to be
satisfactory as low response rates are typical of
mail surveys in health care settings (Asch et al.,
1997; Kellerman and Harold, 2001). On the
other hand, information obtained through selfadministered questionnaire has to be interpreted
with caution due to bias created through
favourable responses. It is possible that dentists
who agreed to participate or completed and
returned the questionnaire were more interested
in the issue as compared to those who did not
participate, resulting in possible overestimation
of positive responses. However, within these
limitations, we conclude that the majority of
dentists in Kelantan believed that smoking
cessation was part of their responsibility
although the extent of their involvement was
considerably low. Lack of training and lack of
time were seen as important barriers.

The authors would like acknowledge Y. Bhg.
Professor Dato' Dr. Ishak Abdul Razak, from
Faculty of Dentistry, Universiti Malaya for giving
us the permission to adapt his questionnaire for
use in this study.

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