Indian Journal of Dental Research

: 2017  |  Volume : 28  |  Issue : 6  |  Page : 629--636

Knowledge, attitude and practices of institution-based dentists toward nicotine replacement therapy

Swikant Shah, Hemamalini Rath, Gaurav Sharma 
 Department of Public Health Dentistry, SCB Dental College and Hospital, Cuttack, Odisha, India

Correspondence Address:
Dr. Gaurav Sharma
Department of Public Health Dentistry, SCB Dental College and Hospital, Cuttack - 753 007, Odisha


Background: Dental institutions provide very good platform to educate budding dentists to inculcate the habit of tobacco cessation counseling, including nicotine replacement therapy (NRT). Aims: The aim of this study is to assess and compare the knowledge, attitude, and practice of institutionally attached postgraduate students and faculty members of the dental profession toward NRT. Methods: For a cross-sectional survey among 201 participants from four dental colleges in Odisha, India, a 28-item questionnaire was developed, subdivided into four categories: demographic details, assessment of NRT knowledge (21-item), assessment of attitude (5-item), practice (1-item with 4 subgroup questions), and 1-item assessing barriers. Statistical Analysis Used: Data were analyzed using descriptive statistics, Chi-square test, and multiple logistic regression. Results: Only one-third of participants were aware of the dosage, mechanism of action, pharmacology, duration of the prescription, brand name, side effects, contraindications, and availability. Around two-third of participants who claimed to practice NRT, agreed to follow up the patients whom they prescribed NRT. Half of the study participants reported that they do not keep a record of these patients. Around 10% of respondents practicing NRT were confident enough to practice it without facing any problem. Major barriers for practicing NRT was found to be a lack of awareness (54.22%) followed by availability and bitter taste. The total knowledge score was found to be the strongest predictor of practicing NRT in multiple logistic regression. Conclusion: Lack of detailed knowledge regarding NRT reduces the chance of practicing inspite of having a positive attitude among institutionally attached dentists.

How to cite this article:
Shah S, Rath H, Sharma G. Knowledge, attitude and practices of institution-based dentists toward nicotine replacement therapy.Indian J Dent Res 2017;28:629-636

How to cite this URL:
Shah S, Rath H, Sharma G. Knowledge, attitude and practices of institution-based dentists toward nicotine replacement therapy. Indian J Dent Res [serial online] 2017 [cited 2020 Oct 22 ];28:629-636
Available from:

Full Text


Tobacco is one of the leading yet preventable causes of noncommunicable diseases and is the second major cause of death globally.[1],[2],[3] In spite of the increasing awareness regarding the health hazards associated with tobacco consumption, a large number of tobacco users are still existing only due to addiction to the tobacco products. Addiction is a factor condition of being addicted to a particular substance or activity.[4]

Nicotine 1-methyl-2-(3-pyridyl) pyrrolidine, a highly addictive psychoactive drug found in tobacco plants, is mainly responsible for the withdrawal symptom among habitual tobacco users attempting to quit after successful psychological counseling. Hence, the combination of psychological counseling and pharmacologic therapies can produce higher quit rates than either one alone. Pharmacotherapy like nicotine replacement therapy (NRT) aims to reduce the symptoms of nicotine withdrawal, thereby making quitting easier.[5],[6]

NRT eases withdrawal symptoms by providing an alternative source of nicotine. The attempt to quit is broken into two stages. Initially, the tobacco user continues with a reduced dose and speed of nicotine supply while overcoming the loss of the behavioral side of the dependence. Subsequently, it breaks the nicotine dependence by stopping the use of NRT product.[7] A meta-analysis conducted for the “Treating Tobacco Use and Dependence: Clinical Practice Guidelines” further confirmed that all forms of NRT are superior to placebo in increasing cessation rates.[8]

Several recent publications have highlighted the role and need for the dental professional to get involved with tobacco intervention. They are in a better position to find this addiction and habits as oral changes occur earlier than systemic changes. Hence, a dental professional has higher chances to help patients and guide them. Moreover, for this, they should have a sound and proper knowledge about the various methods of tobacco cessation (pharmacological and nonpharmacological) with a positive attitude and healthy practice for the society's wellbeing.[9],[10],[11]

This knowledge, attitude, and practices obtain their foundation from the dental institutions. Dental colleges provide an ideal academic environment for the comprehensive oral health care of the patients, including tobacco cessation counseling. The students learn mostly by the process of modeling and following the senior postgraduate students and the faculty members managing, treating, and counseling their patients. Hence, the institution-based postgraduate students and faculty members should have complete knowledge of this important pharmacotherapy of tobacco control.[11]

Several KAP studies have been conducted to evaluate the dental professionals' perception toward tobacco cessation counseling, but their perception specifically toward NRT as a whole is scarce in the literature. A study conducted in Karnataka assessed the knowledge and perception of around 2000 under graduate students toward NRT and showed that major proportion of students were unaware of NRT, and only around 50% of the students were aware of the effectiveness of NRT for the rescue of smokers to quit and felt transdermal patch (42%) could be the most effective way for smokers to quit followed by chewing gums.[12]

Another study conducted in Bengaluru among 232 interns and postgraduates, highlighted that the majority of participants reported on-going tobacco cessation activity in their college. Regarding NRT, significant differences were seen for items related to practice (assisting, assessing motivation for NRT), belief (not an appropriate activity for dentist, a valuable resource, increase in quit attempts), and barriers (bitter taste, cost, and fear of addiction) (P < 0.05).[13]

A thorough literature search reveals that there is no study reported regarding assessment and comparison of knowledge, attitude, and practice of institution-based faculties and postgraduate students toward NRT. Hence, this study aimed at assessing and comparing the knowledge, attitude, and practice of institutionally attached postgraduate students and dental faculty members toward NRT.


The present study was conducted among dental faculty members and postgraduate students in all the dental institutions (SCB Dental College and Hospital, Hi-Tech Dental College and Hospital, Institute of Dental Sciences and Kalinga Institute of Dental Sciences) of Odisha. A total of 277 participants were approached after getting approval from Institutional Review Board of SCB Dental College, Cuttack.

Data collection tool

A self-structured 30-item questionnaire was developed and checked for its content validity using Aikens Index from two subject experts, one statistician and one psychiatrist. After appropriate changes, it was pilot tested. The final version of the questionnaire had 28 questions, subdivided into four categories: demographic details, estimation of self-assessed knowledge about NRT (21-item), assessment of attitude (5-item), practice (1-item with 4 subgroup questions), and 1-item assessing barriers. Knowledge was assessed with 12-item rated on a 3-point Likert scale (0 = no, 1 = not completely, 1 = yes), attitude was assessed using 5-item on a 5-point scale (1 - strongly disagree to 5 - strongly agree), practice was assessed with one question with only two options, barriers were assessed with one question with seven options where multiple responses were allowed.

Participants were contacted directly in the respective departments of the institution, after obtaining permission from authority during clinical hours. A brief introduction was given to all the participants about the study and its objectives before obtaining written consent. After clarifying all the queries, a questionnaire was handed over during clinical hours and were collected within an hour. A minimum number of two repeated visits were made to account for absentees on the day of the survey.

Statistical analysis

The statistical analysis was performed using Statistical Package for Social Sciences version 16, IBM Corporation, (SPSS Inc., Chicago, IL, USA). Chi-square test was used for comparison of categorical data, and independent t-test was used for comparison of continuous data. Responses for both knowledge and attitude domains are analyzed both as categorical as well as continuous data. Practice domain was analyzed as categorical data. Univariate logistic regression was performed considering all the demographic variables, total knowledge score, and total attitude score. Then, multiple logistic regression analysis was performed to determine the strongest predictors of practice after adjusting for confounders. For all the statistical inferences, value of P < 0.05 was considered to be statistically significant.


Overall response rate was 72.6% as out of the total number of the study participants (n = 277; postgraduate students = 115, faculty members = 162), 201 (postgraduate students = 94, faculties = 107) responded.

Descriptive statistics for demographic details

Mean age (in years) of postgraduate students was 28.3 ± 3.5 and faculty members was 34.3 ± 4.8. Among postgraduate students, 45 (47.9%) were males in comparison to 64 (59.8%) among faculty members. Among postgraduate students, 76 (80.9%) were never smoker, whereas among faculty members, 93 (86.9%) had never smoked. Only 42 (44.7%) students and 45 (42.1%) faculty members had attended tobacco cessation workshop. There were no statistical differences in demographic characteristics between students and faculties except for age [Table 1].{Table 1}


The mean knowledge score of all the respondents was 21.5 ± 8.2 which is around 50% of the maximum knowledge score of 42. There was no statistically significant difference between the two study groups.

The term NRT was familiar to 86 (91.5%) postgraduate students and 98 (91.6%) faculty members. Around 90% of participants were aware of the uses of NRT to some extent. More than 90% of participants knew the types of NRT. Around 90% knew about chewing gums while around 50% knew about patches and lozenges. A quarter of participants knew about nasal spray and inhalers. Surprisingly, almost half of the participants reported being unaware of dosage, duration of prescription, cost, and contraindications for the prescription. About one-third of the participants expressed complete ignorance about the brand names, forms, and availability of NRT.

As far as the pharmacology of NRT is concerned, one-third of participants agreed that they do not know the mechanism of action as well as the pharmacology of the product. Almost 50% of participants expressed their complete ignorance about the existence of any tobacco counseling cell prescribing NRT. Acquaintance with Centers for Disease Control and Prevention guidelines for treating nicotine dependence was claimed by only one-fourth participants [Table 2].{Table 2}


The mean attitude score for all the 5-item of the respondents was 21.5 ± 2.5 which is 84% of the highest possible attitude score (25), and the difference was not statistically significant between the groups. For each of the 5-item assessing attitude, the mean score in both the groups was more than 2.5, indicating the positive attitude of all the respondents toward NRT [Table 3].{Table 3}


Among all the postgraduate students, 34 (36.2%) claimed to practice NRT in comparison to 61 (57.0%) faculty members and the difference was statistically significant (P = 0.004).

There was no significant difference between the two groups as regards to the time spent with the patients while prescribing NRT and mostly the participants reported to spend less than 15 min. Although two-third of participants who claimed to practice, agreed to follow up the patients whom they prescribe NRT, 50% agreed that they do not keep a record of these patients. Only 10% of the respondents practising NRT were confident enough to practice it without facing any problem [Table 4].{Table 4}


The most common barrier for not prescribing NRT as perceived by the respondents was a lack of awareness. Although other factors such as bitterness, fear of addiction, availability, and awareness play some role, almost 20% of respondents enumerated all the listed factors as barriers. There was no significant difference between the groups for any barrier except for fear of addiction (P = 0.043) [Table 5].{Table 5}

Predictors of the practice of nicotine replacement therapy

The outcomes of the binary logistic regression to enumerate the predictors of the practice of NRT showed that the odds ratio for age, being a faculty, having attended a workshop, and mean total self-assessed knowledge score were significant. However when all the factors were simultaneously put into an adjusted model, only total self-assessed knowledge score remained as the strongest predictor of the practice of NRT. The adjusted odds ratio for the knowledge score was 1.10 (95% confidence interval 1.05–1.15), i.e., with one unit increase in the total knowledge score, there is 10% increased odds of practising NRT [Table 6].{Table 6}


The findings of the present study shows that in spite of having a positive attitude toward NRT, only 34% of the postgraduate students and 57% of the faculty members claim to practice NRT along with their tobacco cessation counseling. This might be attributed to their lack of detailed knowledge regarding the therapy as their self-assessed knowledge score was only 50% of the highest possible score. Most commonly reported possible barriers were a lack of awareness. The total knowledge score was found to be the strongest predictor of the practicing NRT.

Dental institutions provide a very good platform to educate budding dentists to inculcate the habit of tobacco cessation counseling as regular practice during patient management from the beginning of their clinical career. The faculties as well as the postgraduate students who are usually involved with the undergraduate training should not only have the foundation of the knowledge of this important pharmacotherapeutic measure but also should have the attitude to help their patients and practice it regularly so that they can teach the under graduates.

The response rate in this survey was around 70%. The low response rate inspite of the direct approach of the investigator might be due to poor attitude of the faculties and the postgraduate students toward participation in any research or because of no incentive awarded.

In the present study, almost 90% of the study participants reported to be familiar with NRT which is very high in comparison to study conducted among undergraduate students in Karnataka where 75% of participants were unaware of the term NRT.[12] The global awareness assessment for NRT conducted among 3rd-year dental students in 43 countries in 2014 reported that 37% (Mongolia) to 97% (Slovakia) of the respondents ever heard of NRT, though in India it has been reported to be 63%.[14] The authors attributed this disparity of knowledge to several factors such as socioeconomic status of the country, tobacco intervention policy of the country, importance of tobacco education in Bachelor of Dental Surgery curriculum, exposure to various tobacco intervention initiatives, or free access to pharmacotherapy for nicotine dependence to all smokers who visit a health-care setting.[14] In the present study, participants being postgraduates, are expected to have increased level of awareness than undergraduate students regarding NRT as observed in the study, though tobacco control policies of India are not so strongly implemented.

Mere familiarity cannot help anyone practice NRT without psychological counseling. To ensure adequate knowledge of the participants toward effective NRT practice, questions were asked regarding the detailed aspect of this pharmacotherapy. Although 90% of participants knew about nicotine gums, mean total knowledge score obtained was 50% of the highest expected score with no statistical difference between the postgraduate students and the faculty members. This indicates knowledge being a barrier toward effective NRT practice across the study groups.

It was also observed that around 40% of the participants had previously attended tobacco cessation workshop. This is highly surprising to find many participants who were lacking detailed knowledge about NRT even after attending the workshop. Hence, most of the participants were aware of the nicotine gum as the only form of NRT available as there are few brands of nicotine gums readily available in the market, but the detailed knowledge required for the prescription of the same was also lacking among the participants. This finding is also very much similar to the study conducted among undergraduate students of Karnataka.[12]

It was surprising to find that even after doing postgraduation, there is no practical increase of the knowledge regarding NRT. This self-reported insufficient knowledge might be attributed to practical nonimplementation of the tobacco cessation counseling in clinical patient management as well as undergraduate training.

This study showed a positive attitude of the participants toward NRT with a 5-item attitude scale and it is in agreement with a number of studies reported in the literature.[12],[13],[14] The results revealed that in the present study, in spite of having a positive attitude, only around half of the participants claimed to practice NRT and significantly more number of faculties reported to practice NRT than the students (P = 0.004). This percentage is comparatively high in comparison to other studies such as 9.8%,[11] 12.5%,[15] 18.1%,[13] 19%,[16] 33.4%,[17] and 41.14%.[18] The present study revealed that most of the dentist who practice NRT spent 5–15 min for counseling while more than half of them do not keep records and follow up of the patients. In other studies, half to 80% of the practicing dentists keep patients record,[11],[19],[20] 25%–75% of respondents follow up their patients.[11],[16],[18],[19],[20]

It is well expected that with increase in knowledge, confidence increases which may influence the practicing behavior and attitude. Hence, the faculties reported significantly more practicing behavior than the students. However, there is a disparity between the detailed knowledge of NRT and practice of prescribing NRT. Although very few participants claimed to have the proper knowledge of NRT, including the brand names and availability nearby, 50% claimed to practice it. Hence, their practice might be confined to prescription of nicotine gum as and when required, because 90% of participants knew about it or the result might be the outcome of social desirability bias.

In the present study, major barrier for practicing NRT was found to be a lack of awareness (54.22%) followed by availability and bitterness. There was no significant difference for barriers between the groups except for fear of getting addicted to NRT (P = 0.043). The participants were well aware of the fact that lack of detailed knowledge regarding NRT is inhibiting them to practice NRT and the same is reported in finding of multivariate logistic regression where the participants who had attended workshop related to NRT reported to practice it more than those who have not attended. In other studies, major barriers reported were cost, fear of addiction, bitterness,[13] time,[11],[20],[21] uncomfortable to ask about patients' tobacco habits,[20] lack of knowledge and training,[11],[15],[21] negative impact on clinical practice,[15],[21] lack of manpower, educational aids,[11] and awareness among patients.[17]

Bivariate logistic regression determined four obvious predictors. However, of those, three factors such as age, being a member of the faculty and attending a workshop previously ultimately increased the knowledge level, making them the strongest predictors as revealed in the adjusted model. Surprisingly, increased level of attitude score did not influence the practice of NRT.

There can be several limitations of this investigation. Though we tried to take a universal sample, the lower response rate (50%) might reduce the generalizability of the findings. The present study assessed self-reported knowledge of participants, rather than exact knowledge toward NRT, so chances of introduction of social desirability bias cannot be ruled out. As the study was a quantitative one, related to the behavioral aspect of health professional, the outcomes might not be adequate to explore various barriers inhibiting the institutionalized health professionals to prescribe such an important pharmacotherapeutic agent. Hence, a well-designed cross-sectional study using a mixed methodology approach and a larger sample size is suggested, which may help the policy maker to strengthen the tobacco control policy of India.


Having the advantage of working in an academic environment, the postgraduate students and members of faculty lack a detailed knowledge about NRT restricting them to practice it whenever required though they report a strong positive attitude toward this pharmacotherapy. Hence, there is a strong need for implementation of tobacco control policy in India, making repeated training on tobacco cessation counseling giving importance to NRT, not only to students but also to all the faculty members of all the dental institutions of this country where tobacco-related problems are highly prevalent.


We are thankful to all the principals of various dental colleges of Odisha for their remarkable aid during the course of the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Doll R, Peto R, Wheatley K, Gray R, Sutherland I. Mortality in relation to smoking: 40 years' observations on male British doctors. BMJ 1994;309:901-11.
2Niu SR, Yang GH, Chen ZM, Wang JL, Wang GH, He XZ, et al. Emerging tobacco hazards in China: 2. early mortality results from a prospective study. BMJ 1998;317:1423-4.
3Annual Smoking-Attributable Mortality, Years of Potential Life Lost, and Economic Costs- United States, 1995-1999. Available from: [Last accessed on 2017 Mar 13].
4WHO,Dependence Syndrome. Available from: [Last accessed on 2017 Mar 13].
5Barbeau AM, Burda J, Siegel M. Perceived efficacy of e-cigarettes versus nicotine replacement therapy among successful e-cigarette users: A qualitative approach. Addict Sci Clin Pract 2013;8:5.
6Nicotine Replacement Therapy for Smoking Cessation or Reduction: A Review of the Clinical Evidence. Canadian Agency for Drugs and Technologies in Health; 2014. p. 1-20.
7McNeill A, Foulds J, Bates C. Regulation of nicotine replacement therapies (NRT): A critique of current practice. Addiction 2001;96:1757-68.
8Cepeda-Benito A, Reynoso JT, Erath S. Meta-analysis of the efficacy of nicotine replacement therapy for smoking cessation: Differences between men and women. J Consult Clin Psychol 2004;72:712-22.
9Albert D, Ward A, Ahluwalia K, Sadowsky D. Addressing tobacco in managed care: A survey of dentists' knowledge, attitudes, and behaviors. Am J Public Health 2002;92:997-1001.
10Helping Smokers to Stop: (A Guide For The Dental Team). Available from: [Last accessed on 2017 Mar 13].
11Wyne AH, Chohan AN, Al-Moneef MM, Al-Saad AS. Attitudes of general dentists about smoking cessation and prevention in child and adolescent patients in Riyadh, Saudi Arabia. J Contemp Dent Pract 2006;7:35-43.
12Ajagannanavar SL, Alshahrani OA, Jhugroo C, Tashery HM, Mathews J, Chavan K, et al. Knowledge and perceptions regarding nicotine replacement therapy among dental students in Karnataka. J Int Oral Health 2015;7:98-101.
13Sharma G, Puranik MP, Sowmya KR. Nicotine replacement therapy in dental settings: An exploratory survey in Bangalore city, India. Addict Health 2016;8:25-32.
14Agaku IT, Ayo-Yusuf OA. A global assessment of knowledge of dental students about nicotine replacement therapy: Findings from 43 countries. Eur J Dent Educ 2014;18:154-61.
15Singla A, Patthi B, Singh K, Jain S, Vashishtha V, Kundu H, et al. Tobacco cessation counselling practices and attitude among the dentist and the dental auxiliaries of urban and rural areas of Modinagar, India. J Clin Diagn Res 2014;8:ZC15-8.
16Saddichha S, Rekha DP, Patil BK, Murthy P, Benegal V, Isaac MK, et al. Knowledge, attitude and practices of Indian dental surgeons towards tobacco control: Advances towards prevention. Asian Pac J Cancer Prev 2010;11:939-42.
17Murugaboopathy V, Ankola AV, Hebbal M, Sharma R. Indian dental students' attitudes and practices regarding tobacco cessation counseling. J Dent Educ 2013;77:510-7.
18Applegate BW, Sheffer CE, Crews KM, Payne TJ, Smith PO. A survey of tobacco-related knowledge, attitudes and behaviours of primary care providers in Mississippi. J Eval Clin Pract 2008;14:537-44.
19Abdullah AS, Rahman AS, Suen CW, Wing LS, Ling LW, Mei LY, et al. Investigation of Hong Kong doctors' current knowledge, beliefs, attitudes, confidence and practices: Implications for the treatment of tobacco dependency. J Chin Med Assoc 2006;69:461-71.
20Bhat N, Jyothirmai-Reddy J, Gohil M, Khatri M, Ladha M, Sharma M, et al. Attitudes, practices and perceived barriers in smoking cessation among dentists of Udaipur city, Rajasthan, India. Addict Health 2014;6:73-80.
21Ibrahim H, Norkhafizah S. Attitudes and practices in smoking cessation counseling among dentists in Kelantan. Arch Orofac Sci 2008;3:11-6.