Dental students’ attitude towards anti-smoking

programmes: a study in Flanders, Belgium

J. Vanobbergen, P. Nuytens, M. van Herk and L. De VisschereDe Pintelaan 185, Ghent, Belgium

Objective: The aim of the study was to assess the dentalstudents’ attitude towards tobacco cessation counselling in the

dental setting and to explore the influence of knowledge, belief ineffectiveness, smoking status, gender and curriculum.

Material and methods: The study group consisted of allundergraduate students from the 2002–2003 classes of the

Ghent University (n ¼ 96). A validated questionnaire was admin-istered to all students involving four different sections: demogra-

phic characteristics, attitude related to tobacco cessationprogrammes in the dental setting, belief in their effectiveness

and knowledge concerning tobacco health effects. Statisticalanalysis included simple univariate nonparametric tests for

evaluating differences in attitude towards tobacco cessation

programmes, belief in effectiveness of tobacco cessation pro-grammes in the dental setting and knowledge of students

concerning tobacco health effects by year of graduation, smokingstatus and gender. Multiple logistic regression was chosen to

calculate adjusted odds ratios and 95% confidence intervals.Results: Students view willingness to advise individual patients

to quit using tobacco. Yet only 51.3% are willing to co-operate inanti-tobacco programmes at the community level, and the

perception of students of the effectiveness of smoking cessationcounselling in the dental setting is low. The variance of attitude

towards tobacco cessation programmes was significantly affec-ted by knowledge and the belief in effectiveness of tobacco

cessation programmes in the dental setting. Better knowledgeand belief in effectiveness of tobacco cessation counselling was

associated with an increasing positive attitude towards tobaccocessation programmes expressed by an odds ratio of 3.12 (95%

CI 1.00–9.67) and 1.17 (95% CI 1.00–1.37) respectively.Conclusion: Belief in effectiveness and knowledge seem to

influence the attitude of students towards tobacco cessationcounselling.

Practice implications: Besides imparting knowledge, theattitude of newly graduated dentists could be improved by

stressing the effectiveness of smoking cessation activities during

lectures and integrated training modules in the undergraduateeducation.

Key words: tobacco control; dental students; attitudes; patientcounselling.

ª 2007 The Authors. Journal Compilation ª 2007 BlackwellMunksgaard

Accepted for publication, 3 January 2007

Introduction

S moking has an important negative effect on

health. According to the most recent estimate by

the World Health Organization (WHO), 4.9 million

people worldwide died in 2000 as a result of their

addiction to nicotine (1). Tobacco use also causes

serious oral health problems. It is firmly established

that tobacco use is a primary cause of many oral

diseases and adverse oral conditions (2). Tobacco is a

risk factor for oral cancer, oral cancer recurrence, adult

periodontal diseases and congenital defects such as

cleft lips and palate in children (3, 4).

The dental team can play an important role in

tobacco control programmes, both, directed towards

the community as a whole or towards the individual

patient. Through participation in community and

political action and in counselling their patients to

quit, the health professional, in particular the dentist

and his/her team, can contribute to a more tobacco-

free society. Besides the important impact of national

and international legislation, there is ample evidence

that general medical practitioner advice to quit

tobacco use is respected by the majority of patients,

and several recent studies show that the efforts of

dentists can be equally effective (5–7).

The problem is that, while the majority of dentists

believe that providing information about tobacco

cessation and offering smoking cessation support are

both part of their duty, fewer dentists actually do so.

The reasons for not providing it include time and

reimbursement issues, poor education and lack of

further postgraduate training and poor co-ordination

of dental and smoking cessation services (8–10).

Another matter of research is the attitude of dental

students, the future dentists, towards tobacco control

177

Eur J Dent Educ 2007; 11: 177–183All rights reserved

ª 2007 The Authors. Journal Compilation ª 2007 Blackwell Munksgaard

euro pean journal of

Dental Education

programmes. Even when some reservations are men-

tioned, USA dental students appear to be positive

regarding their responsibility to educate patients

about the risks of tobacco use. There was a general

agreement that their educational programme ade-

quately prepared them to help smokers quit (11–13).

The majority of Australian dental students planned to

advise patients about tobacco use, although their

perception of the effectiveness of smoking cessation

counselling seems to be low (14). The same trend was

observed in Europe where Greek students considered

tobacco cessation counselling a duty for every dentist,

although an important part (32%) believed it to be

ineffective. On the other hand, students showed

significant knowledge on tobacco health effects (15).

The high rate of smoking among healthcare profes-

sional students in Hungary, Eastern Europe (16),

compared with Western European, American and

Australian students, could be an explanation why

they are less proactive regarding tobacco intervention.

The effectiveness of training health professionals to

deliver smoking cessation interventions to their

patients has been reviewed recently and reported in

the Cochrane database. The authors concluded that

training health professionals to provide smoking

cessation interventions had a measurable effect on

professional performance but that there was no

strong evidence that it changed smoking behaviour

(17). At least there is an agreement that students’

attitude will be influenced by peers, teachers and

curriculum content. The educational system’s move-

ment towards prevention and holism is a trend that

deals with the relevant themes in our changing

society and that can contribute to the development

of students’ attitudes. The reformation of the dental

and medical curriculum at Ghent University

switched the traditional biomedical orientation into

a more biosocial oriented and integrated approach:

patient-centred; student-centred; community orien-

ted; problem and evidence based. Within this new

dental curriculum, attention is paid to oral health

promotion, including tobacco cessation counselling.

Yet tobacco cessation counselling is taught only in

theoretical terms during the second year of the

education. This reformation should be beneficial in

reorienting dental students’ attitudes towards a more

positive attitude regarding health promotional and

educational programmes (18).

The aim of the present study was to assess the

dental students’ attitude towards tobacco cessation

promotion in the dental setting and to explore the

influence of knowledge, belief in effectiveness,

smoking status, gender and curriculum.

Materials and methods

The study group for the present study comprised

the dental students from the 2002–2003 classes of the

Ghent University. Dental education programme at

the Ghent University consists of two first-cycle years

(bachelor) and three second-cycle years (master). All

undergraduate students (n ¼ 96) participated in the

study with 25 students in the first year, 25 in the

second, 13 in the third, 11 in the fourth and 22 in

the final year. The final year students went through

their undergraduate education in the old curriculum.

As, from this moment, the new curriculum was

entered progressively, comparison between curricula

is possible.

A questionnaire was administered to all students

(Fig. 1). This questionnaire was designed with four

different sections: demographic characteristics, atti-

tude related to tobacco cessation programmes in

the dental setting, belief in their effectiveness and

knowledge concerning tobacco health effects.

In the first section respondents were asked about

their age, sex, actual smoking status and undergradu-

ate level. Non-smokers and ex-smokers were classified

as non-current smokers, moderate/social and heavy

smokers as current smokers.

In the second section, a seven-item tool generated a

total score for attitude related to tobacco cessation

programmes in the dental setting, both on an individ-

ual and on community level. This score was calculated

by totalising the ‘yes’ responses and was further

standardised to a maximum of 10 [(number of positive

answers/number of questions) · 10], a higher score

indicating a more positive attitude. For use in the

logistic regression analyses this variable was dicho-

tomised with the median value as the cut-off.

The third section comprised items dealing with

students’ belief in effectiveness of tobacco cessation

programmes in the dental setting. Two ‘yes or no’ close-

ended questions and one rank ordering question were

used to assess this item. The rank ordering question

asked the respondents to rank, in order of importance in

the tobacco counselling process, a list including health-

care workers, family, friends and the media. All three

questions had the same weight (maximum 1—mini-

mum 0). The rank ordering question was scored from 0

(the dentist ranked in the last place) to 1 (the dentist

ranked in the first place). This variable was further

handled the same way as the variable attitude.

In the last section 19 questions were included

assessing students’ knowledge concerning tobacco

health effects, in particular oral health effects. This

variable was calculated as the sum of correct answers

Vanobbergen et al.

178

and standardised to a maximum of 10. The questions

in this section were checked for relevance and the

evidence of the answer was based on data directly

addressing the question (2,3, 19–25).

The questionnaires were administered anony-

mously during scheduled class times and/or clinical

courses.

The questionnaire was pilot-tested prior to the

study. The relevance of questions, response formats

and wording was tested. The process resulted in

some questions being deleted and others being

changed. A test–retest with 10 students, spread over

the graduations years, smoking status and gender,

was performed to assess the reliability of the ques-

tionnaire with an interval of 1 month. Test–retest

measures (intra-class correlation) were combined

with nonparametric tests for related samples and

were used for the sum scores of attitude, belief in

effectiveness and knowledge (Table 1). The Wilcoxon

signed rank test was used to measure systematic

differences between the two related measurements.

For knowledge a significant systematic increase was

Graduation year:……………………………………………………………………….. Age:……………………… Gender: o male o female Smoker: o never o in the past o moderate/ social smoker

o heavy smoker

1. Are you willing to show your patients the damage that smoking can cause upon oral health?2. Are you willing to show your patients the damage that smoking can cause upon general health? 3. Are you willing to forbid the patients to smoke in the waiting-room of your own practice? 4. Are you willing to advise patients to stop smoking? 5. Are you willing to cooperate actively in anti-tobacco programs on community level? 6. Are you willing to use anti-tobacco programs in your own practice? (e.g. flyers, advisement,…etc.) 7. Do you think that every dentist has the duty to cooperate in anti-tobacco programs? 8. Do you think that anti-tobacco programs in the dental practice can be effective? 9. Do you think that the patients will take notice of your advisement?

What/who has the greatest influence on smoking behaviour: (classify from 1 to 10, starting with 1 = of greatest influence and 10 = of smallest influence) School Commercials on the street Doctor Friends

Colleagues Dentist

Do you think that smoking: 1. -can cause a nose polyp? 2. -can cause lung cancer? 3. -can slow down oral wound healing? 4. -can slow down growing? 5. -can cause nefropathology? 6. -can increase an existing periodontal pathology? 7. -can cause cancer of the oesophagal tractus? 8. -can cause oral cancer? 9. -can cause liver-dysfunction?

10.11.12.13.14.

15.

16.17.18.19.

-combined with alcohol has an increased risk of oral cancer? -can cause oral implant failure? -on elder age influences saliva-constitution? -of selfmade-cigarettes is worse than filter-cigarettes? -occurs more in upper class of the society? -during the pregnancy can cause breathing problems on the newly born child? -influences oral candidiasis? -influences leukoplakia? -influences taste sensitivity?

-influences the amount of saliva?

Fig. 1. Questionnaire (translated from the original Dutch).

Belgian dental students’ attitude towards tobacco control

179

found at the retest compared to the first test

(P < 0.05).

The survey was analysed using the SPSS 12.0

software package. Descriptive statistics were gener-

ated for relevant items. Univariate analysis was

performed with nonparametric Kruskal–Wallis and

Mann–Whitney tests.

Multiple logistic regression analyses were carried

out to determine the factors that were independently

related to the attitude towards tobacco cessation

programmes, belief in their effectiveness and know-

ledge of students concerning tobacco health effects.

Data were analysed as dichotomous variables (except

for ‘age’ and ‘year of graduation’) and compared

using odds ratios. Point estimates and 95% confidence

intervals were calculated. Odds were calculated in one

group (e.g. males) by dividing the number of males

with e.g. high knowledge by the number of males with

low knowledge. This odds calculation was repeated

for girls. The odds ratio was obtained by dividing the

odds of having a high knowledge among males by the

odds of having a high knowledge among girls.

Statistical significance level was set at P < 0.05.

Results

Response rate was 81% (78/96). Respondents were

62% female and 38% male. The average age of the

sample was 21.79 (SD 4.16) years. Seventy-five per

cent of respondents reported to be non-smokers.

A narrow majority of the students (53.8%) had an

explicit positive attitude towards tobacco cessation

programmes, receiving an average rating of at least 7.5

out of 10 (a score of 10 is the best possible attitude) on

the responses related to this item. All respondents

agreed to show their individual patients the oral

health hazards of tobacco use and 96% of respondents

were willing to use anti-tobacco programmes in their

practice to advise patients to quit using tobacco.

However, only 40% of respondents agreed that it

is the responsibility and duty of every dentist to

co-operate in anti-tobacco programmes and only

51.3% are willing to co-operate actively in anti-tobacco

counselling programmes at the community level.

Based on the descriptive analyses of the responses

related to the effectiveness of tobacco cessation activ-

ities in the dental setting, one can observe that the

mean score of all respondents was clearly lower

compared with the mean scores of attitude and

knowledge (5.1 vs. 8.1 and 8.3 respectively). Only

32% of the respondents had a score equal to or higher

than 7 on the 1 to 10 scale.

Figure 2 shows the different values for the three

important outcome variables (attitude, belief in effect-

iveness and knowledge) during the 5 years of the

undergraduate education.

In the univariate analysis (Table 2) some relevant

correlations were observed among the studied varia-

bles. There was a significant difference in attitude

depending on the level of belief in effectiveness

(P < 0.05). In fact, the more students believe in the

effectiveness of tobacco cessation programmes, the

more likely they are to have a positive attitude

towards these programmes. Furthermore, a trend

was observed towards a better attitude in students

with a higher knowledge (P ¼ 0.09). A slightly differ-

ent situation is observed for belief in effectiveness,

where female students were shown to have a higher

TABLE 1. Reliability measurement for sum scores related to knowledge, belief in effectiveness and attitude (n ¼ 10)

Testmean (SD)(up to a max. of 10)

Retestmean (SD)(up to a max. of 10) P-value1 ICC

Attitude towards tobacco cessation counselling 6.8 (2.1) 7.3 (2.2) 0.08 0.97Belief in effectiveness of tobacco counsellingprogrammes in the dental setting

6 (1.4) 5 (2.3) 0.26 0.89

Knowledge concerning tobacco health effects 5.9 (0.7) 6.6 (1.2) 0.048 0.69

ICC, intra-class correlation coefficient.1Wilcoxon signed rank test.

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

1styear

2nd year

3rd year

4th year

5th year

Graduation year

Val

ue

Attitude

Belief in effectiveness

Knowledge

Fig. 2. Attitude towards tobacco counselling in dental settings,belief in effectiveness and knowledge concerning tobacco healtheffects by year of graduation.

Vanobbergen et al.

180

belief in effectiveness of tobacco counselling than their

male counterparts (P < 0.05). For knowledge the only

significant correlation found in the data was the effect

of graduation level (P < 0.01). No differences were

found between final year students (old curriculum)

and the others (new curriculum).

Logistic regression models determined the inde-

pendent impact of demographic factors (gender,

smoking status, level of graduation and age) on

knowledge of students concerning tobacco health

effects, attitude towards tobacco cessation pro-

grammes and belief in effectiveness of tobacco cessa-

tion programmes in the dental setting. These models

explained about 18% of the variance of the outcome

variable (R2 ¼ 0.18, 0.18 and 0.17 respectively). They

indicated that knowledge increased with year of

graduation, but not necessarily with age (Table 3).

The odds ratio for increasing knowledge per year was

2.03 (95% CI 1.20–3.44), representing a significant

increasing knowledge during the undergraduate

education with a peak between the second and the

third year (first and second cycle). The variance of

attitude towards tobacco cessation programmes was

significantly affected by knowledge and the belief

in effectiveness of tobacco cessation programmes in

the dental setting. Better knowledge and belief in

effectiveness of tobacco cessation counselling was

associated with an increasing positive attitude

TABLE 2. Univariate analysis for differences in attitude towards tobacco cessation programmes, belief in effectiveness of tobacco cessationprogrammes in the dental setting and knowledge of students (n ¼ 78) concerning tobacco health effects by year of graduation, smoking statusand gender

Attitude Belief in effectiveness Knowledge

Mean P-value Mean P-value Mean P-value

Graduation year 0.361 0.741 <0.011

First year 82 5.5 7.8Second year 7.9 5.6 7.9Third year 8.9 5.3 8.9Fourth year 7.8 4.1 8.7Fifth year 7.8 5.0 8.5

Curriculum 0.342 0.662 0.192

New curriculum 8.2 5.2 8.2Old curriculum 7.8 5.0 8.5

Smoking status 0.242 0.642 0.442

Current smoker 7.7 4.8 8.4Current non-smoker 8.2 5.3 8.3

Gender 0.352 <0.052 0.972

Female 8.2 5.4 8.4Male 7.9 4.7 8.3

Belief in effectiveness <0.052

Less effective 7.7Effective 8.3

Knowledge 0.092 0.552

Low knowledge 7.7 5.5High knowledge 8.3 5.0

1Kruskal–Wallis test.2Mann–Whitney test.The P-values in bold are significant values at the 0.05 level.

TABLE 3. Logistic regression model with knowledge, attitude towards tobacco cessation programs and belief in effectiveness of tobaccocessation programs in the dental setting as dependent variables adjusting for gender, smoking status, year of graduation and age

Explanatory variable

Attitude Knowledge Effectiveness

P-value OR 95% CI P-value OR 95% CI P-value OR 95% CI

GenderMale vs. female 0.83 0.89 0.31–2.51 0.87 0.91 0.30–2.75 0.23 0.54 0.20–1.50

Smoking statusSmoker vs. non-smoker 0.51 0.68 0.22–2.16 0.91 0.88 0.25–3.10 0.62 0.75 0.31–2.34

Year of graduation 0.23 0.75 0.48–1.19 <0.01 2.03 1.20–3.44 0.44 0.84 0.54–1.30Age 0.96 1 0.84–1.18 <0.05 0.76 0.61–0.96 0.91 0.99 0.86–1.18Belief in effectiveness 0.05 1.17 1.00–1.37Attitude 0.09 2.22 0.89–5.97Knowledge 0.05 3.12 1.00–9.67 0.44 0.65 0.22–1.95Constant 0.84 0.72 0.02 96.80 0.82 1.44

Nagelkerke R 2 ¼ 0.18.

Belgian dental students’ attitude towards tobacco control

181

towards tobacco cessation programmes expressed

by an odds ratio of 3.12 (95% CI 1.00–9.67) and 1.17

(95% CI 1.00–1.37) respectively.

Discussion and conclusion

DiscussionWhen interpreting the results of this study one has to

take into consideration some limitations. First, not-

withstanding the high response rate, the 78 students

represent a rather small sample. The number of

incoming dental students in Flanders is actually very

low. During a national campaign a few years ago,

pursued by the dental association, young people were

dissuaded from attempting a dental career. This

resulted in a political debate followed by the restric-

tion of the intake of students to the programmes of

medicine and dentistry in Flanders through an

entrance examination. Second, the development and

implementation of the present study was conducted in

only one dental school (there are two dental schools in

Flanders). Thus, the findings reported in this study

may have a limited generalisability and the power of

the study may be limited. Non-response bias was

evaluated but no significant differences were found

between non-responders and responders in gender,

year of graduation and smoking status.

Nevertheless, the results may reveal important

information about Flemish dental students’ attitude,

beliefs and knowledge towards tobacco cessation

counselling in the dental setting.

Compared to the current literature, smoking pre-

valence of dental undergraduates in the University of

Gent remains high with 25% of the students being

current smokers. Unfortunately, smoking prevalence

increased progressively with the year of study from

12.5% in the first year to 38.1% in the final year, which

goes against the trend observed in several interna-

tional reports (12). In comparing current smokers with

non-smokers, no differences in attitudes, beliefs and

knowledge were observed, which is in agreement with

the literature.

Approximately two-thirds of the respondents were

female, reflecting the actual trend towards increasing

numbers of females in dental schools all over the

Western world. The only gender difference observed

in the univariate analysis was that females tended to

have more confidence in the effect of tobacco coun-

selling in the dental setting. Gender was one of the

confounders included in the logistic regression model,

but no gender differences were found in the multiple

analyses.

The fact that 96% of students were willing to advise

patients to quit using tobacco is consistent with the

results of previous studies mentioned in the Introduc-

tion, but it seems remarkable that a lower percentage

of them (40%) reported that it is their responsibility

and duty to co-operate in anti-tobacco programmes.

Knowledge seems to influence the attitude of dental

students, but the very wide confidence interval may

threaten the validity of this finding.

The low mean score observed for ‘belief in effect-

iveness’ indicates that respondents have low confid-

ence in the fact that tobacco counselling offered in the

dental office can have an impact on patients’ quitting.

This rather low perception of effectiveness follows the

general trend reported in the literature (13–15). These

responses suggest that many students may still be

sceptical about the extent to which tobacco cessation

counselling is effective in helping patients to quit.

Much remains to be done in the undergraduate

education to show the scientific evidence on both the

efficacy and cost-effectiveness of tobacco prevention.

Standardised and simple schemes, such as the ‘Four

As’, are widely used around the world, and advice on

how to use this scheme is available. Here too, there is

ample evidence proving that dentists’ advice to quit

tobacco use is respected by the majority of patients (26,

27). The present study shows that belief in effective-

ness of tobacco cessation counselling may also con-

tribute to the attitude of students towards tobacco

counselling. It is all the more reason why the effect-

iveness of tobacco programmes should be emphasised

in the dental curriculum.

So far, the effect of the new curriculum on students’

attitude, belief and knowledge has been minimal. As

suggested in the literature one may need more

alternate teaching methods such as problem-based

discussions, tutorials, small group discussion and

skills laboratories to improve the awareness, belief

and skills of dental students, especially in this matter,

in which attitudes play a significant role. Gradually

these alternate methods will be implemented in the

new curriculum, recently once again adapted to the

Bologna agreement. However, the follow-up period in

the present study was too short to reveal the longer

term effects of the new curriculum. Further research

will be carried out to evaluate this new Bachelor-

Master structure.

ConclusionDental students’ attitude towards tobacco cessation

counselling in the dental setting represents a promis-

ing baseline for future tobacco cessation programme

development. Students view willingness to advise

Vanobbergen et al.

182

individual patients to quit using tobacco. Yet only a

minority are willing to co-operate in anti-tobacco

programmes at the community level, and the percep-

tion of students of the effectiveness of smoking

cessation counselling in the dental setting is low.

Knowledge and belief in effectiveness seem to influ-

ence the attitude of students towards tobacco cessation

counselling.

Practice implicationsBesides imparting knowledge, the attitude of newly

graduated dentists could be improved by stressing the

effectiveness of smoking cessation activities during

lectures and integrated training modules in the

undergraduate education. Both aspects, the commu-

nity-based programmes and the individual communi-

cation skills, need to be emphasised.

References

1. Petersen PE. The World Oral Health Report 2003:continuous improvement of oral health in the 21stcentury – the approach of the WHO Global Oral HealthProgramme. Community Dent Oral Epidemiol 2003: 31(Suppl. 1): 3–23.

2. Petersen PE. Tobacco and oral health – the role of theWorld Health Organization. Oral Health Prev Dent 2003:1: 309–315.

3. Reibel J. Tobacco and oral diseases. Update on theevidence, with recommendations. Med Princ Pract 2003:12 (Suppl. 1): 22–32.

4. Little J, Cardy A, Munger RG. Tobacco smoking and oralclefts: a meta-analysis. Bull World Health Organ 2004: 82:213–218.

5. Warnakulasuriya S. Effectiveness of tobacco counsellingin the dental office. J Dent Educ 2002: 66: 1079–1087.

6. Johnson NW. The role of the dental team in tobaccocessation. Eur J Dent Educ 2004: 8 (Suppl. 4): 18–24.

7. Carr AB, Ebbert JO. Interventions for tobacco cessation inthe dental setting. Cochrane Database Syst Rev 2006: 1:CD005084.

8. Monaghan N. What is the role of dentists in smokingcessation? Br Dent J 2002: 193: 611–612.

9. Allard RH. Tobacco and oral health: attitudes andopinions of European dentists; a report of the EUworking group on tobacco and oral health. Int Dent J2000: 50: 99–102.

10. Allard RH. The role of health professionals in discour-aging tobacco use. Ned Tijdschr Tandheelkd 2004: 111:396–399.

11. Yip JK, Hay JL, Ostroff JS, Stewart RK, Cruz GD. Dentalstudents’ attitudes toward smoking cessation guidelines.J Dent Educ 2000: 64: 641–650.

12. Fried JL, Reid BC, DeVore LE. A comparison of healthprofessions student attitudes regarding tobacco curriculaand interventionist roles. J Dent Educ 2004: 68: 370–377.

13. Victoroff KZ, Dankulich-Huryn T, Haque S. Attitudes ofincoming dental students toward tobacco cessation pro-motion in the dental setting. J Dent Educ 2004: 68:563–568.

14. Rikard-Bell G, Groenlund C, Ward J. Australian dentalstudents’ views about smoking cessation counselling andtheir skills as counsellors. J Public Health Dent 2003: 63:200–206.

15. Polychonopoulou A, Gatou T, Athanassouli T. Greekdental students’ attitudes toward tobacco control pro-grammes. Int Dent J 2004: 54: 119–125.

16. Nagy K, Barabas K, Nyari T. Attitudes of Hungarianhealthcare professional students to tobacco and alcohol.Eur J Dent Educ 2004: 8 (Suppl. 4): 32–35.

17. Lancaster T, Silagy C, Fowler G. Training health profes-sionals in smoking cessation. Cochrane Database SystRev 2000: 3: CD000214.

18. Deveugele M, Derese A, DeMaesschalck S, Willems S,Van Driel M, De Maeseneer J. Teaching communicationskills to medical students, a challenge in the curriculum?Patient Educ Couns 2005: 58: 265–270.

19. Bergstrom J. Tobacco smoking and chronic destructiveperiodontal disease. Odontology 2004: 92: 1–8.

20. Whiteford L. Nicotine, CO and HCN: the detrimentaleffects of smoking on wound healing. Br J CommunityNurs 2003: 8: S22–S26.

21. Vehemente VA, Chuang SK, Daher S, Muftu A, DodsonTB. Risk factors affecting dental implant survival. J OralImplantol 2002: 28: 74–81.

22. Macgregor ID. Effects of smoking on oral ecology.A review of the literature. Clin Prev Dent 1989: 11:3–7.

23. Sudbo J, Samuelsson R, Risberg B, et al. Risk markers oforal cancer in clinically normal mucosa as an aid insmoking cessation counselling. J Clin Oncol 2005: 23:1927–1933.

24. Charalabopoulos K, Assimakopoulos D, Karkabounas S,Danielidis V, Kiortsis D, Evangelou A. Effects of cigarettesmoking on the antioxidant defence in young healthymale volunteers. Int J Clin Pract 2005: 59: 25–30.

25. Khan GJ, Mehmood R, Salah UD, Ihtesham UH. Effectsof long-term use of tobacco on taste receptors andsalivary secretion. J Ayub Med Coll Abbottabad 2003:15: 37–39.

26. Havlicek D, Stafne E, Pronk NP. Tobacco cessationinterventions in dental networks: a practice-based eval-uation of the impact of education on provider know-ledge, referrals, and pharmacotherapy use. Prev ChronicDis 2006: 3: A96.

27. Silagy C, Stead LF. Physician advice for smokingcessation. Cochrane Database Syst Rev 2001: 2:CD000165.

Address:

Prof Jacques Vanobbergen

De Pintelaan 185

Ghent

Belgium 9000

Tel: +32 9240 4025

Fax: +32 9240 3851

e-mail: Jacques.vanobbergen@ugent.be

Belgian dental students’ attitude towards tobacco control

183