Journal of Dentistry (2006) 34, 173178

www.intl.elsevierhealth.com/journals/jden

Dental patient awareness of smoking effects on oral health: Comparison of smokers and non-smokers
Khalaf F. Al-Shammaria,*, Mohamed A. Moussab, Jassem M. Al-Ansaric, Yousif S. Al-Duwairya, Eino J. Honkalad
a

Ministry of Health, P.O. Box 758, Jahra 01009, Kuwait Faculty of Medicine, Jabriyah, Kuwait c College of Health Sciences, Shuwaikh, Kuwait d Faculty of Dentistry, Jabriyah, Kuwait
b

Received 10 February 2005; accepted 27 May 2005

KEYWORDS
Smoking; Oral health; Oral cancer; Wound healing; Patient knowledge

Summary Objectives: The negative effects of cigarette smoking on oral health are well established, yet few studies assessed patient awareness of such effects. The aim of this study was to examine differences in dental patient knowledge and awareness of the effects of smoking on oral health between smokers and non-smokers. Methods: Adult patients from 12 dental centers in Kuwait were asked to complete a 14-point self-administered structured questionnaire on the effects of smoking on oral health in this cross-sectional survey. Signicant associations between oral health knowledge, smoking status, and sociodemographic variables were examined with univariate analysis and logistic regression. Results: A total of 1012 subjects participated (response rateZ84.3%). The prevalence of smoking was 29.3%. Fewer smokers than non-smokers thought that oral health and smoking are related (92.2% vs. 95.8%; PZ0.020), and that smoking affected oral cancer (52.4% vs. 66.8%; P! 0.001), periodontal health (72% vs. 78%; PZ0.040), or tooth staining (86.1% vs. 90.9%; PZ0.018). Logistic regression analysis showed smokers to be signicantly less aware of the oral health effects of smoking than non-smoking patients (ORZ1.51; 95% CI: 1.052.16; PZ0.025). Conclusion: Smoking dental patients are signicantly less aware of the oral health effects of smoking than non-smokers. Comparative studies in other populations may be warranted to ascertain the validity of these results. Q 2005 Elsevier Ltd. All rights reserved.

Introduction
The negative effects of smoking on the general health of tobacco users are well documented. Smoking has been established as a risk factor for death from several systemic diseases, including

* Corresponding author. Tel.: C965 9676688; fax: C965 4562346.

0300-5712/$ - see front matter Q 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.jdent.2005.05.006

174 lung cancer, respiratory diseases, and cardiovascular disease.13 Smoking has also been demonstrated to affect the oral health of smokers in a variety of ways ranging from cosmetic effects, such as tooth staining, to potentially life-threatening conditions such as oral cancer.4,5 Some of the reported effects of smoking on oral health include increased susceptibility to periodontal diseases,68 reduced response to both surgical and non-surgical periodontal therapies,9,10 an increased risk of dental implant failure,11 and a higher risk for oral cancer and pre-cancerous lesions.1214 Despite these established negative effects of smoking on oral health, few studies examining dental patient knowledge and awareness of such effects are available.1520 Moreover, most of the available studies have focused on oral cancer, and none has examined other oral health aspects. The aim of this study was, therefore, to assess dental patient knowledge and awareness of the oral health effects of smoking, and to investigate the role of smoking status and sociodemographic characteristics on such knowledge.

K.F. Al-Shammari et al. status (number of cigarettes smoked per day, duration of smoking). Both smokers and non-smokers were asked whether smoking had an effect on oral health in general or not. This was followed by specic questions in which respondents were asked to select what oral and dental conditions they thought smoking had an inuence on. These conditions included four established oral health effects of smoking (oral cancer, periodontal disease, delayed wound healing, and tooth staining), and a control question of an effect with no proven association with cigarette smoking (caries). Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 12.0 (Chicago, IL, 2003) statistical software. Differences in age between smokers and non-smokers were compared using the student t-test. Association between smoking status and sociodemographic characteristics (age range, gender, education level, and marital status) with knowledge of each of the oral health effects and differences in knowledge between smokers and non-smokers were assessed using the chi-square test. Differences in knowledge of the specic oral health effects in all patients were assessed with chi-square test for linear trends. Binary logistic regression was utilized to examine which factors were signicant in multivariate analysis after adjusting for confounding between effects. The regression model used the dependent variable knowledge score calculated in the following manner: a score of 1 was given if the patient correctly responded to all four established effects (oral cancer, periodontal disease, wound healing, and tooth staining) as being inuenced by smoking; a score of 0 was given if any of these variables was not selected. Independent variables entered in the model were age range, sex, marital statue, level of education, and smoking status.

Methods
A cross-sectional survey was carried out during June 2003. Twelve primary dental care centers were randomly selected, two from each of the six health districts in Kuwait. Data were collected through a self-administered questionnaire. The inclusion criteria comprised Kuwaiti nationals 18 years of age or older. The study protocol was approved by the Ministry of Health Review Board, and informed consent was obtained from all study participants. A total of 1200 patients were approached while awaiting access to the dentist (100 in each of the 12 centers) and asked to complete the questionnaire by each dental centers reception personnel. Out of the 1200 questionnaires distributed, 1012 were returned, for a response rate of 84.3%. No other data was available from the 188 patients who did not return the study forms. The questionnaire consisted of 14 questions and was divided into three sections: sociodemographic characteristics, knowledge about the effects of smoking on oral health, and willingness of the patient to quit smoking if he/she knew about the hazards of smoking on oral health. The questionnaire was tested on 15 patients prior to the start of the survey, and unclear items were modied accordingly. Sociodemographic variables included age, gender, marital status, education, and self-reported smoking

Results
The mean age and standard deviation of all study subjects were 33.92 and 8.67 years, respectively, and the number of self-reported smokers was 297 (29.3%). Table 1 presents the sociodemographic characteristics of respondents according to smoking status. Smokers were mainly males (93.3%), married (75.1%), and with high school education or less (52.2%). There was a signicant difference between smokers and non-smokers according to gender (P!0.001) and education level (PZ0.017), but not in age or marital status.

Dental patient awareness of smoking effects

Table 1 Variable Sex Male Female Marital status Married Not married Education level High school or less University education Age (years)
a b

175

Sociodemographic characteristics of participants according to smoking status. Smokers (nZ297) n (%) 279 (93.9) 18 (6.1) 223 (75.1) 74 (24.9) 155 (52.2) 142 (47.8) Mean (SD) 33.85 (8.49) Non-smokers (nZ715) n (%) 361 (50.5) 354 (49.5) 0.274 522 (73.0) 193 (27.0) 0.017 319 (44.7) 395 (55.3) Mean (SD) 33.95 (8.74) 474 (46.9) 537 (53.1) Mean (SD) 33.92 (8.67) 745 (73.6) 267 (26.4) p-valuea !0.001 640 (63.2) 372 (36.8) All patients (nZ1012) n (%)

p-valueb 0.87

Chi-square. Student t-test.

The majority of patients (94.7%) reported that smoking and oral health are related. Tooth staining was recognized by 89.5% of patients as an oral health effect of smoking, effects on periodontal health by 76.2%, on oral cancer by 62.6%, and on wound healing by only 27.7%. Additionally, 50.8% of patients correctly reported that caries was not affected by smoking. Differences in knowledge of these effects were signicant (P! 0.001; chisquare for linear trends). Differences in knowledge related to smoking status are presented in Table 2. Smoking patients were generally less aware of the oral health effects of smoking than non-smokers. Specically, fewer smokers than non-smokers thought that oral health and smoking are related (92.2% vs. 95.8%; PZ 0.020), and that smoking affected oral cancer (52.4% vs. 66.8%; P! 0.001), periodontal health (72% vs. 78%; PZ0.040), or tooth staining (86.1% vs.
Table 2 status. Variable Smoking and oral health are related Smoking affects oral cancer Smoking affects Periodontal health Smoking does not affect caries Smoking affects wound healing Smoking affects tooth staining Knowledge scoreb 1 0
a b

90.9%; PZ0.018). No signicant differences were found in awareness of the effects on wound healing (PZ0.088) or caries (PZ0.141) between smokers and non-smokers. Overall awareness level was further assessed through a knowledge score of 1 (if the respondent correctly identied oral cancer, periodontal disease, wound healing, and tooth staining as being inuenced by smoking) or 0 (if one or more of these effects was not selected). Only 258 subjects (25.5%) scored 1, and smokers signicantly less than non-smokers (19.9% vs. 27.8%; PZ0.005). Binary logistic regression analysis with knowledge score as the dependent variable (1 or 0) and all the examined sociodemographic variables (age range, sex, marital status, and education level) and smoking status (smoker vs. non-smoker) identied smoking status to be the only signicant variable associated with knowledge level

Reported knowledge of participants about the effects of smoking on oral health according to smoking Smokers n (%) 272 155 213 161 71 255 (92.2) (52.4) (72.0) (54.4) (24.0) (86.1) Non-smokers n (%) 684 (95.8) 477 (66.8) 557 (78.0) 352 (49.3) 209 (29.3) 649 (90.9) 199 (27.8) 516 (72.2) p-valuea 0.02 !0.001 0.04 0.141 0.088 0.018 0.005 All patients n (%) 956 (94.7) 632 (62.6) 770 (76.2) 513 (50.8) 280 (27.7) 904 (89.5) 258 (25.5) 754 (74.5)

59 (19.9) 238 (80.1)

Chi-square. Knowledge score: 1, if correctly identied oral cancer, periodontal health, wound healing, and tooth staining to be inuenced by smoking; 0, ifR1 of these variables was not selected.

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Table 3 Factor Smoking status Education level Marital status Sex Age

K.F. Al-Shammari et al.

Logistic regression analysis of factors associated with knowledge level of effects of smoking on oral health. B (SE) 0.410 (0.18) 0.205 (0.15) K0.113 (0.18) 0.051 (0.16) 0.002 (0.01) OR (CI) 1.51 1.23 0.89 1.05 1.00 (1.052.16) (0.921.64) (0.631.28) (0.761.45) (0.981.02) p-value 0.025 0.161 0.534 0.755 0.839

OR, adjusted odds ratio; CI, 95% condence interval.

(Table 3). Smokers were signicantly less likely to be aware of the oral health effects of smoking than non-smokers (ORZ1.51; CI: 1.052.16; PZ0.025). To assess whether awareness of these effects on oral health would encourage smokers to seek smoking cessation help, smokers were asked whether they would quit smoking if a link between smoking and oral health is proven to them. Most of the 297 smoking patients (nZ230; 77.4%) reported they would consider quitting smoking if they were shown that such a link existed.

Discussion
Cigarette smoking affects the oral cavity in a multitude of ways ranging from staining of the teeth to serious diseases such as oral cancer, a disease with a 5-year relative survival rate of only about 50%.5 Between these two extremes are several oral conditions and diseases affected by smoking that, although the consequences of which are not as severe as those of oral cancer, still present the potential for signicant oral health morbidity and tooth mortality. For example, smoking has been identied by numerous crosssectional and longitudinal studies as a signicant risk factor for periodontal disease, one of the two major causes of tooth loss.8, 2125 In fact, a hidden periodontitis epidemic mainly fueled by smoking has been suggested to have existed in the 20th century.26 In addition, smoking has been shown to reduce the success rate of dental implants, a treatment modality that is increasingly utilized in modern dentistry.27,28 In light of these established signicant effects of smoking on oral conditions that are either relatively uncommon but life-threatening such as oral cancer, or not as serious yet affect a signicant proportion of the population, such as periodontal disease, it is somewhat surprising to nd that only few studies have examined patient knowledge of these effects.1520 Examining patient awareness of these effects could aid with at least one important

preventive parameter: the targeting of at risk groups for these oral diseases, i.e. smoking dental patients, with educational programs based on reasonable estimates of their existing knowledge. The prevalence of smoking in studied dental patients was 29.3%. This gure is close to the population estimates of smokers in Kuwait of 34. 4%.29 This may indicate that this sample of patients was fairly representative of the general population. Smoking in this study was also signicantly associated with gender and education level. This corresponds with previous reports relating smoking to these two variables both in Kuwait29 and other nations.5 The majority of subjects in this study were aware of smoking effects on tooth staining (89.5% of all subjects). Awareness levels decreased with the other variables of periodontal health (76.2%), oral cancer (62.2%), and wound healing (27.7%). A signicant proportion (49.2%) also incorrectly identied caries to be affected by smoking. The association between caries and cigarette smoking has not been clearly established,5 and this question was added to improve the validity of the questionnaire through the use of a control variable, which proved valuable in assessing careful response from study participants since answers were at almost exactly the same level of knowledge as if answered by chance. The level of knowledge regarding oral cancer appears low relative to its serious consequences. Also, this awareness level is low compared to the other study providing similar data that reported a higher awareness level of 72%.17 This study demonstrated a signicant gap in knowledge of the oral health effects of smoking between smokers and non-smokers. Smokers were less aware that a link exists between smoking and oral health in general, and of the specic effects of smoking on oral cancer, periodontal health, and tooth staining. This agrees with previous studies evaluating patient knowledge of smoking and oral cancer.18,20,30,31 Comparison with other reports on the effects of smoking on the other variables could not be made, since, to our knowledge, this is the

Dental patient awareness of smoking effects rst report examining dental patient awareness of smoking effects on periodontal health and wound healing. In addition, smoking status was the only variable signicantly associated with overall patient awareness of these effects assessed through an awareness score based on the overall numbers of correctly identied effects by the subjects. This association was independent of age, gender, marital status, or education level. Given the small differences in overall knowledge observed between smokers and non-smokers (92% vs. 95.8%), the clinical relevance of such small difference may be questioned. However, since the difference of knowledge was greatest regarding the most serious oral health risk from smoking, oral cancer (52.4% vs. 66.8%), the clinical relevance of these ndings may be better illustrated. Additionally, whether smokers were biased in their answers is difcult to assess. Psychological aspects may contribute to smokers being unwilling to admit that they continue to smoke despite being aware of the effects of smoking on oral health.31 Whether this signicant difference in knowledge is the main factor in patients decision to smoke cannot be ascertained from this study, but the fact that most smoking patients reported interest in quitting smoking if the link between smoking and oral health is proven to them may indicate that lack of knowledge about these effects may indeed be at least a contributing factor to this decision. As discussed previously, the sort of information obtained from this study may aid in focusing educational and interventional programs to patients with the greatest risk for these oral conditions. It has increasingly been recognized globally that all oral health professionals should integrate tobacco use prevention and cessation services into their daily practice.32 Studies have already shown that the use of an educational pamphlet about the effects of smoking on oral cancer signicantly improved smoking patient knowledge to levels similar to non-smokers.16,33 The effects of education on actual quit rates are more difcult to demonstrate, though, due to the complex, multifactorial etiology and psychology of smoking.34

177 cross-section of patients in one country, and therefore, the applicability of these ndings to other populations of dental patients in other geographical locations cannot be ascertained, comparative studies of other populations may be warranted to validate these results.

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Conclusion
The results of this study implicate smoking status as the factor associated the most with dental patient awareness of the oral health effects of smoking. Since this survey was undertaken in a

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