Discussion
The main aim of the study was to identify the association of depression, anxiety, and stress with initiation of tobacco use among undergraduate dental students of Moradabad, India. The study shows the prevalence of moderate to severe depression, anxiety and stress is 14.4%, 33.70%, and 16.04%. This is lower than the study done among Melaka Manipal Medical College, Malaysia students wherein the percentages are 30.7%, 55.5%, and 16.6% respectively17. The prevalence of depression is found to be highest in first year while prevalence of anxiety and stress was found to be highest in final year students. Hawazin W. Elani et al conducted a systematic review and found that academic factors (84%) are the main sources of stress, anxiety, and depression, followed by the clinical factors (63%) 18. As the study was conducted one month before the examination, so workload, examination, and grades are most important contributing factors causing stress, anxiety, and depression among undergraduate dental students. As the dental students have to perform well in academics as well as surgical aspects of dental care, including performing treatments on patients to qualify as a competent dentists. In confirmation to previous studies (T.L Ravishankar et al, S. Kumar et al ) examinations were one of the most potent factors of stress, anxiety, and depression among all the year of students19,7.
Tobacco use is one of the most common tools that is used to cope with anxiety 20-23 (Park and Breland, 2007; Parrott and Murphy, 2012; Perkins et al., 2010; Slopen et al., 2012). Self-report studies have shown that one of the main reasons of tobacco use is to reduce stress, and anxiety and induce a state of relaxation 24-26 (Aronson et al., 2008; Fidler and West, 2009; McEwen et al., 2008).
A nationwide survey also shows that people primarily use tobacco to manage their anxiety and stress levels (American Psychological Association, 2012)27. It is found that 44.6%, 25%, and 29.5% of dental students initiated tobacco users who are suffering from depression, anxiety, and stress. Sekhon et al. considered tobacco use as the negative coping mechanism by the students to relieve stress and anxiety 28. A few studies (16.7 percent) suggested changes in dental students’ behaviors like smoking habits in relation to high-stress levels18. Gordon and Rayner, in a study of dental students in Africa, described smoking practices and found that students reported “examination stress” and “relaxation” among their reasons to smoke29.
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20.57% dental students were tobacco users before joining the institution and 32.51% dental students started tobacco using after joining the institution while the initiation of tobacco use was found to be highest in final-year students. The final year students had more workload, clinical as well as academics as compared to other years of graduation30. As final year students might be more stressed about learning clinical procedures as during this period most of the advanced clinical procedures are learnt and practiced31 (Zac morse et all). One of the other reasons might be insecurity among students regarding career establishment after graduation is the major issue affecting the students in India. Another reason might be heavy competition among students to achieve job in abroad and to get admission in post-graduation (S. Kumar). The association of stress and anxiety with initiation of tobacco use was found to be significant. This suggests that stress, and anxiety are might be trigger factors for initiation of tobacco use among dental students. Several studies have confirmed the stressful nature of dentistry and the stress-related problems among dental students32-33(Newbury-Birch et al., 2002; Gordon and Rayner, 2010; Plasschaert et al. 2001).
The reassessment of the existing educational system towards more student-oriented could help collaborative learning among the students, which may have a positive effect towards difficulties faced during their course of study34. Many intervention studies have evaluated such programs for dental students, including specific courses, stress-reduction programs, introduction to behavioral sciences, and faculty-incorporated advising systems35 (Howard et al).
In our opinion, it would be better for more experienced dental professionals and dental educators to recognize that there are stressors of different types and that these need to be managed. The institutions should plan a regular counselling programs for students to cope with stress and anxiety. Positive coping mechanisms should be encouraged from early years of graduation among dental students.
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