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2nd quarter 2021 • volume 22 no. 2 • ISSN 1018-1466

JOURNAL

OHASAOfficial mouthpiece of the Oral Hygienists’ Association of South Africa

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EDITORIAL 20 decolonising dental education: If not 2 From the Editor’s desk now, then when? Part 1 Rugshana Cader Sizakele Ndwandwe (BOH) and Tasneem Ajam (BOH) 3 From the President’s desk Stella Lamprecht 24 South African tobacco smoking cessation clinical practice guideline 4 guest Editorial RN van Zyl-Smit, B allwood, D Stickells, Bruna Dessena G Symons, S Abdool-gaffar, k murphy, a vanker, k dheda, gA richards RESEARCH 5 Positioning depression as a critical OHASA NEWS factor in creating a toxic workplace 32 news from the Gauteng Branch environment for diminishing worker productivity 34 uwC update Samma Faiz Rasool , Rashid Maqbool, Madeeha Samma, Yan Zhao, and Amna 35 ISDH 2020 call for abstracts Anjum 37 Faculty of health sciences 47th 15 the effectiveness of a pre- annual awards ceremony procedural mouthrinse in reducing bacteria on radiographic phosphor plates allison Hunter, Sajitha Kalathingal, Michael Shrout, Kevin Plummer, Stephen Looney

EDITORIAL COMMITTEE Managing Editor Rugshana Cader | Tel: (021) 937 3123/(021) 370 4409 | Cell: 082 710 7103 | E-mail: [email protected] or [email protected]

Co-Editors Published by Anri Bernardo, E-mail: [email protected] | Lesley Vorster, E-mail: [email protected] Stella Lamprecht, E-mail: [email protected] OHASA OFFICE PO Box 830, Newlands, 0049 | Fax: 086 696 7313 | E-mail: [email protected] | [email protected] | Website: http://www.ohasa.co.za PUBLISHER Kashan Advertising | Reg. 2020/131924/07 | E-mail: [email protected] On behalf of PRODUCTION OFFICE Kashan Advertising | Tel: (012) 342 8163 | Fax: 086 645 0474 | E-mail: [email protected] | Website: www.kashan.co.za Sub-editor: Caro Heard | Layout and Design: Kashan Advertising

ISSN 1018-1466 © 2021 All rights reserved in text: OHASA. © 2021 All rights reserved in design: Kashan Advertising. OHASA Journal is published four times a year on behalf of (OHASA), the Oral Hygienists’ Association of South Africa. No part of this publication may be reproduced or transmitted in any form, by any means, electronic or mechanical, including photocopying, recording or any information storage or retrieval system, without written permission from the editor. Member of Opinions and statements of whatever nature are published under the authority of the submitting author, and the inclusion or exclusion of any medicine or procedure; do not necessarily reflect the view of the editor, The Oral Hygienists’ Association of South Africa or Kashan Advertising. While every effort is made to ensure accurate reproduction, the authors, advisors, publishers and their employees or agents shall not be responsible, or in any way liable for errors, omissions or inaccuracies in the publication, whether arising from negligence or otherwise or for any consequences arising therefrom. The publication of advertisements in this magazine does not imply an endorsement by the publisher or its editorial office/board and does not guarantee any claims made for products by their manufacturers.

2nd quarter 2021 • volume 22 no. 2 PAGE 1 editorial

from the Editor’s desk

Earlier this month, I was with a group of people We sat in gob-smacked silence when Kim finished and we were all lamenting the current state of speaking. She simply smiled and said, “Come on affairs – COVID-19, the Third Wave, should we guys. It’s no big deal. It’s not as if I invented sliced take the vaccine or not, the Palestinian Struggle, bread or something.” But it WAS a big deal and it is the Zondo Commission, the corruption, the crime, even better than sliced bread. We all felt a seismic same old, same old. It was all so tiring, draining and shift in the conversation, in the rest of the evening depressing, until a lady (let’s call her Kim) spoke and yes, in our lives. For many of you, that last bit up and gave us a perspective that quite honestly, sounds melodramatic but please stay with me on is potentially life-changing. this. I said this is potentially life-changing and it IS, Rugshana Cader Kim said, “You are all talking about such negative if you allow it to be. Managing Editor things. Things that weigh you down, things that add Take a moment, close your eyes and place to the immense weight on your shoulders. Reading your hand on your heart. Breathe in slowly and about the negatives, speaking about them, agitating listen to the silence. Now open your eyes and if they have a child at school – if yes, then invite about them can easily turn the negative part of your stay in the moment. Think of everything you can them home on a weekend to use your Wi-Fi; carry life into the person you are. It means you fill your be grateful for – your health, your family, your job, fruit in your car to give to the car guard. Whatever being with that which is negative. How then will your material possessions, the beauty of nature you do, just GIVE, of your money, of yourself. Trust you emerge as a positive being?” around you. Compare that to bombs landing on me, the giver always feels better than the recipient. Kim continued, “I am not saying that we must housing settlements in Gaza, the COVID-19 death And that ultimately is what this piece is all about. ignore the painful realities of life around us or that rate in India, the poverty in our rural areas, the We are all looking to improve our lives – to feel we should all be tree-hugging airy-fairies – what I joblessness of especially our youth, the suffocating better, to be in better spaces. Only we can get am saying is that there is another way. And it is the smog of so many cities in the world. Spare a thought ourselves into that space. It starts with gratitude. way of positivity. How about we only skim over all for children whose futures are destroyed by war; If we begin our day in gratitude, invariably the rest the negative stuff and then focus, really focus, on for the gogos who must now raise grandchildren of the day will be spent like that. Make gratitude a the positive things, the innumerable blessings in our because their parents are no more; for the victims habit and watch the blessings pour into your life. It lives; things we should be grateful for in our lives and the survivors of the horrific crimes that occur is true that what you put out into the universe will and in the lives of our friends and families. I follow in our country. Spare a thought for all of that, look come back to you. Have you ever wondered how the news, I know what is going on in the world, I what is happening in the world and ask yourself, some people always seem so happy and they are am not an ostrich with my head in the sand. I read “How can I NOT be grateful for all that I have?” always smiling and content? That has nothing to all the negative stories but I CHOOSE not to fixate Now that we understand that we do, in fact, have do with money or material wealth – we all know on them. Rather, I look for the positive, feel-good so much to be grateful for, we can turn that gratitude of very wealthy people who are very miserable. stories and then I FOCUS on those, and I let them into action. Allow me to share examples of actions A meaningful life is not being rich, being popular, become a part of my being. I focus on the petrol of gratitude that will make a huge difference in your being highly educated or being perfect. It is about attendant who paid for a lady’s fuel when she life. Here goes: the next time you order take-outs, being real, being humble, being able to share forgot her purse at home, or my colleague who sent order a drink or hot chips for the delivery guy and ourselves and touch the lives of others. money via e-wallet to a student because he was watch his face light up in surprise and gratitude; if hungry over a weekend, or my son’s teacher who you can afford it, go to PEP Stores and ask if any You have no need to look beyond yourself. What initiated reading sessions at a local old-age home. customer has put school uniform on lay-bye, then you seek is within, if only you reflect● Such stories lift me up, fill me with hope, and help pay for it anonymously and just imagine how that to wash away all the negativity around me. Focus mom will feel when she finds out the uniform is paid on the positive and the positive will become YOU.” for; if you are lucky to have a domestic worker, ask

PAGE 2 OHASA JOURNAL EDITORIAL

From the Stella Lamprecht OHASA president president’s desk

As we welcome the second quarter of the year, we are all still faced with the COVID-19 pandemic; however, it is my hope that our oral healthcare practitioners will take comfort in knowing that many of our healthcare practitioners have now been vaccinated (by choice), proper infection control is being practiced, and correct personal protective equipment is being used. A big thank you goes to the members of the DTO Board for ensuring that our fees were not increased. We acknowledge how hard you have worked to cut costs so as to ensure that our fees remain the same. As a reminder, the due date for HPCSA fee payment was 31 March 2021 for the registration period 2021/22. However, due to the financial constraints felt by all, the due date has been extended to 31 May 2021. Please ensure that you pay timeously. Voluntary erasure should also have been completed on or before 31 March 2021 to avoid having to pay fees while not practicing. Please ensure that you update your CPD portfolios, contact details and any change of address at the HPCSA. MP Consulting is exploring options to enable your CPD certificates to be transferred directly through to your HPCSA profiles and will keep us updated.

2022 International Symposium on Dental Hygiene Members are encouraged to visit the 2022 International Symposium on Dental Hygiene (ISDH) website. To do this click on the 2022: Dublin, Ireland icon quick link on the OHASA website. • House of Delegate Business Meeting: 9–10 August 2022 • International Symposium on Dental Hygiene: 11–13 August 2022 The call for abstracts is now open, and there is an option to sign up to receive the 2022 ISDH newsletter and updates.

Seminar Videos We encourage you to please use the OHASA website. Our seminar videos are located under the Knowledge Share tab, along with slides which are located on the Member News tab, both on the website.

SADA Conference The annual SADA conference will take place virtually from 27–29 August 2021 with a two-hour slot for oral hygienists on the Sunday. Adverts will be sent out as soon as the programme has been finalised. To our traders we thank you for your continued support during these difficult financial times.

God Bless

Stella ●

OHASA’s VISION OHASA is a dedicated, dynamic, professional association representing hygienists as invaluable members of the health profession team. OHASA’s MISSION OHASA aims to promote quality oral healthcare by representing, protecting and advancing the profession in partnership with stakeholders.

OHASA National Executive Committee President Stella Lamprecht | Immediate Past President Stella Lamprecht | Vice-President Gail Smith | Secretariat Anri Bernardo | Treasurer Suné Herman Additional Members Mart-Marié Potgieter, Elaine Johnson | OHASAJ Editor Rugshana Cader

2nd quarter 2021 • volume 22 no. 2 PAGE 3 Guest Editorial

Guest Editorial Bruna Dessena

I remember when I was asked, as a guest lecturer, to give a talk at one of the is now. Even the lay person, due to COVID-19, knows what a SATS monitor Oral Hygiene conferences, and started by stating that I am what one would call is; knows it measures percentage of saturated oxygen in the haemoglobin an “anomaly”. I say that because I am an Advanced Life Support Paramedic, and if SATS drop less than 94 that’s a bad sign! In the same hospital, as I was and still practice in the field of remote-site work such as oil rigs and gold packing up my equipment, I walked down the corridor to find the sluice room. mines all over the world. But from 1999–2001 I took a break and studied Oral I watched a dentist extract a tooth and place a tea bag in the socket. Yes, you Hygiene at Wits. At the time I was a paramedic in Hillbrow, and it was getting heard right, a tea bag! Tea contains tannins, which are a vaso constrictor and harder and harder to reach patients in buildings that had become derelict, with although not very hygienic it works! They often used Rooibos teabags for lifts not working, etc. I wondered what other medical profession one could wound care before using a normal bandage over it! Once again I was humbled follow which is dynamic, interesting and where one works alone and thinks by the reminder of how much I have, how good our medical facilities are in for oneself, and yes – its Oral Hygiene! South Africa and how superior our training is. I am blessed that as a remote-site paramedic I have travelled to strange and Our paramedics are well trained. Because we are a gun-carrying nation, interesting places all over the world, many of them off-course, very remote gunshots are something we are good at treating. Overseas, a gunshot victim will places that one would not ordinarily look for on a map unless you had to have a team of specialists waiting to treat them, whereas here, our emergency organise a visa to get there. I have come to realise that we are all the same, doctors, nurses and ICU sisters in the casualty departments know exactly what we all disapprove of our governments, love our children, hate paying tax and to do – and do it well. As in the Oral Hygiene field, one now does a 4-year we all just want to love and be loved. degree (the BEMC at a Technikon) to become a paramedic. The paramedical I have had the privilege of working for Dr Ashraf Laher, a wonderful orthodontist field is no longer a place for “ambulance drivers” but has evolved into a highly who gave me a job as soon as I qualified, and I love his orthodontic practice. specialised field of pre-hospital emergency care where what we do in the first He is a deeply religious man and very respected for the ethical way he runs the hour, or as we say the “platinum ten minutes”, will definitely have bearing on practice and treats his staff. The same cannot be said for the huge corporations the patient’s prognosis and outcome. We measure our success at a resus that employ remote-site paramedics on long rotations (eight weeks on and (resuscitation) not by getting spontaneous circulation back but rather by seeing four weeks off) with no really good or definitive medical back-up – making the patient walk out of the hospital further down the line. you age faster than you can say “grey hair”. I remember one small village clinic It’s no different to Oral Hygienists; correct diagnosis of the patients presenting where it took me four hours by road to drive a 204 km journey because the signs and symptoms will lead us to a proper treatment plan and have a huge road was so bad, and the patient had a suspected spinal injury. He was not bearing on the final outcome. on a package that covered a fixed wing flight to medivac him off site, so we I love attending the breakfast meetings and chatting to my fellow Oral drove to the small clinic 204 km away. Upon arrival my heart sank; I could see Hygienists – such a wonderful group of dedicated, enthusiastic and hard- that there was never going to be an MRI and the nursing sister was looking at working professionals. I wish you all well for this year, and pray it is nothing my SATS monitor as if it had just landed from Mars! How different the world like last year. Be careful out there, you are precious!

PAGE 4 OHASA JOURNAL research

Positioning Depression as a Critical Factor in Creating a Toxic Workplace Environment for Diminishing Worker Productivity

Samma Faiz Rasool1 , Rashid Maqbool2, Madeeha Samma1,*, Yan Zhao1,* and Amna Anjum3

1 School of Management, Shanghai University, Shanghai 200444, China 2 Department of Construction Management, Tsinghua University, Beijing 100084, China 3 Glorious Sun School of Business and Management, Donghua University Shanghai, Shanghai 200051, China * Correspondence: [email protected] (M.S.); [email protected] (Y.Z.)

Source: Sustainability 2019, 11, 2589; doi:10.3390/su11092589

Abstract sources of incremental organizational outcomes, while “toxic” workers drive This study determined how a toxic workplace environment can influence organizations to unproductive circumstances. Prior studies also indicated worker productivity, directly and indirectly, using work depression as that most of the working issues are directly related to worker productivity or a mediating variable. A toxic workplace environment with multiple work performance. The workplace environment is especially involved when dimensions (harassment, bullying, ostracism, and incivility) was used in employees are assigned tasks [9]. The literature describes that workers and this study. We used a questionnaire survey approach to evaluate the data. working environments change over time. At times, workers are engaged in A total of 53 items were used in the questionnaire with a five-point Likert only one dimension of work, while at other times they have different work scale. The data were collected from 23 branches of five Chinese banks assignments. While switching work assignments, they can encounter varied in the vicinity of Shanghai. The authors distributed 250 questionnaires working environments [10]. The working environment controls all the situations among targeted employees (senior managers, middle managers, and and systems in which employees have to be involved to perform their work [11]. administrative staff) and received 186 filled questionnaires, among which Significantly, there exist two types of working environment: toxic workplace six were incomplete. Thus, the completed sample size of the research was environments and collaborative workplace environments [12–14]. 180, and the overall response rate was 72%. To estimate the proposed A cooperative workplace environment can enhance worker productivity, relationships in the research model, we used partial least-squares structural but a toxic workplace environment can deteriorate worker performance [15]. equation modelling (PLS-SEM 3.2). The outcomes of this study indicate In the extant literature, a toxic workplace environment manifests with bullying, that for direct and indirect relationships, a toxic workplace environment inactivity, ostracism, and harassment [16,17]. A toxic environment is considered a negatively influences worker productivity. Moreover, the outcomes of disaster for organizational stakeholders and permeates the whole environment this study also show that work depression negatively impacts worker of the organization with toxicity such as a lack of employee involvement, toxic productivity. The study concludes with a discussion, limitations, and culture, and eventually toxic leaders [18]. Toxic workplace behaviour and low future research directions. self-esteem raise organizational cost, subsequently leading to organizational losses, high turnover, ill repute in terms of positive company image, low Keywords: Toxic workplace environment; work depression; worker employee morale, conflicts between work and life, high absenteeism, lower productivity. employee performance, loss of organizational productivity, and reduced employee well-being [19,20]. Research has shown that a toxic workplace environment diminishes 1. introduction organizational outcomes at a noticeable scale. This problem is in dire need of The effects of a toxic workplace environment on employee productivity are further exploration and the attention of researchers to determine the potential discussed in the literature [1–3]. However, insights into the depression it consequences and deep-rooted causes of the toxic workplace for business creates among organizational personnel are still lacking in the academic entities and stakeholders [21,22]. This study intends to draw the attention of body of knowledge. This study puts forth an effort to fortify the mediating management researchers to various forms of toxic workplace environments effect of work depression between a toxic workplace environment and worker and the potential effects related to the loss of productivity, low employee productivity to determine implications for academicians and practitioners. efficiency, social comparisons, and high levels of workplace depression. Past studies exemplified that most organizations show concern about Work depression is considered to be a distasteful issue in the workplace. measuring “profit” to calculate their productivity [4–6]. However, depression Many people face workplace depression. Most workers do not reveal their and harmful workplace determinants leading to employee turnover are other depression because of fear of discrimination and stigmatization among their vital indicators for computing organizational productivity. Employees are peers. However, most workers face workplace discrimination and negative the most significant asset for any organization, but, in many sectors, they reactions from employers and coworkers due to depression and anxiety. are ignored in the computation of productivity [7]. The literature categorizes Workplace depression is a mental illness associated with disadvantages from employees as “star” (incremental) or “spark” (toxic) [8] because they are direct toxic workplace environments [23].

2nd quarter 2021 • volume 22 no. 2 PAGE 5 research

Based on the insights about the toxic workplace environment, workplace 2.1.2 Workplace Bullying depression, and worker productivity in the above literature, this study proposes Mushtaq, Sultana [37] suggested that workplace bullying causes disastrous the following research questions: mental trauma for any individual or employee. Abusive blaming, humiliation, RQ1. How is work productivity influenced by a toxic workplace environment social isolation, bullying, criticism, and sarcastic mockery by an employee or (bullying, inactivity, ostracism, and harassment)? employer is marked as workplace bullying [38,39]. Bullying rises in different RQ2. How does work depression intervene between worker productivity and the situations with different styles and is not restricted to the workplace [40–42]. It toxic workplace environment (bullying, inactivity, ostracism, and harassment)? can be seen as deeply rooted in organizational culture and climate, negatively The paper is structured as follows: Section 2 is devoted to the literature review. affecting the well-being of employees, causing mental sickness, and job burnout Section 3 provides logical arguments for the development of the hypotheses [43]. Bullying can be organizational or individual. Individual bullying is related to and research model of the study. Section 4 shows the research methods of disputes and can be described as wrong guy/good guy, escalated, delegated, the study, and Section 5 presents the analysis and results. Section 6 provides complex, merry-go-round, bystander, subordinate, personality disorder, or a discussion, and Section 7 presents the practical implications, limitations, and gang bullying. Organizational bullying includes organizational cultural bullying, future research directions. The last section presents the conclusion of the study. bully processing, and senior team bullying (from senior peers’ tactics) [44,45]. Leymann [46] introduced the concept of organizational bullying, which has been 2. lIterature Review adopted in different sectors and countries with different styles [44,47,48]. A toxic workplace environment and bullying create and accelerate work depression, stress, low levels of work engagement, a high ratio of absenteeism, a lack of 2.1 toxic Workplace Environment work performance, and work destruction [49]. According to Azuma, Ikeda [24], the intra- and interrelationships of workers within the workplace present a clear picture of the workplace environment 2.1.3 Workplace Ostracism [17]. Researchers note that there are two types of workplace environment: Workplace ostracism is described as workplace isolation that is perceived toxic and collaborative. The collaborative workplace environment has a by an employee due to his/her peers or employers [50–52], with negative sense of agreeableness, pleasure, and high involvement, including a feeling consequences for and by the employee toward organizational development in of empathy and organizational citizenship behaviour (OCB) [25,26]. The toxic the form of high turnover, lack of work involvement, and high job dissatisfaction workplace generates narcissistic behaviour, abusive leadership, threatening [9]. Previous studies have presented findings showing that workplace ostracism behaviour, harassment, humiliation, and bullying among employees. The toxic has an embedded impact on the psychological and physical well-being of workplace is prone to high absenteeism, depression, job burnout, and severe employees, and this traumatic experience results in hostility, stress, and psychological health issues such as work strain and counterproductive work adversarial outcomes [53,54]. Therefore, workplace ostracism produces behaviour (CWB), eventually leading to the loss of organizational efficiency counterproductive work behaviour [54,55], negative work behaviour, depressive and repute [27]. behaviour, and emotional exhaustion [56]. In critical situations, an employee may start to avoid doing tasks and hold back due to the stress of ostracism. 2.1.1 Workplace Harassment Workplace ostracism lessens motivation among employees, and both employees Von Gruenigen and Karlan [21] argued that an individual’s dignity is ruined and the workplace have to suffer in the form of lower efficiency. by deviant or unwanted behaviour. Humiliation and terrorization of one individual by another at the workplace is called workplace harassment [28]. 2.1.4 Workplace Incivility Therefore, sexual intimations, pornographic jokes, images, and taunts, and In the literature, there are also reports showing that – with a specific or nude mockery at the workplace related to sex, beliefs, race, religion, genes, abusive purpose – an employee or employer can be troubled or saddened origin, colour, ethnicity, or age are all part of a toxic workplace environment by the workplace’s norms with his/her intentions of generating stressful [29,30]. The concept of workplace harassment was considered in 1978 [31], and situations for personal gain [57–59]. Non-verbal abuse or verbal actions and is a trendy topic in the recent era that is gaining consideration and attention disrespectful/hostile behaviour toward peers are also part of incivility at the by researchers due to its significance. Research and investigations have been workplace [38,60]. Educators, management scientists, health care practitioners, done at a very limited level in Asian countries because Asian people do not and researchers have focused on eliminating the foundational roots of non- want to talk about this topic, considering it as “taboo” relative to workplace productive employees, such as when they have to sacrifice their self-esteem, or domestic matters, and that it even has disgrace for victims too [32]. Very level of satisfaction, degree of respect, and productivity. Moreover, a business few people are willing to talk or communicate about harassment, specifically entity has to face socially harmful, depressive, and isolated circumstances with in the Chinese working context. Most research conducted on the topic of a lower level of development [30]. This type of deviancy and modest intensity workplace harassment is with women at an alarming ratio. Unfortunately, the prompt employees to undermine performance and create a bad image of the topic of workplace harassment in men does not get much attention [33]. Men workplace among their peers [61,62]. and women of every age and at any stage experience workplace harassment. Feminist scholars relate this concept with bourgeois or male-dominated society, 2.2 work Depression in which women have to face gender discrimination, male stereotypes, job Depression is also considered a taboo subject in the workplace. Many people threats, and a paradoxical power threat, which leads to low literacy for women face workplace depression. Most employees do not reveal their depression due to the male-dominated society [34]. Workplace harassment is deep-rooted because of the fear of discrimination and stigmatization among their peers. and has traumatic effects on the emotional well-being of an entire workplace However, most employees face workplace discrimination and negative reactions [35]. Workplace harassment lowers employee morale, which directly affects from employers and coworkers due to depression and anxiety. Workplace organizational productivity [36]. depression is a mental illness associated with disadvantages due to a toxic

PAGE 6 OHASA JOURNAL research

workplace environment [23]. Employees spend approximately 90,000 h at problems and family conflicts to achieve the core job tasks to upgrade work work throughout their working life [63]. An employee’s poor mental health productivity [75]. Second, toxic workplace environments and workplace ostracism can be caused by internal and external factors at the workplace as well as cut employee targets and social unity with organizational peers [76]. In this ineffective management, which has a toxic and severe impact on productivity, critical situation, employees cannot get access to work-related information and career prospects, and, more broadly, organizational development [64]. resources because they are cut off from social ties, which ultimately results in Workplace depression is considered a stigma, and most employees who suffer low worker and organizational productivity [77]. Ferris et al. (2008) conducted mental illness face additional challenges; they conceal their mental status at an empirical study on the relationship between workplace ostracism and job the workplace because people have a lack of awareness about workplace performance, and found that a toxic workplace environment has a negative depression. Presentism is also considered part of workplace depression, which relationship with worker productivity [78]. Some previous studies pointed out is another loss of employee productivity when the employee comes to work, but that a toxic workplace environment has a negative relationship with worker the level of function is very low or there is low involvement (mentally absent). productivity [79,80]. These findings generate significant understanding of the Turnover costs come when employees leave the workplace due to workplace connection between a toxic workplace environment and work productivity. depression and other employees replace them, and the organization has to Thus, the negative relationship of a toxic workplace environment with work bear the employment cost [65]. productivity is depicted in the following hypotheses (Figure 1): Hypothesis 1a. Work harassment negatively influences worker productivity. 2.3 worker Productivity Hypothesis 1b. Work bullying negatively influences worker productivity. Cocker, Martin [66] reported that work productivity indicates the measurement Hypothesis 1c. Work ostracism negatively influences worker productivity. of employee effort, and that work engagement, efficiency, accuracy, and Hypothesis 1d. Work incivility negatively influences worker productivity. effectiveness indicate the input of human resources into productive output. Therefore, to spend time for the desired outcome, it is expected that employees 3.2 mediating Effect of Work Depression will expend effort and have high work engagement by using limited resources, A toxic workplace environment creates work depression among employees and and this is known as work productivity [67]. Previous researchers suggested in negatively affects the overall performance of the organization. Similarly, work their studies that productivity does not have a single operational definition, but depression plays a significantly negative role in mental illness in organizations it varies according to multifaceted situations and the types of organizations and worldwide. Also, a toxic workplace environment, including inductive and their cultures [39,68,69]. Worker productivity is integrated with organizational depressive working environments, affect employees’ decision-making power productivity and employee work performance, which determines the quality and work synergy [81], which will be disadvantageous to the organization due of work [70]. The productivity of a job is connected to multiple factors, such to low production, high absenteeism, high turnover, and excessive economic as working environment, supportive supervision, individual abilities, and an costs [82]. Employee quality of life suffers from the toxic and depressive integrated motivational set of policies and organizational standard operational workplace environment [83]. Work depression pushes employees at high procedures (SOPs). It can be measured in monetary terms, by which organizational risk of stress and anxiety rather than other occupational employees [13]. Prior attributes (social, human, financial, and organizational capital) can measure and studies found that 65.3% of Chinese workers experienced depression [44,84]. monitor worker productivity [71,72]. The work environment also plays a vital role Frank and Dingle demonstrated that severe workplace depression leads to in producing and raising worker productivity in line with the employee’s ability suicide attempts [9]. A toxic and depressive workplace environment not only and social network. Employees who are satisfied with their work environment reduces the performance and productivity of employees and organizations, will be more productive and engaged with their work. Thus, business entities but also causes lower professional behaviour of employees [85]. should focus on generating a workplace conducive to the well-being of the According to the study of Warr [86], employees who suffer from a high organization and the workforce as a priority [73]. level of work-related depression are also vulnerable to mental sickness and react with aggression, anxiety, isolation, low morale/confidence, and the 3. hYPothesis Development feeling of self-denial. Work-related depression is a contributive mediator of the association between the toxic workplace environment and employee 3.1 toxic Workplace Environment and Worker Productivity productivity. In line with the model from Spector and Fox including Affective Organizations are designed to organize and arrange the workforce according events theory (AET), internal status including mental status is the territory of to their social nature for better output within groups as the toxic workplace employee assessments, which they get from the workplace environment, environment causes panic and is unpleasant. This is significant for the workplace, resulting in the influential behaviour with a range of worker performance and where the frequency of a diverse workforce and teamwork is increased and behaviour [87]. Hence, according to the above discussion, this study indicates the business entity is in dire need of charismatic leadership to communicate that work depression plays a mediating role in the relationship between the between employees, colleagues, and stakeholders [74]. The above-mentioned toxic workplace environment and worker productivity. Thus, taking the above arguments described that a toxic workplace environment creates lower levels arguments together, we propose the following hypotheses (Figure 1): of satisfaction, negative organizational commitment, and high degrees of Hypothesis 2a. Work depression mediates between toxic workplace harassment anxiety, depression, and turnover [27]. and worker productivity. Furthermore, by deteriorating psychological well-being and job-related Hypothesis 2b. Work depression mediates between toxic workplace bullying attitudes, a toxic workplace environment plays a vital role in undermining and worker productivity. worker productivity. First, the toxic workplace environment threatens employees’ Hypothesis 2c. Work depression mediates between toxic workplace ostracism necessities and their psychological resources [17]. Limited psychological resources and worker productivity. are critical for employee growth, and to redeem or recapture such resources, Hypothesis 2d. Work depression mediates between toxic workplace incivility the employee has to spend time, effort, and energy managing interpersonal and worker productivity.

2nd quarter 2021 • volume 22 no. 2 PAGE 7 research

recommended some changes. Thus, the instrument was revised according Toxic Workplace Work Worker to feedback from the respondents. The revised instrument was disseminated Environment Depression Productivity among the selected population for data collection.

4.3 Sampling and Data Collocation Harassment Data were collected from 23 branches of 5 banks of China in the vicinity of Shanghai. Due to data confidentiality, we renamed the selected banks as Bank A, B, C, D, and E. We focused on the banking sector for 2 reasons: first, to concisely interpret the views of banking executives, and second, because of Bullying the importance of the toxic workplace environment and work depression which affect work productivity in the banking sector. The data were collected from Depression Productivity banking personnel (senior managers, middle managers, and administrative staff) as we believe that all concerned banking employees were aware of the topic of the research. The authors provided necessary explanations about Ostracism the aim of survey analysis and the related definitions of the constructs used. The respondents were also addressed with the research objects at the start of the questionnaire. A purposive sampling technique with the questionnaire survey was followed to collect data from staff members. The goals of the study Incivility were introduced to all respondents at the start of the questionnaire in the guidelines. Moreover, according to the ethical rules of research, respondents were told that the information they provided would not be revealed to anyone Note: Arrows indicate hypothesized negative relationship. Solid arrows suggest and would be used for research purposes only. At the time of designing a direct relationship and dashed arrows suggest an indirect relationship in the questionnaire, a pilot study was conducted. There were 20 pilot study the model. respondents who were aware of the topic of this study. Nunnally and Bernstein recommended that the ideal value of Cronbach’s alpha for data reliability is Figure 1. Proposed research model. 0.7 or higher [100]. Thus, outcomes show that the overall Cronbach’s alpha of this study is according to the suggested standard value. The results indicate 4. research Methods that all scales are acceptable. Hence, the measures used in this study were considered highly reliable. 4.1 research Approach The questionnaire survey approach takes into account a real investigation 4.4 Measures of circumstances that supplements the quantitative approach [88,89]. The In this study, we used 4 independent variables (harassment, bullying, ostracism, quantitative method typically begins with designing a questionnaire and and incivility), 1 mediating variable (work depression), and 1 dependent collecting data based on a hypothesis, and it is followed by applying descriptive variable (worker productivity). or inferential statistics [90]. Therefore, according to Hartley [91], surveying is The workplace harassment items were adopted from Kamal et al. [94]. A total a research technique that allows the collection of data directly from persons of 10 items were used for work harassment with a 5-point Likert scale (ranging involved in the research through a set of questions organized in a particular order. It is one of the most frequently used quantitative techniques since it allows from 1, “strongly disagree,” to 5, “strongly agree”). Sample items included “My obtaining information about a given phenomenon by formulating questions supervisor/co-worker/subordinate tried to touch my hands while giving me that reflect the opinions, perceptions, and behaviours of a group of individuals. something,” and “My supervisor/co-worker/subordinate often shares some Quantitative surveys offer several benefits, and in this study, this method was dirty jokes with me.” The ideal Cronbach’s alpha value for data reliability is 0.7 selected due to the high representativeness of the entire population and the or higher, which is considered adequate [101,102]. Our results show that the low cost of the technique when compared to other alternatives. On the other Cronbach’s alpha value is 0.805 for work harassment. The results indicate that hand, the reliability of survey data is dependent on the survey structure and the value of workplace harassment is greater than the standard value. Hence, the accuracy of the answers provided by the respondents [92,93]. the measures used in this study were considered highly reliable. The workplace bullying items were adopted from Carteret et al. [95]. To 4.2 Instrument Development measure work bullying, 8 items were used with a 5-point Likert scale (ranging The purpose of this study was to determine how a toxic workplace environment from 1, “strongly disagree,” to 5, “strongly agree”). Sample items included “My (harassment, bullying, ostracism, and incivility) directly and indirectly influences supervisor/co-worker/subordinate ignores me or gives me a hostile reaction worker productivity, using work depression as a mediating variable. All the when I approach,” and “My supervisor/co-worker/subordinate spreads gossip items of the toxic workplace environment and worker productivity were and rumours about me.” Our results show that the Cronbach’s alpha value is adopted by Anjum et al. [44], which were adapted and modified from prior 0.717 for workplace bullying, which is higher than 0.70. The results indicate studies [94–98]. The items of the mediating variable, work depression, have that the scale is acceptable. Therefore, the measures used in this study were been adopted and modified from Kroenke et al. [99]. A total of 53 items were considered adequate. used in the questionnaire with a 5-point Likert scale (ranging from 1, “strongly Workplace ostracism used 9 items developed by Lindenberg [96]. All items disagree,” to 5, “strongly agree”). Then, a pilot study was conducted to check were measured with a 5-point Likert scale (ranging from 1, “strongly disagree,” the reliability and validity of the instrument. The respondents of the pilot study to 5, “strongly agree”). Sample items included “I noticed my supervisor/co-

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worker/subordinate would not look at me during work,” and “My supervisor/ middle managers, and 58.3% were administrative staff. Also, 6.1% were under co-worker/subordinate refused to talk to me at work.” The Cronbach’s alpha 25 years of age, 42.2% were between 25 and 34 years, 31.7% were between was 0.783 for work ostracism. Hence, the measures used in this paper were 35 and 44, and 20% were older than 44 years. Participants’ responses showed considered highly reliable. that 43.3% had an undergraduate education, 40.5% had a graduate education, Workplace incivility used 9 items developed by Handoyo et al. [97]. All items and 16.1% were postgraduates. Of the 5 major Chinese banks considered for were measured on a 5-point Likert scale (ranging from 1, “strongly disagree,” this study, the distribution was: Bank A, 26.7%; Bank B, 28.3%; Bank C, 23.3%; to 5, “strongly agree”). Sample items included “I often talk to someone who Bank D, 21.7%; and Bank E, 20.3%. Details of the demographics of the study can help me with the situation,” and “I took my anxiety out on other people.” are shown in Table 1. The Cronbach’s alpha was 0.810 for workplace incivility. The results indicate that the scale is acceptable. Hence, the measures used in this study were 5. analysis and Results considered adequate. The partial least-squares structural equation modelling (PLS-SEM 3.2) approach Workplace depression used 7 items developed by Kroenke et al. [99]. was used to analyze the relationships drawn in the theoretical framework All items were measured on a 5-point Likert scale (ranging from 1, “strongly [103]. The reason for selecting variance-based structural equation modelling disagree,” to 5, “strongly agree”). Sample items included “I have little interest or (SmartPLS) was its comparatively lower sensitivity to sample size as compared pleasure in doing things,” and “I feel tired or have little energy.” The Cronbach’s to covariance-based SEM approaches like AMOS (analysis of moment structures) alpha was 0.766 for workplace depression, which is higher than 0.7. Thus, the [104]. First, we examined the reliability and validity of the scales used [105]. measures used in this research were highly reliable. Table 2 presents the statistics for the reliability and validity of all constructs Worker productivity was measured by 9 items adopted from Beck et al. [98]. used. The reliability measures (Cronbach’s alpha, rho A) for all constructs However, the items of work productivity were modified according to the needs were found to be greater than the proposed benchmark value of 0.7 [106]. Similarly, Table 2 shows that the average variance extracted (AVE) value for of the research. Therefore, work productivity was calculated by averaging each construct is greater than or equal to 0.50 [107], which indicates that the the items to ensure that higher scale values would represent higher levels of data used for this study are valid and reliable. productivity. Sample items included “During the past six months, often I could not complete my work because of my health problems,” and “I don’t sleep Table 2: Construct reliability and validity well, which affects my work productivity.” Our results show that Cronbach’s Construction Alpha Rho_A AVE alpha value is 0.791 for workplace bullying. Hence, the results indicate that Harassment 0.805 0.802 0.634 the measures used in this study were considered highly reliable. Bullying 0.717 0.714 0.545 Ostracism 0.783 0.786 0.606 4.5 Demographics Incivility 0.810 0.822 0.636 The authors distributed 250 questionnaires among the targeted employees and received 186 filled questionnaires, among which 6 were incomplete. Thus, the Work Depression 0.766 0.769 0.588 completed sample size of the research was 180 and the overall response rate Worker Productivity 0.791 0.792 0.706 was 72%. The majority of respondents were men; women made up just 25% of Note: Alpha, Cronbach’s alpha; AVE, average variance extracted. the total respondents. In this sample, the working experience of respondents Also, to check the reliability of constructs used and their specified convergent was as follows: 25.5% had less than 5 years of working experience, 43.9% validity, it is believed that the condition of discriminant validity must be achieved had 5–10 years of working experience, and 30.5% had more than 10 years of [107]. For this purpose, the square root of the AVE for each construct should working experience; 11.1% of respondents were senior managers, 30.5% were be higher than the shared variance among constructs. Table 3 shows the diagonal values in bold as higher than the inter-construct correlation values. Table 1: Demographics The discriminant validity is recognized. Measure Item Frequency Percentage Gender Male 135 75 5.1 hypothesis Testing Female 45 25 Hypothesis testing was done through a bootstrapping mechanism in Smart PLS. Working Experience Less than 5 years 46 25.5 [103]. Table 4 shows the direct effects discussed in the theoretical framework 50-10 years 79 43.9 along with t-values and p-values. The results indicate that workplace harassment More than 10 years 55 30.5 negatively influences worker productivity (ß = 0.824; p < 0.000), which supports Position Senior manager 20 11.1 hypothesis H1a. This means that if harassment increases in the organization, Middle manager 55 30.5 Administrative staff 105 58.3 then worker productivity will decrease. Workplace bullying, as an independent Respondent Age Younger than 25 years 11 6.1 variable, also negatively influences worker productivity (ß = 0.624; p < 0.000), 25–34 years 76 42.2 which is supported by hypothesis H1b. This means that if workplace bullying 35–44 years 57 31.7 increases, then worker productivity will decrease. There is also a negative Older than 44 years 36 20 influence of ostracism on worker productivity (ß = 0.723; p < 0.000), which Education Undergraduate 78 43.3 supports hypothesis H1c. Thus, it has been proven that worker productivity Graduate 73 40.5 Postgraduate 29 16.1 will decrease if workplace ostracism increases. Furthermore, it was found that incivility negatively influences worker productivity (ß = 0.447; p < 0.000), thus Banks A 48 26.7 B 51 28.3 H1d is also accepted. Findings of this hypothesis indicate that more incivility C 42 23.3 results in lower worker productivity. Table 4 highlights detailed information D 39 21.7 about the direct effect of a toxic workplace environment on worker productivity.

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Table 3: Discriminant validity of constructs Harassment Bullying Ostracism Incivility Depression Productivity Harassment 0.798 Bullying 0.331 0.796 Ostracism 0.392 0.44 0.895 Incivility 0.416 0.461 0.584 0.825 Depression 0.407 0.534 0.48 0.597 0.767 Productivity 0.426 0.614 0.498 0.514 0.577 0.778

Table 4: Path model results (direct effects) productivity. The values are as follows: effects of ostracism on work depression Hypothesis Estimate S.E. C.R. P (ß = 0.423; p < 0.000) and worker productivity (ß = 0.149; p < 0.000), and Hypothesis 1 a,b,c work depression on worker productivity (ß = 0.98; p < 0.000). Similarly, hypothesis H2d also supports our study. The results show that work depression Productivity ← Harassment 0.824 0.034 5.146 *** mediates between incivility and worker productivity, indicating the mediating Productivity ← Bullying 0.624 0.121 6.214 *** relationship of incivility on work depression (ß = 0.587; p < 0.000) and worker Productivity ← Ostracism 0.723 0.036 3.224 *** productivity (ß = 0.54; p < 0.000), and work depression on worker productivity Hypothesis 1d (ß = 0.42; p < 0.000). Hence, the indirect hypotheses H2a, H2b, H2c, and H2d Productivity ← Incivility 0.447 0.052 4.264 *** were also accepted. Moreover, Table 5 shows detailed information (estimated, Note: S.E., standard error; C.R., composite reliability; asterisks (***) demonstrate the standard error, and composite reliability values) of the mediating effects of significance of the variables’ relations. work depression between a toxic workplace environment (harassment, bullying, incivility, and ostracism) and worker productivity. 5.2 mediated Effects To inspect the mediating effects of work depression between a toxic 6. Discussion workplace environment and worker productivity, we used the Smart With the impetus to find the direct effects of a toxic workplace environment PLS-SEM (Partial least square structure equation modelling) data analysis (harassment, bullying, incivility, and ostracism) on worker productivity and the technique. Table 5 presents the indirect effects of work depression on worker intervening influence of work depression, this research effort provides insightful productivity. In hypothesis H2a, we test the mediating relationship of work results based on the synthesized model framework. To the best of the authors’ depression between harassment and worker productivity. The outcomes knowledge, this is among the earliest research paradigms to investigate indicate the presence of the effects of harassment on work depression the impact of a toxic workplace environment on worker productivity in the (ß = 0.272; p < 0.000) and worker productivity (ß = 0.112; p < 0.000), and work Chinese organizational context, especially by considering work depression depression on worker productivity (ß = 0.095; p < 0.000). Similarly, in hypothesis as a mediating construct. H2b, we test the mediating relationship of work depression between bullying and First, we focused on the direct relationship of a toxic workplace environment worker productivity. The outcomes indicate effects of bullying on work depression (harassment, bullying, incivility, and ostracism) on worker productivity. The (ß = 0.423; p < 0.000) and worker productivity (ß = 0.162; p < 0.000), and work results show that a toxic workplace environment has a negative relationship depression on worker productivity (ß = 0.102; p < 0.000). The results of hypothesis with worker productivity, which supports our intuition drafted in hypotheses H2c indicate that work depression mediates between ostracism and worker H1a–d of the study. Prior studies showed that a toxic workplace environment Table 5: Indirect effects) has a negative relationship with worker productivity [32,40,108,109]. Similarly, Hypothesis Estimate S.E. C.R. P Wu and Hui examined 208 workers employed at two Chinese companies Hypothesis 2a (petroleum and gas companies), and the outcomes of their study indicated that Depression ← Harassment 0.272 0.034 5.61 *** a toxic workplace environment is directly negatively connected with worker Productivity ← Harassment -0.112 0.026 6.126 *** productivity [110]. However, in the banking industry, most of the workers’ tasks Productivity ← Depression -0.095 0.031 8.521 *** are operational, and the working culture of banks is very modern and customer oriented. Operational activities are different than project jobs, in which workers Hypothesis 2b are under more pressure to complete their tasks within a limited time. Due Depression ← Bullying 0.423 0.078 10.347 *** to such high demand and limited time, a natural toxic environment can arise, Productivity ← Bullying -0.162 0.076 0.876 *** which can ultimately diminish worker productivity. Productivity ← Depression -0.102 0.019 0.910 *** Second, this study depicts work depression as mediating between a toxic Hypothesis 2c workplace environment (harassment, bullying, incivility, and ostracism) and Depression ← Ostracism 0.423 0.054 9.541 *** worker productivity. The mediating effect also produces significant results, Productivity ← Ostracism -0.149 0.057 1.490 *** which is a novel and original contribution in the context of emerging or Productivity ← Depression -0.098 0.032 0.474 *** developing countries like China. The mediating results support the findings Hypothesis 2d of past literature and hypothesis H2d [84,86]. Liu and Chang argued that due Depression ← Incivility 0.587 0.072 10.132 *** to work depression, workers cannot sleep well and they have headaches, and Productivity ← Incivility -0.054 0.023 0.876 *** these health problems decrease their productivity [110]. Devonish examined Productivity ← Depression -0.142 0.038 4.465 *** the operations of five wholesale and large-sized retail organizations in the Note: Signs (***) demonstrate the significance of the p-values.

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small developing nation of Barbados located in the English-speaking Caribbean workers’ well-being plays a vital role in improving their productivity, and region, and the outcomes of his study indicate that work-related depression it also reduces the toxic workplace environment. Hence, future research mediates the relationship between a toxic workplace environment and worker efforts could incorporate more determinants of workers’ well-being to find task productivity [48]. The findings of these studies support our study. Thus, work new insights. Future research could also explore insights about workplace depression mediates in the relationship between a toxic workplace environment culture characterized by inherent values, sense of workplace safety, violence and worker productivity. In the banking sector, banking professionals are reduction, and behavioral mechanisms (such as policies and procedures) to required to cope with numerous demands: skills demanded for the job (such address workplace toxicity. as the ability to understand, alter, lead, and control the behavior of individuals and groups), technical demands (such as customer service skills, teamwork, 8. Conclusions learning new technological skills, effective communication), and administrative The research model of this study was developed based on the insights provided demands (such as the need to address financial considerations when dealing in the previous literature. In this paper, our results support linkages among with customers). These demands could naturally result in numerous pressure the determinants of a toxic workplace environment, work depression, and situations for banking personnel. Furthermore, high job demands and work worker productivity. The outcomes of this study show that a toxic workplace pressures affect workers’ health, resulting in conditions such as headaches, environment (harassment, bullying, ostracism, and incivility) directly negatively insomnia, social dysfunction, and depression. influences worker productivity (Table 4). This study also verifies that work depression mediates between a toxic workplace environment (harassment, 7. Practical Implications, Limitations, and Future Research bullying, ostracism, and incivility) and worker productivity (Table 5). The results also indicate that there is an indirect relationship between the toxic workplace environment (harassment, bullying, ostracism, and incivility) and 7.1 Practical Implications worker productivity. The results point out several practical implications for managers that could Specifically, our findings could be summarized as follows: First, workplace reduce the toxicity of workplaces. First, an optimum work environment, harassment is deep-rooted and has traumatic effects on the emotional well- where the bank’s leadership should consider workers as the key pillar of being of the entire workplace. Workplace harassment decreases employee the organization, would be imperative for overall productivity. Second, a morale, which directly decreases worker productivity. Second, the toxic sense of ownership should be realized in the workers’ minds, which would workplace environment and bullying create and accelerate work depression, help to diminish depression, ultimately leading to productive outcomes. stress, low work engagement, high absenteeism, lack of work performance, Third, human resource departments should introduce strict policies against and work destruction. Third, workplace ostracism condenses and lessens work workplace harassment, bullying, incivility, and ostracism. Moreover, human motivation among employees, and both entities (workers and organization) have resource departments should conduct training needs assessments (TNAs) to suffer in the form of decreased efficiency. Fourth, workplace intensity prompts at the organizational level, and where they find a high level of toxicity, they employees to undermine performance and leave a bad image of the workplace should organize training on workplace harassment, bullying, incivility, and among their peers. Fifth, workplace depression is considered a stigma among ostracism. Finally, managers should encourage a positive work environment organizational employees, and most employees undergo suffering and mental and culture to foster teamwork, friendliness, and interpersonal cooperation illness. Another challenge facing workers is concealing their mental status at among workers. For example, organizations should organize some sports and the workplace because people lack awareness about workplace depression. family fairs for workers. These steps can help to reduce the toxic workplace Not limited to workplace depression, presentism issues are also observed environment, which will reduce headaches, insomnia, social dysfunction, and among workers. This is another type of low productivity, which originates when depression among workers. a worker comes to work but projects his/her low work involvement (mentally absent). Moreover, with workplace depression, organizations also experience 7.2 limitations and Future Research worker turnover costs. Finally, the findings of this study indicate that the work The findings of this study provide empirical insights into the banking sector environment plays a vital role in producing and raising worker productivity of China. Based on these findings, the results may not be generalized, as the in line with the employee’s ability and social network. Hence, organizations should focus on generating a conducive workplace environment for the well- authors believe that there are certain limitations. (1) the sample size of this study being of the workforce. We can conclude that a toxic workplace environment is limited. (2) Due to the selection of data collection, genders are not evenly increases the level of work depression. When workers feel negative about the distributed. The banks targeted for data selection had more male than female organization, they tend to compromise their productivity level and performance, personnel. The authors believe that with just drafted limitations, the results which could also increase their level of trauma. cannot be generalized and readers should consider these limitations before Author Contributions: S.F.R. designed the research idea, developed the recognizing the analyzed results. Future research efforts could increase the hypotheses, and drafted the final manuscript; M.S. collected the data and sample size and target evenly distributed respondents from the perspective drafted the research methodology; R.M. worked on analysis and results; of gender. (3) This research was purely based on respondents’ views about Y.Z. supervised this research and suggested extensive revisions during the workplace depression, ignoring demographic specifications such as gender, research work; A.A. work on discussion part of the article. All authors read age, education, race, etc. Since this was a first-time effort on such a sample and approved the final manuscript. for particular research variables, future research would be needed to highlight Funding: This article is supported by the National Natural Science gender (female-specific) depression issues. (4) The workplace stress taken as Foundation of China (71673179): Empirical Research of China on the Coupling a mediator in this research is limited and is not operationalized with further of Clique and Knowledge Flow in Alliance Innovation Network Based on the stress dimension. Future research may explore more thoughtful dimensions Self-Organization Theory. such as burnout, work-family balance, or many more to generate insights Conflicts of Interest: The authors declare that they have no competing for academicians and practitioners. Furthermore, the authors believe that interests.

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59. Shi, Y.; Guo, H.; Zhang, S.; Xie, F.; Wang, J.; Sun, Z.; Dong, X.; Sun, T.; Fan, L. Impact of 83. Lelei, L. Factors Influencing Employee Productivity In The County Government Of Kajiado- workplace incivility against new nurses on job burn-out: A cross-sectional study in China. Kenya; KCA University: Nairobi, Kenya, 2017. BMJ Open 2018, 8, e020461. 84. Maharaj, S.; Lees, T.; Lal, S. Prevalence and risk factors of depression, anxiety, and stress in a cohort of Australian nurses. Int. J. Environ. Res. Public Health 2019, 16, 61. 60. Schindeler, E.; Reynald, D.M. What is the evidence? Preventing psychological violence in 85. Laguna, M.; Mielniczuk, E.; Razmus, W.; Moriano, J.A.; Gorgievski, M. Cross-culture and the workplace. Aggress. Violent Behav. 2017, 36, 25–33. gender invariance of the Warr (1990) job-related well-being measure. J. Occup. Organ. 61. Koser, M.; Rasool, S.F.; Samma, M. High Performance Work System is the Accelerator of the Psychol. 2017, 90, 117–125. 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Heeringa, S.G.; West, B.T.; Berglund, P.A. Applied Survey Data Analysis; Chapman and Hall/ cost analysis of depression-related productivity loss attributable to job strain and bullying. CRC: Boca Raton, FL, USA, 2017. Work Stress 2013, 27, 321–338. 89. Hennessy, J.L.; Patterson, D.A. Computer Architecture: A Quantitative Approach; Elsevier: 65. Cocker, F.; Martin, A.; Scott, J.; Venn, A.; Sanderson, K. Psychological distress, related work Amsterdam, The Netherlands, 2011. attendance, and productivity loss in small-to-medium enterprise owner/managers. Int. J. 90. Hartley, J. Case study research. Essent. Guide Qual. Methods Organ. Res. 2004, 1, Environ. Res. Public Health 2013, 10, 5062–5082. 323–333. 66. Enis Bulak, M.; Turkyilmaz, A. Performance assessment of manufacturing SMEs: A frontier 91. Jones, H.G. Plants and Microclimate: A Quantitative Approach to Environmental Plant approach. Ind. Manag. Data Syst. 2014, 114, 797–816. 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The measurement of workplace incivility in commercial banks. Hum. Resour. Manag. 2015, 54, s45–s62. Indonesia: Evidence and construct validity. Psychol. Res. Behav. Manag. 2018, 11, 217. 72. Shier, M.L.; Nicholas, D.B.; Graham, J.R.; Young, A. Preventing workplace violence in 97. Beck, A.; Crain, A.L.; Solberg, L.I.; Unützer, J.; Glasgow, R.E.; Maciosek, M.V.; Whitebird, human services workplaces: Organizational dynamics to support positive interpersonal R. Severity of depression and magnitude of productivity loss. Ann. Fam. Med. 2011, 9, 305–311. interactions among colleagues. Hum. Serv. Organ. Manag. Leadersh. Gov. 2018, 42, 4–18. 98. Kroenke, K.; Spitzer, R.L.; Williams, J.B. The PHQ-9: Validity of a brief depression severity 73. Mathieu, J.E.; Wolfson, M.A.; Park, S. The evolution of work team research since measure. J. Gen. Intern. Med. 2001, 16, 606–613. Hawthorne. Am. Psychol. 2018, 73, 308. 99. Nunnally, J.C.; Bernstein, I. 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CONTINUING PROFESSIONAL DEVELOPMENT QUESTIONNAIRE – ARTICLE 1

Toxic Workplace Environment

1. A toxic workplace environment may be characterised by: 6. The toxic behaviour that influences the emotional well-being of A. Cooperation the entire organization is: B. Bullying A. Harassment C. Inclusion B. Bullying D. Politeness C. Ostracism E. None of the above D. Incivility

2. Indicators of organisational productivity include: 7. The toxic workplace behaviour that lessens motivation among A. Profit employees is: B. Working environment A. Harassment C. Physical and mental well-being of employees B. Bullying D. All of the above C. Ostracism D. Incivility

3. Susan enthusiastically engages in her job and takes ownership of the tasks delegated to her, while still functioning within a cohesive 8. Work-related depression is a deductive mediator in the association team and feeling fully support by her colleagues. She constantly between a toxic working environment and employee productivity. innovates and in so doing allows for small incremental improvements True or False. in organisational productivity. Susan can be classed as: A. Actively disengaged 9. In the study undertaken by Rasool et al. (2019), the study population B. A spark employee was restricted to the banking industry as employees within these C. Non-collaborative organisations are at an increased risk of suffering a toxic working D. A star employee environment due to (select the incorrect statement): A. Customer-orientated culture

4. A toxic workplace environment and low morale, self-esteem, and B. Project jobs depression among employees leads to increased organisational C. Time constraints costs due to (select the incorrect statement): D. Administrative demands A. Improvements in corporate image E. All of the above B. High staff turnover C. Reduced employee well-being and increased absenteeism 10. A practical mechanism to reduce workplace toxicity is: D. Decreased productivity A. Establishment of an organisational culture that disregards the true value of employees 5. Organisational citizenship behaviour refers to positive and B. Eliminating a sense of ownership over job-related tasks constructive employee actions that enhance social connections C. Establishment and enactment of stringent policies against within the workplace environment and positively influence job toxic workplace behaviours performance. D. Failure to assess the training needs of the workers True or False.

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The effectiveness of a pre-procedural mouthrinse in reducing bacteria on radiographic phosphor plates

Allison Hunter1,*, Sajitha Kalathingal1, Michael Shrout2, Kevin Plummer2, Stephen Looney1,3

1 Radiology Oral Health and Diagnostic Sciences, Georgia Regents University, College of Dental Medicine, Augusta, GA, USA 2 Department of Oral Rehabilitation, Georgia Regents University, College of Dental Medicine, Augusta, GA, USA 3 Department of Biostatistics and Epidemiology Georgia Regents University Medical College of Georgia, Augusta, GA, USA *Correspondence to : Prof. Allison Hunter Georgia Regents University, College of Dental Medicine, Department of Oral Health and Diagnostic Sciences, GC 2248, 1120 15th Street, Augusta, GA 30912-1241, USA (Tel) 1-706-721-4271, (Fax) 1-706-723-0212, (E-mail) [email protected] Source: Imaging Science in Dentistry 2014; 44: 149-54: http://dx.doi.org/10.5624/isd.2014.44.2.149

been shown to exhibit a wider range of exposures, less patient discomfort, Abstract and a decreased requirement for retakes.3-5 For these reasons, PSP plates Purpose: This study assessed the effectiveness of three antimicrobial may be favored in a teaching environment such as dental school clinics. mouthrinses in reducing microbial growth on photostimulable phosphor However, because of the number of personnel involved in the process and (PSP) plates. the inexperience of the operators, keeping PSP plates disinfected in this type Materials and Methods: Prior to performing a full-mouth radiographic of environment can be challenging. Previously, two studies were conducted survey (FMX), subjects were asked to rinse with one of the three test rinses (Listerine®, Decapinol®, or chlorhexidine oral rinse 0.12%) or to by the authors to determine whether, despite precautions, PSP plates can 6,7 refrain from rinsing. Four PSP plates were sampled from each FMX through become contaminated over time. In the first study conducted by Kalathingal collection into sterile containers upon exiting the scanner. Flame-sterilized et al in 2009, approximately 57.8% of the PSP plates demonstrated bacterial forceps were used to transfer the PSP plates onto blood agar plates (5% growth and a microscopic analysis indicated oral flora as the source of the 6 sheep blood agar). The blood agar plates were incubated at 37°C for up Gram-positive rods sampled from the contaminated plates. In the second to 72 h. An environmental control blood agar plate was incubated with study conducted by Kalathingal et al in 2010, Mitis-Salivarius agar was used 7 each batch. Additionally, for control, 25 gas-sterilized PSP plates were to confirm oral streptococci as a source of contamination. plated onto blood agar and analyzed. Chemotherapeutic mouthrinses have been used in dentistry for many years Results: The mean number of bacterial colonies per plate was the to aid in the reduction and removal of plaque. Several different products have lowest in the chlorhexidine group, followed by the Decapinol, Listerine, been used and evaluated for numerous applications. Chlorhexidine is one of the and the no rinse negative control groups. Only the chlorhexidine and most widely used and most effective mouthrinses and is therefore considered Listerine groups were significantly different (p=0.005). No growth was the gold standard.8-11 Chlorhexidine has both bactericidal and bacteriostatic observed for the 25 gas-sterilized control plates or the environmental activity and has been shown to be the most effective antiplaque agent for both control blood agar plates. short- and long-term use.10,11 Listerine® is an over-the-counter product approved Conclusion: The mean number of bacterial colonies was the lowest in the for the control of supragingival plaque.9 The bactericidal effect of Listerine® chlorhexidine group, followed by the Decapinol, Listerine, and the no rinse is accomplished through the disruption of the cell wall and the inhibition of groups. Nonetheless, a statistically significant difference was found only enzyme activity.9 Listerine® has been shown to significantly reduce gingivitis in the case of Listerine. Additional research is needed to test whether a and plaque without extrinsic staining like that reported with chlorhexidine.9 higher concentration (0.2%) or longer exposure period (two consecutive Decapinol® contains delmopinol hydrochloride, which is bactericidal and 30 s rinse periods) would be helpful in reducing PSP plate contamination reduces the adherence of plaque-forming bacteria.8,12,13 Delmopinol has also further with chlorhexidine. (Imaging Sci Dent 2014; 44: 149-54) been shown to dissolve existing plaque.14 Similar to Listerine®, delmopinol does not share the tendency toward tooth staining with chlorhexidine.8 Keywords: Diagnostic Imaging; Listerine; Chlorhexidine; Delmopinol As proven antiplaque agents, mouthrinses may also be effective in reducing the contamination of PSP with oral streptococci. In an effort to evaluate whether a mouthrinse protocol might be efficacious, three antimicrobial rinses were Introduction chosen for this study: chlorhexidine oral rinse 0.12% (Peridex 3M ESPE, St. Paul, Digital imaging using photostimulable phosphor (PSP) plates has been available USA,), Listerine® (Johnson & Johnson, Skillman, USA), and Decapinol® (Sinclair in medical radiology since 1981 and in dental radiology since 1994.1,2 PSP Pharmaceuticals, Milan, Italy). Chlorhexidine was chosen to serve as a positive plates are similar to conventional intraoral films in the sense that they are thin control for comparing the efficacy of chemotherapeutic agents.9-11 Listerine® and flexible and may be used with the same positioning devices for image was chosen as a representative of an effective over-the-counter antiplaque acquisition.1 In contrast to direct digital sensors, also used for intraoral imaging, agent. Decapinol® was chosen due to its ability to dissolve plaque and its the entire surface area of a PSP plate is active. Additionally, PSP plates have decreased association with extrinsic staining.8,14 Because of their antimicrobial

2nd quarter 2021 • volume 22 no. 2 PAGE 15 research

activity, it was proposed that the use of a pre-procedural mouthrinse may assist in reducing microbial growth on PSP plates and aid in reducing cross- contamination in a dental school’s clinical environment. The purpose of this study was to evaluate the effectiveness of using a mouthrinse prior to acquiring a full-mouth radiographic survey in reducing the contamination of PSP plates in a dental school clinical environment. The three mouthrinses tested included: chlorhexidine oral rinse 0.12%, Listerine®, a B C and Decapinol®. Figure 1: Bacterial growth is seen on blood agar plates. A. Listerine test group, B. Decapinol test group, C. Chlorhexidine test group. Materials and Methods using statistical methods for comparing two or more groups in the presence A total of 130 subjects were recruited from the screening population of the of clustered data.17 Statistical methods for clustered data were used since Georgia Regents University College of Dental Medicine (GRU CDM) to be four phosphor plates (the mandibular premolar and molar periapicals) were included in the four treatment groups. Subjects with mandibular premolars examined for each subject in each treatment group. Thus, each patient was and molars that were deemed suitable for a full-mouth radiographic survey treated as a cluster, and the intra-cluster correlation (ICC) was taken into upon review of their clinical needs were included in the study. Subjects with account when comparing the four treatment groups by using cluster-based a reported history of allergy to chlorhexidine, Listerine®, or Decapinol® were analysis of variance (ANOVA) and Tukey-Kramer multiple comparisons. This excluded from the study. There were four test groups: one each for the three cluster-based analysis was carried out using mixed-effects regression models, oral rinses and one no rinse group. This study was approved by the Human as implemented in the MIXED procedure in SAS 9.3 (SAS Institute, Inc., Cary, NC, Assurance Committee of the GRU CDM (HAC file number: 10-10-082). Informed 2009). Mixed-effects regression models were required for the analysis of the consent was obtained from all the subjects prior to their inclusion in the study. study data in order to account for the clustered nature of the data (PSP plates Cassettes of PSP plates (Soredex/Orion Corp., Helsinki, Finland) were were clustered within the patients), as well as the fact that not all patients had checked out from the junior clinic dispensary. The infection control policy of data for all four plates. The MIXED procedure in SAS is particularly well-suited our institution involves sterilizing PSP plates at the end of the work week with for dealing with both of these data situations. The Shapiro-Wilk test was used ethylene oxide gas.7 Therefore, in order to ensure the results represented an to assess the normality of the data in each treatment group, and if violations of equal distribution of dispensed PSP plates, the study was conducted towards normality were found, rank-based statistical methods were used. A significance the beginning and the end of the work week. Prior to performing a full-mouth level of 0.05 was used for all statistical tests. There were no preliminary data radiographic survey, the subjects were asked to either rinse with one of the three or data from previously published studies that could be used to estimate the test rinses or to refrain from rinsing. The no rinse group served as the negative anticipated effect size for the comparison of the four treatment groups. A control group for the study.15 Pre-procedural rinsing with the three test rinses sample size of n=30 patients in each group was chosen because this would was performed according to the manufacturer’s instructions. Chlorhexidine: yield 80% power for detecting a medium-to-large effect size of 0.32 in the 15 mL for 30 s; Listerine ®: 20 mL for 30 s; Decapinol®: 10 mL for 30 s. The ANOVA comparison of the four groups by using a significance level of 0.05.18 radiographic survey was conducted according to the normal school infection control protocol described previously.7 Four PSP plates were sampled from each Results full-mouth survey. To select a PSP plate with the highest probability of salivary Contamination data were available for a total of 500 PSP plates. Additionally, contamination, the plates used to acquire the mandibular premolar and molar the 25 control plates sterilized using ethylene oxide gas and the control blood periapical views were collected. After processing the images, each of the four agar plates exposed to the environment during the plating procedure were PSP plates was captured into a separate sterile container upon exiting from evaluated. Table 1 contains a summary of the data for the negative control the scanner (Digora Optime, Soredex, Helsinki, Finland). The plates were not group and the three mouthrinse groups in terms of the mean, standard allowed to be collected in the plate receptacle attached to the scanning unit deviation, median, and range of bacterial colonies per plate. The mean number by the manufacturer. The PSP plates were removed from their sterile container of colonies per plate was the lowest in the chlorhexidine group, followed by with flame-sterilized forceps and plated onto separate blood agar plates (5% the Decapinol, Listerine, and the no rinse negative control groups. Column 2 sheep blood agar, Lampire Biological Laboratories, Pipersville, USA).6,7 The in Table 1 represents the number of PSP plates available with contamination blood agar plates were labeled with the date, batch number, and test group. data relative to the planned sample size. For example, the planned sample Each set of four blood agar plates were placed in plastic wrap and incubated size for the no rinse group was 160 PSP plates; however, data were available at 37°C for up to 72 h. After incubation, the blood agar plates were evaluated for only 151 plates. Loss of PSP plates occurred for reasons such as PSP plate for the presence or absence of microbial growth. When microbial growth was contact with the receptacle on the Digora Optime scanning unit and handling detected, the number of colonies was recorded (Figure 1). For control, 25 gas-sterilized PSP plates were plated onto blood agar (5% sheep blood agar, of the PSP plate as it exited the scanner. Since the data for the number of Lampire Biological Laboratories, Pipersville, USA) and analyzed using the same colonies were non-normally distributed in all four groups according to the protocol.7 Additionally, a control blood agar plate exposed to the environment Shapiro-Wilk test (p<0.05 in each group), rank-based methods were used. during the plating of the PSP plate was incubated with each sample batch. Treating each patient as a cluster yielded an intra-cluster correlation in the The inclusion of the control agar plates exposed to the environment allowed number of colonies per plate of 0.19. After adjusting for the clustered nature for the detection of any cross contamination occurring during the plating of of the data, we found that the overall F-test based on the ranks indicated a the PSP plate on the blood agar. A similar baseline technique was used by significant difference among the groups in terms of the mean number of colonies Logothetis and Martinez-Welles in 1995 and Feres et al in 2010 for the collection per plate (F=3.83; d.f.=3,370; p=0.010). Tukey-Kramer multiple comparisons of bacteria in aerosols on blood agar plates.15,16 based on the ranked data indicated a significant difference only between the The negative control group (no rinse group) and the three mouthrinse Listerine and the chlorhexidine groups (t=3.35; d.f.=370; adjusted p=0.005). groups were compared in terms of the mean number of colonies per plate by No other significant pair-wise differences were found among the treatment

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groups. No growth was observed for the 25 gas-sterilized control plates or Kalathingal et al in 2010 demonstrated that the oral cavity serves as a the control blood agar plates exposed to the environment. source of PSP contamination.7 Due to the fact that the oral cavity contributes to the contamination of PSP plates and that chlorhexidine is currently the Table 1: Comparison of negative control and mouthrinse groups in terms of mean most effective antimicrobial agent, it seems that the use of chlorhexidine as and median number of bacterial colonies per plate a pre-procedural mouthrinse for radiographic examination would provide the 95% Number Number of greatest reduction in cross-contamination. However, it is important to note confidence of PSP bacterial Treatment group interval for Median that contamination was still detected even with the use of chlorhexidine. In a plates with colonies (Sample size) comparison (Range) contamination per plate meta-analysis, Berchier et al in 2010 found a small but statistically significant with data (Mean±S.D.) 11 chlorhexidine difference favoring 0.2% versus 0.12% chlorhexidine for plaque control. In a No rinse (n=40) 151 6.6±16.2 (-1.7, 9.3) 2.0 (0-130) study by Logothetis and Martinez-Welles in 1995, 0.12% chlorhexidine significantly Chlorhexidine (n=30)* 118 2.8±8.2 - 1.0 (0-66) reduced colony-forming units produced during polishing procedures when used Listerine® (n=30)* 115 5.8±10.8 (0.6, 5.4) 2.0 (0-80) 16 Decapinol® (n=30) 116 3.7±7.3 (-0.7, 2.5) 1.0 (0-57) as a pre-procedural mouthrinse. However, in this study, two consecutive 30 s PSP: photostimulable phosphor. *: p⁄0.05 by Tukey-Kramer method. S.D.: standard deviation rinsing periods were used. Similar to Logothetis and Martinez-Welles, Veksler et al in 1991 demonstrated a statistically significant reduction in the number Discussion of colony-forming units when using 0.12% chlorhexidine as a pre-procedural Feres et al in 2010 demonstrated that 0.12% chlorhexidine was effective in mouthrinse.22 Again, two consecutive 30 s rinsing periods were used. reducing aerosolized bacteria produced during ultrasonic scaling procedures.15 Therefore, perhaps, it is worth testing a concentration of 0.2% chlorhexidine Logothetis and Martinez-Welles in 1995 showed that both Listerine® and or two consecutive 30 s rinse periods with 0.12% chlorhexidine to evaluate chlorhexidine reduced bacterial contamination in aerosols,16 and Hase et al in the effect of chlorhexidine in reducing the cross-contamination on PSP plates. 1998 reported that chlorhexidine and delmopinol significantly reduced mutans An additional source of contamination that should be considered is the streptococci when compared to a placebo.19 Therefore, it is not surprising scanning procedure. The Digora Optime unit comes equipped with an internal that the use of these three products reduced the mean number of bacterial ultraviolet (UV) disinfection feature. This UV disinfection feature has been colonies isolated from PSP plates. shown to eliminate the contamination of the Digora Optime scanning unit Chlorhexidine performed the best of the three mouthrinses tested. However, when contaminated with C. albicans and S. oralis.23 However, this feature a statistically significant difference was detected only with the Listerine group. was not always included in the construction of the Digora Optime units and Based upon the mean and the median colonies per plate, it would appear that was not a feature of the Digora Optime units used in this study. Therefore, chlorhexidine also performed better than the no rinse group; unfortunately, the contamination of the scanning unit could have contributed to the bacterial a statistically significant difference was not detected. The failure to identify colonies isolated from the PSP plates. The Digora Optime system is also a statistically significant difference between the chlorhexidine group and the equipped with cardboard sheaths and plastic envelopes that provide a no rinse group may be attributable to the larger standard deviation (S.D.) and “touch-free” operation of the PSP plate during the scanning process. This therefore, higher variability in the no rinse group. In fact, the S.D. in the no “touch-free” system allows for hygienic PSP plate handling and works well rinse group was much larger than that in any other group and almost twice with experienced users such as faculty and trained dental personnel. However, the S.D. in the chlorhexidine group (16.2 vs. 8.2). This increased variability this system is less effective for inexperienced users such as dental students, would affect any comparison with the no rinse group. Although a statistically and some cross-contamination may occur during the scanning process. This significant difference was not detected between the chlorhexidine group cross-contamination is most likely to occur along the edges of the PSP, while and the no rinse group, it is worth noting that both the mean and the median the operator is preparing to insert it into the scanning unit.6 Therefore, in colonies per plate were reduced by one-half with chlorhexidine in comparison addition to the oral flora contamination through the plastic sheath, these two to the no rinse group. sources of contamination must be considered as well. Listerine® is an over-the-counter product proven effective for the control In conclusion, the mean number of bacterial colonies detected was the lowest of plaque and gingivitis and has been shown to reduce the microbial content in the chlorhexidine group. Unfortunately, a statistically significant difference of aerosols during ultrasonic scaling when used as a pre-procedural rinse.20,21 was detected only between the chlorhexidine group and the Listerine group. However, when Logothetis and Martinez-Welles compared Listerine® to The lack of detecting a statistically significant difference when compared chlorhexidine as a pre-procedural rinse, chlorhexidine performed significantly to the other treatment groups may be attributable to the need for a larger better.16 These results agree with the results of our study and the literature sample size due to the variability of the data. There is a possibility that a higher supporting chlorhexidine as the gold standard.11 Our results showed that concentration or longer exposure period may be helpful in further reducing Listerine® performed similarly to the group that refrained from rinsing and the contamination with chlorhexidine; however, additional research is needed to test Decapinol® (delmopinol) group. Based on the means, the no rinse group and this hypothesis. It is important to note the fact that the bacterial contamination the Listerine® group did not exhibit as much reduction of the contamination of PSP plates was still present, even with the use of chlorhexidine. This source of the PSP plates as the Decapinol® (delmopinol) group did; nevertheless, of contamination may have occurred during the scanning process due to the a statistically significant difference was not detected. The failure to detect improper “touch-free” handling of the PSP plate and/or the contamination of a statistical difference between the Decapinol® (delmopinol) group and the the scanning unit. Therefore, strict adherence to an infection control policy no rinse group may be attributable to the large S.D. in the no rinse group, during clinic operations must be ensured to minimize cross-contamination. similar to the comparison with the chlorhexidine group. Due to the variability *The authors received a small intramural grant from the College of Dental of the data, a larger sample size may be needed in order to detect a statistical Medicine to carry out this research project. difference between Decapinol® (delmopinol) and Listerine ®, and between Received October 12, 2013; Revised November 26, 2013; Accepted Decapinol® (delmopinol) and chlorhexidine. December 4, 2013

2nd quarter 2021 • volume 22 no. 2 PAGE 17 research

References 1. Kitagawa H, Farman AG, Scheetz JP, Brown WP, Lewis J, Benefiel M, et al. Comparison of three intra-oral storage phosphor systems using subjective image quality. Dentomaxillofac Radiol 2000; 29: 272–6. CONTINUING PROFESSIONAL 2. Stamatakis HC, Welander U, McDavid WD. Physical properties of a photostimulable DEVELOPMENT QUESTIONNAIRE phosphor system for intra-oral radiography. Dentomaxillofac Radiol 2000; 29: 28–34. 3. Matzen LH, Christensen J, Wenzel A. Patient discomfort and retakes in periapical examination of mandibular third molars using digital receptors and film.Oral Surg Oral – ARTICLE 2 Med Oral Pathol Oral Radiol Endod 2009; 107: 566–72. 4. Farman AG, Farman TT. A comparison of 18 different x-ray detectors currently used in Pre-procedural mouthrinses and contamination of dentistry. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005; 99: 485–9. phosphor radiographic plates - ARTICLE 2 5. Hayakawa Y, Farman AG, Kelly MS, Kuroyanagi K. Intraoral radiographic storage phosphor image mean pixel values and signal-to-noise ratio: effects of calibration.Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 86: 601–5. 11. Gains in popularity of phosphor plates over direct digital sensors 6. Kalathingal SM, Moore S, Kwon S, Schuster GS, Shrout MK, Plummer K. An evaluation of microbiologic contamination on phosphor plates in a dental school. Oral Surg Oral Med in dental radiography may be attributed to (select the incorrect Oral Pathol Oral Radiol Endod 2009; 107: 279–82. statement): 7. Kalathingal S, Youngpeter A, Minton J, Shrout M, Dickinson D, Plummer K, et al. An A. Entire surface area of the plate is active evaluation of microbiologic contamination on a phosphor plate system: is weekly gas sterilization enough? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010; 109: B. Narrower dynamic exposure range 457–62. C. Improved patient comfort 8. Addy M, Moran J, Newcombe RG. Meta-analyses of studies of 0.2% delmopinol mouth rinse as an adjunct to gingival health and plaque control measures. J Clin Periodontol D. Retakes unlikely 2007; 34: 58–65. 9. Stoeken JE, Paraskevas S, van der Weijden GA. The long-term effect of a mouthrinse containing essential oils on dental plaque and gingivitis: a systematic review. J 12. The periapical projection most likely to lead to salivary contamination Periodontol 2007; 78: 1218–28. of intraoral phosphor plates is: 10. Paraskevas S, Rosema NA, Versteeg P, Van der Velden U, Van der Weijden GA. Chlorine A. Maxillary incisor dioxide and chlorhexidine mouthrinses compared in a 3-day plaque accumulation model. J Periodontol 2008; 79: 1395-400. B. Maxillary molar 11. Berchier CE, Slot DE, Van der Weijden GA. The efficacy of 0.12% chlorhexidine mouthrinse C. Mandibular incisor compared with 0.2% on plaque accumulation and periodontal parameters: a systematic review. J Clin Periodontol 2010; 37: 829–39. D. Mandibular molar 12. U.S. Food and Drug Administration. FDA approves new oral rinse to help treat gingivitis [Internet]. ScienceDaily [updated 2005 April 21; cited 2013 Oct 20]. Available from http://www. sciencedaily.com/releases/2005/04/050419111800.htm. 13. The mean number of bacterial colonies observed per plate in the 13. Burgemeister S, Decker EM, Weiger R, Brecx M. Bactericidal effect of delmopinol on Listerine® treatment group following a 72 h incubation period: attached and planktonic Streptococcus sanguinis cells. Eur J Oral Sci 2001; 109: 425–7. 14. Simonsson T, Hvid EB, Rundegren J, Edwardsson S. Effect of delmopinol on in vitro A. 6.6 dental plaque formation, bacterial acid production and the number of microorganisms in B. 2.8 human saliva. Oral Microbiol Immunol 1991; 6: 305–9. 15. Feres M, Figueiredo LC, Faveri M, Stewart B, de Vizio W. The effectiveness of a pre- C. 5.8 procedural mouthrinse containing cetylpyridinium chloride in reducing bacteria in the D. 3.7 dental office. J Am Dent Assoc 2010; 141: 415–22. 16. Logothetis DD, Martinez-Welles JM. Reducing bacterial aerosol contamination with a chlorhexidine gluconate pre-rinse. J Am Dent Assoc 1995; 126: 1634–9. 14. The only product that showed a significant increase in colony 17. Raudenbush SW, Bryk AS. Hierarchical linear models: applications and data analysis count relative to chlorhexidine: methods. 2nd ed. Thousand Oaks: Sage Publications; 2002. 18. Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale: A. Decapinol® Lawrence Erlbaum Associates; 1988. B. Listerine® 19. Hase JC. Edwardsson S. Rundegren J, Attstrom R, Kelty E. 6-month use of 0.2% delmopinol hydrochloride in comparison with 0.2% chlorhexidine digluconate and C. No rinsing placebo (II). Effect on plaque and salivary microflora. J Clin Periodontol 1998; 25: 841–9. D. None of the above 20. Sharma N, Charles CH, Lynch MC, Qaqish J, Mcguire JA, Galustians JG, et al. Adjunctive benefit of an essential oil-containing mouthrinse in reducing plaque and gingivitis in patients who brush and floss regularly: a six-month study. J Am Dent Assoc 2004; 135: 15. Despite recognition as the most effective anti-microbial rinse 496–504. available today, pre-procedural rinsing with 0.12% chlorhexidine, 21. Fine DH, Mendieta C, Barnett ML, Furgang D, Meyers R, Olshan A, et al. Efficacy of preprocedural rinsing with an antiseptic in reducing viable bacteria in dental aerosols. in the study authored by Hunter et al. (2014), did not completely J Periodontol 1992; 63: 821–4. eliminate bacterial contamination of phosphor radiographic 22. Veksler AE, Kayrouz GA, Newman MG. Reduction of salivary bacteria by pre-procedural plates. Non-evidence-based suggestions to improve the efficacy rinses with chlorhexidine 0.12%. J Periodontol 1991; 62: 649–51. of a chlorhexidine-based pre-procedural rinse in radiography 23. Wenzel A, Kornum F, Knudsen MR, Lau EF. Antimicrobial efficiency of ethanol and 2-propanol alcohols used on contaminated storage phosphor plates and impact on included: durability of the plate. Dentomaxillofac Radiol 2013; 42: 20120353. A. Use of a higher (0.2%) concentration of chlorhexidine B. Halving the recommended rinsing time C. Instructing the patient to rinse more vigorously D. Combining use with a delmopinol hydrochloride containing product

PAGE 18 OHASA JOURNAL Kills human Corona Virus

Kills bacteria

Freshens Breath

Mint flavour research

Decolonising dental education: If not now, then when? Part 1

Sizakele Ndwandwe (UWC, 2015, BOH) and Tasneem Ajam (UWC 2004, BOH)

Introduction to as the ‘being’. The 'beings' positionality refers to the social and political The issue of decolonisation has been on the agenda in South Africa and context that creates one’s identity in terms of race, class, gender and sexuality elsewhere in the world for decades. This topic has gained momentum in the (Dictionary.com, 2021). past few years, seen in student protests regarding institutional norms, and This paper is positioned within the South African context where vast academic debates interrogating the topic. disparities exist within every sector of society including education (Amnesty.org, Post-apartheid, South Africa sought to transform the field of education in an 2020). Inequality creates alienation, which is attributable to social class, race attempt to develop a non-racial education system (Reddy, 2006). Universities in and economic stature. Unequal education is fostered by unequal access to turn were required to transform with respect to the curriculum and encompass resources and the resources needed to strengthen learning (Amnesty.org, decolonial ideologies (Allias, 2003). Higher Education Institutions (HEIs) are 2020). Translating into a student's decline in understanding new information continuously being criticized to construct knowledge that is appropriate to and contextualising knowledge. the South African context, both socially, and economically (Jansen, 2017). This paper seeks to position what decolonising the curriculum in Dental Faculties Constructing knowledge is a characteristic of the diversity of its knowledge in South Africa could mean by utilising the decolonial epistemic perspective producers (Winberg, 2006). The transference of appropriate information as a lens to view the world and education. A decolonial epistemic perspective influences how knowledge is acquired (Roy, 2016) – highlighting the power of is an attitude, regarding how knowledge is viewed and re-learning that which those who produce knowledge and the manner in which knowledge is shared. has been forgotten due to colonialism (Dastile & Ndlovu-Gatsheni, 2013). Contextual knowledge refers to knowledge that is both indigenous and In writing this position paper the authors use the discourse of decoloniality. western, it is acquired throughout one’s life; influenced by who is being Firstly, this paper explores individual’s identity and how it is informed by taught, what the subject taught is, and where the subject is taught (Feldman & education, in this instance higher education, secondly, what is colonial about Herman, 2015). The paucity of contextual knowledge in higher education, led the discipline and lastly, ways in which dental schools can be transformed to the “feesMustFall” protests and a call for decolonisation of the universities through decolonisation. curriculum. Academics were thus challenged to find alternative ways to visualise the world, education and practice (Dastille & Ndlovu-Gatsheni, 2013). As a Identity is determined by the coloniality of knowledge, consequence, universities are increasingly reconceptualising teaching, learning being and power and assessment strategies (Parker, 2003). These strategies are developed Education starting at the foundation level defines, forms and shapes an to be relevant for students who are unprepared and burdened by multiple individual’s identity (Idris et al, 2012). However there are multiple factors that determinants such as: monetary challenges, the university setting being a foreign define one’s identity such as language, family, traditions, and culture (Msila, environment to them (Le Grange, 2016) and being first generation students. 2007). Once a student reaches the adult learning cycle, the level of university, Similarly, the journal of dental education has reported on the evolving nature college or technikon, they have acquired some form of knowledge (CCL-CCA, of the curriculum abroad by stating the need to conceptualise and redesign 2007), known as prior knowledge. The coloniality of knowledge refers to the curriculum; considering the subject “who is being taught” (Pyle, 2012). maintaining ideological ideas such as beliefs and philosophies of that specific To appreciate the decolonisation debate one should understand that discipline, or areas of expertise and disregarding student’s prior knowledge, colonisation refers to the action or process of settling among and establishing which may in fact be of value within the context of the discipline. In essence, control over the indigenous people of an area and in the process dismissing ideological ideas can oppress an individual’s identity, heedless of students' indigenous knowledge and values (Sommer, 2011). This is taken further needs in acquiring new knowledge. through the coloniality of power, namely global economic power and power This prompts the assumption that students are uneducated and therefore differentials that are unequal in relations between people in a capitalist economy are not able to contribute meaningfully (Ndlovu, 2013), as they do not have (Datsile et al, 2013). Of particular relevance is that, this power is maintained knowledge of that discipline (Ndlovu, 2013). However their experiences, through knowledge dissemination (Behari-Leak & Mokou, 2019) and affects traditions and family or social environment could have embedded knowledge all dimensions of social existence, ranging from sexuality, authority, politics, (uncultivated) that is not being accessed. Uncultivated knowledge, based spirituality, language and race (Quijano, 2007). The coloniality of knowledge on life experiences is viewed as futile and substandard to what the 'more is therefore used as the medium to assert and maintain ideological power knowledgeable other' perceives as acceptable. The 'more knowledgeable (Behari-Leak & Mokou, 2019) which can be embedded in various social, political other' may be the lecturer or professor who is placed in that position of power and educational structures. Decoloniality is about invigorating the mind to re- based on the position in the educational system (Behari-Leak & Mokou, 2019). learning knowledge that has been pushed aside, forgotten or discredited by In maintaining ideological ideas and expecting students to adhere to this Eurocentric customs. In talking about decoloniality the individual is referred notion, perpetuates the coloniality of power (Behar-Leak & Mokou, 2019),

PAGE 20 OHASA JOURNAL research

thereby impinging on compassion for humanity. Humanity relates to the Thinking and acting beyond what is considered socially acceptable, commences individual, distinguished by culture, values, beliefs and customs (Dictionary. once we are responsive and understand who we are as people “beings” and as org, 2021). Furthermore it relates to being compassionate towards others educators (Rodney, 2016). Transformation will manifest through understanding (Merriam-Webster, 2021). As a consequence, the coloniality of power does not that knowledge emerges only through creation and innovations (Freire, 1970). acknowledge and restore the student’s diversity, beliefs, and values. Freire (1970) states, “transformation is through the restless, impatient, hopeful The colonial lens is determined by the three notions 'coloniality of power, and inquiry human beings”. Knowledge is not static, it is ever changing, it knowledge and being' that occur simultaneously (Behari-Leak & Mokou, 2019). evolves; it is acquired by those that interrogate, question and engage with The colonial lens is prejudice, it is a result of colonisation of the mind and knowledge, alluding to the importance of critical engagement between being. The being defines “who” we are, and “how” we are (Walker, 2017), and students and lecturers. therefore can influence one's epistemic perspective. Heleta (2016), states the need to reconsider and restructure Eurocentric Education can be colonial in practice through pedagogical approaches pedagogical approaches and curriculum that is still colonial in practice. The and integration that is inflexible. Colonial practices hinder the marginalized curriculum can incorporate indigenous knowledge and continue to apply from being exempt (Southard, 2017) and integrated into higher education’s Eurocentric knowledge into the Global South context. culture and society The decolonial lens views the importance of critical pedagogy and educational To resist exhibiting colonial customs, academics/lecturers need to immerse approaches that are focused on empowering learners. These educational themselves in positionality and in humanism (Ubuntu). Decoloniality is in our approaches need to be aligned to students' own experiences, needs, and everyday practice and living – it forms who we are. knowledge that is relevant to the students and their communities (Noordien- Fataar and Daniels, 2016). Dental profession Lecturers are primarily cognitive beings in their role as academics and should The dental profession assumes authority and dominance, due to the roles embrace the heart or Ubuntu. The consequence of not embracing humanism and responsibilities of the profession. The roles and responsibilities of dental will continue to oppress and marginalize students as students are prevented professionals can exude the coloniality of 'knowledge, being and power' by from reaching their full potential (Pour Ali et al, 2017). wearing the white clinical coat, manner of offering dental education, and Decolonising the curriculum, will lead to Higher education instituting an the options presented for dental treatment. According to Buldur & Armfield, education and training programme where students are inquiry focused, (2017), the dental profession is seen as having a high social status supporting knowledgeable and caring beings, who help to create a better and more the assumption of authority. peaceful world through intercultural understanding and respect (IB, 2013). One can therefore ask the questions – what can be regarded as colonial? And All that has been stated above, is ways to develop the decolonial lens; how what is problematic about the dental profession that needs to be reconstructed? we see higher education and the curriculum. “The well-educated person nowadays is not simply the one who has Problematizing the dental profession acquired knowledge or skills, but the one who possesses the capacity to Firstly, it is implementing a curriculum that includes the acknowledgement of interrogate that knowledge” Fanon, 1967. indigenous knowledge related to the discipline. This indigenous knowledge is being greatly appreciated to this day. For example, dental product manufacturers Conclusion have incorporated 'indigenous remedies' as part of the therapeutic product Decolonising the curriculum in dental schools goes beyond transforming range, such as charcoal for whiter teeth, and cloves to assist as an anaesthetic the curriculum. Academics need to be conscientious about the concept of for pain relief. colonialism and how it manifests. Furthermore, investigate ways to view the Secondly, academics own beliefs and practices influence pedagogical discipline differently through a decolonial lens. approaches. This may be evident in teaching and learning opportunities, To be able to transform the mind, identity of the students, and the curriculum, which consider or exclude the diversity of the student body; what constitutes it is crucial to eliminate alienation of students and the discipline. Accept the competence and how competence is measured. socio-cultural exchange of knowledge; by recognizing that no knowledge is Thirdly, students exuding coloniality of the mind, by exhibiting supremacy and more superior to another. dominance in how they interact with patients because of how they are taught Furthermore, to associate the values and culture of the university with the or reflective of the social background; relatively affecting effective citizenship. needs of the individual and communities. Effective citizenship would be how students are open and accepting of diverse knowledge that the community possesses (America, 2001). Terms defined As we emerge into the new realization of decolonization, it is necessary to be • Epistemic – relates to knowledge or knowing; cognitive. cognisant of the three key notions of coloniality 'knowledge, being and power' • Decoloniality – an epistemic, ethical, political and pedagogical project (Behari-Leak & Mokou, 2019). This awareness can alert us to be consistent in and the inclusion of principles of knowledge. Focuses on understanding maintaining the decolonial attitude. modernity in the context of a form of critical theory applied to ethnic studies • Decolonial lens – constant, critical reflection on how the colonial encounter Decolonial lens as an approach towards transformation underpins our perceptions and practice. A lens refers to the 'outlook', how we view and perceive the world. A decolonial • Decolonial epistemic perspective – production of knowledge from a lens refers to a constant, critical reflection on how the colonial encounter decolonial lens, generating analytical-reflexive detours necessary for the underpins our perceptions and practice (Schoneberg, 2019). analysis of reality; and to find the substance of the problems with 'others'.

2nd quarter 2021 • volume 22 no. 2 PAGE 21 research

• Coloniality of being – the decoloniality of being is concerned with re inserting 18. Merriam-Webster's Collegiate Dictionary (2021). Merriam-Webster Incorporated (10th ed). the full humanity of people as thinking , feeling and doing individuals in a Available from: <>. [Accessed: 15 August 2020/2021]. 19. Msila, V. (2007). From Apartheid Education to the Revised National Curriculum Statement: collective , irrespective of race , gender , ability and religion and so on. Pedagogy for Identity Formation and Nation Building in South Africa University of South Africa, South Africa. Nordic Journal of African Studies. References 20. Ndlovu-Gatsheni, S. J. (2013). ‘Perhaps decoloniality is the answer? Critical reflections on 1. Allais, S. M. (2003). ‘The National Qualifications Framework in South Africa: A democratic development from a decolonial epistemic perspective’, Africanus. project trapped in a neo-liberal paradigm?’ Journal of Education and Work. Available from: 21. Ndlovu, M. (2014). ‘Why indigenous knowledges in the 21st century? A decolonial turn’, . Accessed: 01 May 2020. Practices of Disadvantaged Students at a South African University’, Alternation, 2. America, S. (2001). ‘The Corporation for National Service’. New York: Washington DC. 23(January), pp. 90–112. 3. Amnesty International. (2020). Available from: https://www.amnesty.org/en/latest/ 23. Parker, J. (2003). ‘Reconceptualising the curriculum: from commodification to news/2020/02/south-africa-broken-and-unequal-education-perpetuating-poverty-and- transformation’, Teaching in Higher Education, 8(4), pp. 529–543. inequality/. Accessed: 18 January 2021. 24. PourAli, P. N., SeifNaraghi, M. and Naderi, E. (2017). ‘Humanistic education and students’ 4. Badat, S. (2010). The Challenges of Transformation in Higher Education and Training educational motivation in Tehran primary schools’, International Journal of Mental Health Institutions in South Africa. Development Bank of South Africa. and Addiction, 15(2), pp. 312–322. 5. Behari-Leak, K. and Mokou, G. (2019). ‘Disrupting metaphors of coloniality to mediate 25. Pyle, M. A. (2012). ‘New Models of Dental Education and Curricular Change: Their Potential social inclusion in the global south’, International Journal for Academic Development. Impact on Dental Education’, Journal of Dental Education. 6. Buldur, B. and Armfield, J. M. (2018). ‘Perceptions of the dental profession: a comparative 26. Quijano, A. (2007). ‘Coloniality and modernity/rationality’, Cultural Studies, 21(2–3), pp. analysis through scale development’, European Journal of Oral Sciences, 126(1), pp. 168–178. 46–52. 27. Reddy, T. (2006). Higher Education and Social Transformation in South Africa since the fall 7. Canadian council on learning. (2007). Redefining how success is measured in first nations. of Apartheid. Cahiers de La Recherche Sur l’éducation et Les Savoirs. Ottawa: Canada. 28. Rodney, R. (2016). ‘Decolonization in health professions education: reflections on teaching 8. Dastile, N. P., & Ndlovu-Gatsheni, S. J. (2013). Power, Knowledge and Being: Decolonial through a transgressive pedagogy’, Canadian Medical Education Journal. Combative Discourse as a Survival Kit for Pan-Africanists in the 21st Century. Alternation. 29. Roy, T. S. (2016). ‘Quality Teaching: It’s Importance in Higher Education – A Conceptual 9. Fanon, F. (1967). ‘The So-Called Dependency Complex of Colonized Peoples + The Fact of View’, International Research Journal of Interdisciplinary & Multidisciplinary Studies Blackness’, Black Skin, White Masks. (IRJIMS), 2(11), pp. 91–102. 10. Feldman, A. and Herman, B. C. (2015). ‘Teacher Contextual Knowledge’, in Encyclopedia of Science Education. 30. Schoneberg, J. (2019). Development: a failed project. [ONLINE] Open Democracy. Available 11. Freire, P. (1972). Pedagogy of the Oppressed 30th Anniversary Eds. Continuum, New York. from: https://www.opendemocracy.net/en/oureconomy/development-failed-project/. 12. Heleta, S. (2016). ‘Decolonisation of higher education: Dismantling epistemic violence and [Accessed: 20 February 2021]. Eurocentrism in South Africa’, Transformation in Higher Education. 31. Sommer, M. (2011). ‘COLONIES – COLONISATION – COLONIALISM: A Typological 13. Idris, F. et al. (2012). ‘The Role of Education in Shaping Youth’s National Identity’, Procedia - Reappraisal’, AWE. Classic and ancient history. University of Liverpool: Liverpool. Social and Behavioral Sciences, 59, pp. 443–450. 32. Southard, J. (2017). Colonial education. Post-colonial studies. [ONLINE] Available from: 14. International Baccalaureate Organization. (2013). What is an IB education? Switzerland. https://scholarblogs.emory.edu/postcolonialstudies/2014/06/20/colonial-education/. 15. United Kingdom. Accessed from: . [Accessed: 15 August 2020]. 33. Walker, T. (2017). On the coloniality of the being. The medium. Available from: 16. Jansen, J. (2017). ‘Introduction - Part II. Decolonising the university curriculum given a https://medium.com/@walkertj/on-the-coloniality-of-being-cb5f7d30c56d. [Accessed: dysfunctional school system?’ Journal of Education (University of KwaZulu-Natal). 15 January 2021]. 17. Le Grange, L. (2016). Decolonising the university curriculum. South African Journal of 34. Winberg, C. (2006). ‘Undisciplining knowledge production: development driven higher Higher Education. 30(2): 1–12. Stellenbosch University: Cape Town. education in South Africa’, Springer.

PAGE 22 OHASA JOURNAL Nicorette_A4 Advert_Final_26May21.indd 1 26/05/2021 16:29 research

South African tobacco smoking cessation clinical practice guideline

RN van Zyl-Smit,1,2,3 MB ChB, MRCP (UK), FCP (SA), Dip HIV Man (SA), MMed, Cert Pulm (SA), PhD; B Allwood,1,2 MB BCh, DCH (SA), DA (SA), FCP (SA), MPH, Cert Pulm (SA); D Stickells,4 MB ChB, FCP (SA); G Symons,2 MB ChB, FCP (SA), Cert Pulm (SA); S Abdool-Gaffar,5 MB ChB, FCP (SA), FCCP; K Murphy,3 PhD; U Lalloo,6 MB ChB, FCCP, FRCP (UK); A Vanker,7 MB ChB, FCPaed, MMed, Cert Pulm Paed; K Dheda,1,2 MB BCh, FCP (SA), FCCP, PhD, FRCP (UK); GA Richards,8 MB BCh, PhD, FCP (SA), FRCP

1 University of Cape Town Lung Institute, Department of Medicine, University of Cape Town, South Africa 2 Division of Pulmonology, Department of Medicine, University of Cape Town, South Africa 3 Chronic Disease Initiative for Africa, University of Cape Town, South Africa 4 Pulmonologist, Private Practice, Port Elizabeth, South Africa 5 Pulmonologist, Private Practice, Durban, South Africa 6 Department of Pulmonology and Critical Care, School of Clinical Medicine, Nelson R Mandela College of Medicine, University of KwaZulu-Natal, Durban, South Africa 7 Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, University of Cape Town, South Africa 8 Departments of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa

This guideline has been complied on behalf of the South African Thoracic Society to provide practising clinicians with a resource from which to base individual cessation interventions for patients within the South African environment.

Corresponding author: RN van Zyl-Smit ([email protected])

Source: S Afr Med J 2013;103(11):869-876. DOI:10.7196/SAMJ.7484

ABSTRACT: Tobacco smoking in South Africa Tobacco smoking (i.e. cigarettes, rolled tobacco, pipes, etc.) is associated with significant There are an estimated 1.3 billion smokers worldwide and over health risks, reduced life expectancy and negative personal and societal economic 5 million deaths per year attributable to tobacco smoking.[1] Even impact. Smokers have an increased risk of cancer (i.e. lung, throat, bladder), chronic though smoking rates are declining, there are an estimated 7 million obstructive pulmonary disease (COPD), tuberculosis and cardiovascular disease (i.e. stroke, smokers in South Africa (SA).[2] Tobacco smoking is undoubtedly heart attack). Smoking affects unborn babies, children and others exposed to second the primary risk factor for chronic obstructive pulmonary disease hand smoke. Stopping or ‘quitting’ is not easy. Nicotine is highly addictive and smoking is frequently associated with social activities (e.g. drinking, eating) or psychological (COPD), which is estimated to be the third highest cause of factors (e.g. work pressure, concerns about body weight, anxiety or depressed mood). death globally by 2030. SA has a particularly high prevalence [3,4] The benefits of quitting, however, are almost immediate, with a rapid lowering of blood of smoking (20%). SA also has one of the highest burdens of pressure and heart rate, improved taste and smell, and a longer-term reduction in risk tuberculosis (TB) and HIV, which are both risk factors for COPD and of cancer, heart attack and COPD. Successful quitting requires attention to both the exacerbate the effects of smoking. 5,6] Tobacco smoking increases factors surrounding why an individual smokes (e.g. stress, depression, habit, etc.) and the risk for TB, cancer, pneumonia, ischaemic heart disease the symptoms associated with nicotine withdrawal. Many smokers are not ready or and stroke, which are all leading causes of death globally.[1] The willing to quit and require frequent motivational input outlining the benefits that would mortality among current smokers in SA is nearly double that of accrue. In addition to an evaluation of nicotine dependence, co-existent medical or non-or ex-smokers.[7,8] Up to a third of all male deaths in SA adults psychiatric conditions and barriers to quitting should be identified. A tailored approach over the age of 35 years have recently been attributed to tobacco encompassing psychological and social support, in addition to appropriate medication use.[7,9] Passive smoking also increases the risk of cardiovascular to reduce nicotine withdrawal, is likely to provide the best chance of success. Relapse disease in adults and respiratory disease, particularly among is not uncommon and reasons for failure should be addressed in a positive manner children. The cost of smoking related disease to the SA economy and further attempts initiated when the individual is ready. is estimated to be R1.2 billion.[10] Key steps in smoking cessation include: (i) identifying all smokers, alerting them to The benefits of stopping smoking are almost immediate, with the harms of smoking and benefits of quitting; (ii) assessing readiness to initiate an a lowering of blood pressure within minutes, and longer-term attempt to quit; (iii) assessing the physical and psychological dependence to nicotine benefits such as improved lung function and reduced risk for and smoking; (iv) determining the best combination of counselling/support and pharmacological therapy; (v) setting a quit date and provide suitable resources and lung cancer, stroke and heart disease. Smoking cessation is [11] support; (vi) frequent follow-up as often as possible via text/telephone or in person; (vii) a critical component of the effective management of COPD. monitoring for side-effects, relapse and on-going cessation; and (viii) if relapse occurs, Savings of disposable income, achieved by quitting smoking, providing the necessary support and encourage a further attempt when appropriate. would also be available for basic necessities, particularly for those living in poverty.

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Many smokers have no desire to quit and will require repeated engagement Motivational interviewing approach by health practitioners to affect behaviour change. Interviewing techniques Many patients lack the motivation to quit or express a lack of readiness to have changed from the more traditional approach, typified by scolding or quit. This may be because they lack information, have concerns about quitting, lecturing, to one that involves support, encouragement and the provision of face significant social/environmental barriers or lack confidence in their ability information. 12] For those who wish to stop there are many options available to quit. Such patients may benefit from counselling methods derived from such as ‘cold turkey’, cognitive behavioural therapy, acupuncture, hypnosis, motivational interviewing (MI).[12] internet and cellular phone-based support programmes, and medication. In this approach, the clinician encourages the smoker to explore their This guideline assesses published evidence and reviews international feelings of ambivalence about smoking/quitting by discussing, for example, guidelines, applying them to the specific needs and circumstances in SA in the pros and cons of smoking from their perspective, and by exploring how developing a clinical practice guideline for SA clinicians. personally important cessation may be and how confident they feel about it. In Published international guidelines from the US Centers for Disease Control, this process, the provider supports and strengthens any intentions to change, the American College of Chest Physicians (ACCP), the UK National Institute which come from the patients themselves. The idea is to elicit self-motivational for Clinical Excellence (NICE) and the Cochrane Collaboration Database of statements, rather than tell the patient what they should do and how they Systematic Reviews for all topics relating to tobacco smoking were reviewed. should do it. MI posits that a good collaborative relationship, in which a client In addition, PubMed was searched for newer studies on specific topics such is viewed as the expert on his/her own life, serves to minimise resistance to as e-cigarettes, smoking in pregnancy, and smoking in persons infected with change and thereby enhances motivation.[15] This varies significantly from the HIV or TB. Smoking in this guideline refers to all forms of smoking tobacco traditional, advice-giving approach, which casts the provider in a dominant, products such as cigarettes, cigars and rolled tobacco. Smoking cessation – also directing role and the patient merely as a passive recipient of their expert referred to as quitting, is the process of stopping smoking. Where available, knowledge. Meta-analyses have shown that MI can significantly improve evidence grading is provided with the grading source. smoking cessation rates over brief advice.[16]

Tobacco smoking cessation strategies The individual who is not ready to quit Smoking cessation can be broadly divided into two phases: (i) the identification • Encourage the individual to think about quitting, identify the reasons for of smokers and assisting them to quit; and (ii) initiating and sustaining the quit smoking and the barriers to quitting and provide an opportunity for follow-up. attempt (Figure 1). The strength of evidence for each intervention varies. For For individuals who are not ready or willing to quit, on-going encouragement each stage and intervention, key points and strength of supporting data are and offers of support are necessary. The practitioner can provide information presented and expert opinion was relied on where data was lacking. about the risks of smoking and the benefits of quitting and encourage the patient to return for further discussions if and when they are ready to quit. Assisting Identifying smokers and initiating quit attempts the patient to identify the perceived benefits that they gain from smoking • The strategy of identifying smokers during routine consultations with (i.e. stress reduction, weight control), their perceived barriers to quitting (i.e. healthcare practitioners increases quit attempts (Grade A[13]). social pressure, withdrawal symptoms) and the benefits of quitting (i.e. health • Brief smoking cessation interventions should be implemented, regardless improvement, cost savings) can lay the foundation to behavioural change at of the availability of, and access to, specialised services (Grade A[13]). a later date and enhance the possibility of a quit attempt. ‘If you don’t think about it, you won’t do it’. Using stickers, tags or reminders in folders for the nurses or doctors increases the likelihood of discussions Assisting the motivated patient to quit with patients around smoking, counselling and referral for cessation advice. • Counselling plus medication to treat nicotine withdrawal is more effective The inclusion of smoking as one of the vital signs identifies 80% or more of than either intervention alone (Grade A[13]). smokers attending primary care facilities.[14] • Multiple options are available and can be tailored to suit the individual patient and circumstance. Clinical interventions to initiate and sustain smoking cessation • Smokers who are motivated, have supportive networks and are ready to • Repeated encouragement and assistance provided by more than one change, have higher success rates. physician/healthcare worker, through a range of supportive options, increase • Smokers who are highly nicotine dependent, have social stressors and the likelihood of abstinence (Grade A[13]). psychiatric comorbidities, are less likely to be successful. Interventions as brief as 3 min can significantly increase quit rates, but intensive interventions are more effective (more comprehensive treatments being those Pharmacological intervention (drug treatment to aid that occur over multiple visits, for a longer period of time and/or are provided smoking cessation) by more than one clinician).[14] The goal should be for every tobacco user to be Several pharmacological strategies are available to assist in smoking cessation identified and offered at least a brief intervention at every clinical consultation. – predominantly to address acute nicotine withdrawal. These may be simply A commonly recommended approach is the 5As model, which is an effective, classified as nicotine replacement therapies (NRTs) or drugs that reduce addiction. structured approach to providing brief interventions (3–10 min) in the primary Although both classes of drug are an aid to smoking cessation, they have little care setting. The 5 steps are: (i) asking about smoking; (ii) alerting the patient or no effect on the underlying addiction and do not address the psychosocial to the benefits of quitting; (iii) assessing readiness to make a quit attempt; factors that cause a person to smoke. Most studies of pharmacological (iv) assisting those willing to quit; and (v) arranging for follow-up contact and interventions have been conducted in subjects who smoke >10 cigarettes/day referral to further resources, such as quitlines. Problem solving, skills training and frequently >20 cigarettes/day. There is little evidence to guide the use of and psychosocial support during treatment are all effective elements of pharmacological therapy in subjects who smoke only 3–5 cigarettes/day or counselling. They can be used as part of brief interventions, but also form the in those with very low nicotine dependence. Table 1 outlines the comparative foundation of more intensive interventions.[14] performance of the various drugs available to assist in smoking cessation.

2nd quarter 2021 • volume 22 no. 2 PAGE 25 research GUIDELINE

1. Do you smoke? Ask 2. Do you know the risks? 3. Have you thought of quitting?

1. Do you know the bene ts of quitting? Alert 2. Do you know that we can help you?

Assess 1. Are you ready to quit?

Give motivational pamphlet and Assist/Arrange encourage follow-up Quitlines and useful websites

No · National Council Against Smoking quitline: 011 720 3145 · CANSA Call Centre: 0800 22 66 22 website: http://www.ekickbutt.org.za Maybe Yes · Patient resources: http:/www.ichange4health.co.za

Arrange for cessation intervention

Speci c nicotine dependence review

Fagerström/CO levels Current smoking and history of quit attempts Motivated Social stressors/household smokers Motivated Low dependence High dependence

Have you How soon after How many already waking in the times do Level of attempted morning do you smoke dependence Could manage with counselling/ to quit you smoke your Probably will need added per day? support alone or NRT smoking? rst cigarette? pharmacological support

Yes >30 >5 min Very high

Yes 20 - 30 5 - 30 min High Assess medical/psychiatric history Support group Evaluate capacity to purchase Text/internet/smartphone-based Yes 10 - 20 30 - 60 min Medium medicine support No <10 >60 min Low Review availability of medication

Set quit date Arrange appropriate support and medication if needed

Medication options · Nicotine replacement therapy Follow-up patch/gum/spray · Assess withdrawal syptoms and · Varenicline drug side-eects · Bupropion · Evaluate mood and psychosocial stressors · Identity potential for relapse

Figure 1: Smoking cessation approach in clinical practice. All smokers should be identified and their readiness to quit evaluated. If resistance to quitting exists, information Fig.and 1. suitable Smoking follow-up cessation should approach be provided in clinical (top). Ifpractice. an individual All smokersis ready toshould make bea quitidentified attempt, andevaluation their readinessof nicotine to dependence, quit evaluated. co-morbid If resistance disease andto quitting psychosocial exists, informationfactors should and guide suitable the clinician follow-up in theshould choice be ofprovided effective (top). interventions If an individual (bottom). is readyCO = carbon to make monoxide; a quit attempt, NRT = nicotine evaluation replacement of nicotine therapy. dependence, co-morbid disease and psychosocial factors should guide the clinician in the choice of effective interventions (bottom). CO = carbon monoxide; NRT = nicotine replacement therapy.

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Table 1: Comparisons of abstinence rates achieved with different pharmacological Nortriptyline (not registered in SA) is generally considered a second- interventions to support smoking cessation* line therapy for those who have failed NRT and bupropion/varenicline.[23] Estimated Nortriptyline is a metabolite of amitriptyline, which is available in SA. There Medication Arm, n OR (95%CI) abstinence rate are, however, no published data on smoking cessation using amitriptyline. (95%CI) Given the increased associated risk of suicide in smokers,[24,25] the serious Placebo 80 1 13.8 complications of amitriptyline overdose and its unknown efficacy as a smoking NRT cessation aid, the drug cannot be recommended for smoking cessation until Nicotine gum 15 1.5 (1.2 - 1.7) 19 (16.5 - 21.9) further data are available. Nicotine patch 32 1.9 (1.7 - 2.2) 23.4 (21.3 - 25.8) Table 2: Fagerström test for nicotine dependence[85] Nicotine spray 4 2.3 (1.7 - 3) 26.7 (21.5 - 32.7) Question Score Antidepressants/centrally acting agents 1. How soon after you wake up do you smoke your first cigarette? Bupropion SR 26 2 (1.8 - 2.2) 24.2 (22.2 - 26.4) Within 5 min 3 6–30 min 2 Nortriptyline 5 1.8 (1.3 - 2.6) 22.5 (16.8 - 29.4) 31–60 min 1 Clonidine 3 2.1 (1.2 - 3.7) 25 (15.7 - 37.3) After 60 min 0 Nicotine receptor agonist 2. Do you find it difficult to refrain from smoking in places where it is forbidden? Yes 1 Varenicline (2 mg/day) 5 3.1 (2.5 - 3.8) 33.2 (28.9 - 37.8) No 0 OR = odds ratio; CI = confidence interval; NRT = nicotine replacement therapy; SR = slow release. 3. Which cigarette would you hate most to give up? *Data from Fiore et al.,[13] comparisons are with placebo treatment. The first in the morning 1 Any other 0

NRT 4. How many cigarettes per day do you smoke? • NRT is effective and should be encouraged (Grade [13]A ). ≤10 0 11–20 1 • A controller (patch) and reliever (gum, spray) approach is the most effective 21–30 2 way to use NRT (Grade A[13]). ≥31 3 NRT has been the mainstay for addressing nicotine withdrawal. It is particularly 5. Do you smoke more frequently during the first hours after waking than during the effective when employing dual NRT – one as a ‘controller’ and one as a ‘reliever’ rest of the day? (odds ratio (OR) 3.6 (95% confidence interval (CI) 2.5–5.2) for success, and Yes 1 No 0 abstinence rates 36.5% (95% CI 28.6–45.3) at the end of therapy).[14] This approach, which is advocated by the ACCP, is more effective than using a single 6. Do you smoke even if you are so ill that you are in bed most of the day? Yes 1 [17] form of NRT (relative risk (RR) 1.34; 95% CI 1.18–1.51). Titration of the NRT (via No 0 patch strength) to the level of symptom severity based on the Fagerström scale TOTAL SCORE (Table 2), or of cotinine level is recommended to ensure that adequate control Interpretation of total score[86] of withdrawal symptoms is achieved. If ‘breakthrough’ symptoms occur the 0–3 Mild dependence ‘reliever’ NRT should be used (gum, spray, etc.). The use of nicotine spray may be preferred to gum in some individuals.[18] Combinations of NRT with bupropion 4–6 Moderate dependence are more effective than NRT alone (OR 2.57; 95% CI 1.05–6.32),[19] but based 7–10 Severe dependence on the theory of their mechanism of action, there should be no value in using both NRT and varenicline together. Despite this, there are anecdotal reports of Nicotine receptors agonists additional benefit, and this has recently been tested in the VARNIC study, the • Varenicline is an effective smoking cessation therapy (Grade [13]A ). results of which are expected during 2014. Note: at the time of writing these • Although not confirmed in large studies and meta-analyses, there is concern practice guidelines, nicotine patches were not available in SA. about incidents of suicide or suicidal behaviour. • It is strongly advised that all patients who are prescribed these drugs are Antidepressants closely monitored for behavioural change and/or neuropsychiatric symptoms. • Bupropion is an effective drug for smoking cessation particularly in combination Two nicotine receptor partial agonists have been marketed: varenicline with NRT (Grade A[13]). (Champix – registered in SA) and cytisine (Tabex – not registered in SA). • Nortriptyline is a moderately effective drug for smoking cessation (Grade [13]A ). By acting as partial agonists, they stimulate dopamine release and reduce • The use of bupropion or nortriptyline must be under medical supervision nicotine withdrawal symptoms. [26-28] In controlled trials and meta-analyses, due to potential side-effects and interactions. varenicline has been shown to be the most effective single drug for smoking Bupropion (Zyban) used at doses of 150 mg twice daily for 7–12 weeks is cessation (RR 3.1; 95% CI 2.5–3.8)[29,30] whereas cytisine, although effective, effective (RR 1.69; 95% CI 1.53–1.85).[20] Additionally, bupropion appears to appears to result in only a modest increase in quit rates.[29,31] The most common reduce long-term relapse and the weight gain associated with quitting.[21] Its side-effects reported with varenicline include abnormal dreams, nausea and most frequent side-effects are insomnia, dry mouth and nausea.[20] Bupropion headache. [32,33] While smokers as a group are at higher risk of suicide than may also reduce the seizure threshold and a seizure risk of 1/1 000 has been non-smokers,[24,25] there are concerns about the neuropsychiatric side-effects reported.[22] There is no evidence that selective serotonin re-uptake inhibitors of varenicline. While the US Food and Drug Administration (FDA) mandated a (SSRIs) are effective for smoking cessation.[20] ‘black box’ warning in 2008, meta-analyses have not confirmed this risk.[29,34]

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Recent studies have also reported that varenicline appears to be safe in patients data existed comparing hypnotherapy with other methods for smoking cessation. with schizophrenia[35] and in patients with cardiac disease.[29,36-38] Nevertheless, Estimates in the two separate meta-analyses for success of hypnotherapy in it should be used with caution and under supervision. Champix is a schedule 5 achieving smoking cessation were: OR 4.55 (95% CI 0.98–21.01)[46] and RR 1.49 drug in SA and patients should be monitored regularly with particular attention (95% CI 0.86–2.5)[47] to changes in their emotional state, unusual behaviour and suicidal ideation. Acupuncture Electronic cigarettes • ‘There is no consistent, evidence that either acupuncture or acupressure • There is no evidence that electronic cigarettes (e-cigarettes) are effective are effective in smoking cessation’.[48] aids to smoking cessation, although they may reduce the number of Several studies and meta-analyses have evaluated the effects of acupuncture on cigarettes smoked. smoking cessation in a controlled, randomised manner.[48-50] Differing methods E-cigarettes are battery-powered devices, similar in appearance to conventional used in these studies (e.g. the nature of control procedures and the selection of cigarettes that vaporise nicotine. A large variety of products are on offer. They control groups) do not provide sufficient consistency for a bias-free analysis. The are available in different flavours and may be used in an attempt to reduce the most recent and comprehensive Cochrane review concluded that acupuncture symptoms of nicotine withdrawal while allowing the smoker to participate in is less effective than NRT (RR 1.05; 95% CI 0.82–1.35).[48] the ‘ritual’ of smoking. E-cigarettes are available over the counter and there is currently little legislative control on their use, availability and marketing. Smoking cessation in specific situations Recently however, both the FDA and the South African Medicines Control Council have begun to consider regulation of these products.[39] Pregnancy The role of e-cigarettes in smoking cessation algorithms remains unclear. As • Smoking poses significant risks to mother and fetus. they are likely to be less hazardous than tobacco smoking,[40] they may, in future, • Brief counselling by a healthcare provider as part of routine antenatal care have a role in smoking cessation, either to reduce nicotine intake or as a bridge is effective and well received by pregnant women. to smoking cessation. In a small pilot study, they appeared to decrease cigarette • There is, as yet, insufficient, high-quality evidence to determine whether consumption,[41] and they may be especially useful in reducing consumption in the use of pharmacotherapy (i.e. NRT, bupropion or varenicline) is effective chronic psychiatric (schizophrenic) patients.[42] Side effects include mouth and and safe during pregnancy. throat irritation, dry cough, nausea and headache, although these appear to The risks to mother and child from smoking during pregnancy, and in the post- decrease over time. Concerns have been raised about the long-term safety natal period are well established. Maternal smoking is associated with obstetric of e-cigarettes, particularly with regard to the flavouring used.[43] Additionally, risks (miscarriage and premature rupture of membranes, placental abruption, although e-cigarettes do not produce classic smoke, they have been found to intra-uterine growth retardation and stillbirth).[51] Maternal exposure to second- produce short-term adverse physiological effects on the airways. [44] Currently, hand smoke in pregnancy can also increase the risk of low-birthweight children. given the lack of data on efficacy and limited long-term safety data, they are [52] Although quitting early in pregnancy will produce the greatest benefits, not recommended as part of smoking-cessation strategies. stopping at any stage during pregnancy yields benefits to the fetus and mother, and the child in the post-natal period.[53] Passive smoking increases the risk for Nicotine vaccine asthma, middle ear and recurrent chest infections in children.[54] Counselling • The theory behind nicotine vaccines is that they induce antibodies that bind should be offered at the first antenatal visit and if possible, smokers in the to nicotine, reducing its availability to central receptors. household or workplace should be identified. A smoking cessation intervention • Nicotine vaccines are still in development and their efficacy has not been involving brief counselling by lay counsellors, supported by midwives and by confirmed.[45] educational materials specifically tailored to pregnancy, was shown to be effective in increasing cotinine-validated quit rates among disadvantaged Complementary medicine women attending public sector antenatal care clinics in SA.[55] On the basis of Several forms of complementary medical approaches are in common use and the substantial evidence of benefit from NRT in the general population and are widely advertised as aids to smoking cessation. These include hypnotherapy, the limited evidence available among pregnant women,[53,56,57] some guidelines acupuncture, acupressure and electro-stimulation. However, none of these recommend the use of NRT in pregnancy under medical supervision, but only methods are supported by convincing efficacy data when subjected to review when behavioural therapy has failed and in heavily dependent smokers who using Cochrane Library methods. Although positive results have been reported remain motivated to quit.[58] in individual studies, there is a lack of data from large, randomised, controlled studies. When performed by experienced and qualified individuals, they are Adolescents/paediatrics likely to be safe and may benefit some. However, they are not recommended • Treatment strategies relying on behavioural change are effective. as effective strategies. • No smoking cessation medication is licensed for use in children aged less than 18 years. Hypnotherapy • Paediatricians and healthcare workers providing care to children must • There is no evidence to support hypnotherapy as an effective aid to smoking address smoking by parents and advise on smoking-cessation strategies. cessation. Tobacco smoking in adolescents frequently leads to long-term nicotine addiction Hypnotherapy is a widely promoted aid to smoking cessation and multiple and the consequent adverse health-effects. In SA in 2008, 21% of learners approaches, techniques and success rates have been reported. Two recently (grade 8–10) were found to be current smokers, with 6.8% having initiated published meta-analyses, in which different study selection criteria were smoking before the age of 10 years.[59] The smoking of hookah pipes (‘hubbly- employed, concluded that hypnotherapy was not effective, as insufficient quality bubbly’) should be addressed among adolescents who frequently believe it

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to be tobacco-free and, hence, safe. Preventing adolescents from starting to with caution.[74] Varenicline is not metabolised by the liver, thus drug-drug smoke is vital to reduce the numbers of adults who smoke. interactions should not occur, but common side-effects such as nausea may Nearly half of adolescent smokers in SA attempt to quit each year but factors interfere with ARV compliance.[73] such as stress, depression, peer pressure and weight gain impact on their success.[59-62] Behavioural change can be encouraged by focussing on the health Mental illness benefits and improved school and sport performance, and by recognising the • Smoking is common in individuals with mental illness. effects of cultural differences and the social pressures that exist with regard • Adequate management of the underlying psychiatric illness is key to [60-62] to smoking. A variety of methods (ranging from one-on-one sessions to successful smoking cessation. group therapy, telephonic helplines and web-based programmes) have been Anxiety disorders, depression, and schizophrenia are strongly associated with tried and, if tailored to individual needs, may double success rates. There tobacco smoking.[35,77,78] There is evidence to suggest that psychiatric disorders are insufficient studies comparing these models in order to recommend one may lead to self-medication with nicotine and that smoking may predispose particular strategy in adolescents.[13,63] It is imperative to speak to the adolescent individuals to mental illness.[78,79] Smoking cessation is important even in those alone (without the caregiver present) and to maintain confidentiality when with complex psychiatric disorders. Where necessary, consultation with an encouraging behavioural change. experienced psychiatrist may be beneficial in choosing the best options for SA data show that adolescents who have been exposed to smokers are management of the mental illness and drugs for smoking cessation if required. more likely to smoke than those who have not (74.5% v. 44%, respectively).[59] A recent Cochrane review concluded that bupropion and varenicline appear to Counselling of parents on the harmful effects of smoking and on interventions be safe and effective in schizophrenia, but NRT and psychological interventions to aid quitting may reduce secondary smoke exposure in children.[13] Parental [35] smoking cessation is also associated with higher quit rates among adolescents.[62,64] show no benefit. In patients with current depression, management of the No smoking-cessation medications are FDA-approved in children or depression should be addressed first, as there is limited success of smoking [77] adolescents (under 18 years). The UK NICE guidelines, however, support the cessation interventions (even bupropion). use of NRT if required, along with behavioural interventions in teenagers over 12 years of age.[58] If a decision is made to use NRT in a teenager, it should be In-hospital cessation used in conjunction with behavioural therapy and should be individualised. • In-hospital cessation counselling with post-discharge follow-up is an effective Although safety studies have been conducted with bupropion and varenicline intervention to assist in smoking cessation. in adolescents, both are only approved for adults in SA.[33] • The addition of NRT substantially improves quit rates, but insufficient data exist as to the additional benefits of bupropion or varenicline. Tuberculosis As smoking is banned in most public places and particularly in hospitals, • Smokers have approximately double the risk of developing TB and of dying acute admissions in which smoking cessation is imposed are convenient from TB than non-smokers. opportunities to promote smoking cessation. Many trials have demonstrated • Smoking cessation for people with active TB is a feasible and effective that appropriate in-hospital counselling and post-discharge follow-up are intervention. effective.[80] The additional use of NRT appears to be highly effective (54% There is substantial epidemiological evidence that smokers have a higher risk increase in cessation rates).[80] There are insufficient data concerning the use of of developing TB (both latent and active) and dying from TB.[65-67] In SA, with bupropion or varenicline during hospitalisation. Acute pre-operative cessation the added risk of HIV, the importance of smoking cessation to reduce the risk has mixed reports of long-term success, although lower complication rates (in [6,68] of TB, HIV-related diseases and COPD is unquestionable. There are some relation to wound healing and lung function) occur in those who quit at least data to show that integrating smoking cessation efforts (support plus NRT) 6–8 weeks prior to surgery.[81-84] with TB treatment is feasible,[69] improves quit rates (77% v. 8.7%, respectively) and completion of TB treatment (97.5% v. 84.8%, respectively).[70] It is unclear, Relapse however, whether stopping smoking during TB therapy will reduce the excess Relapse is common; frequently, because the underlying psychosocial factors mortality associated with smoking and TB,[71] nor are there any efficacy data or nicotine addiction have not been adequately addressed. Relapses can be available on whether using bupropion or varenicline with concomitant anti-TB viewed as an opportunity to learn how to approach a subsequent quit attempt, therapy may be of benefit. Smoking cessation should, however, be encouraged rather than as outright failure. Many attempts may be required before long- in all TB patients and appropriate support provided. term success is achieved. If relapse does occur, appropriate support should be provided and the reasons for relapse reviewed before another quit attempt. HIV/antiretroviral therapy • Smoking cessation is an important and effective intervention in individuals living with HIV. Implementation and further research • Drug-drug interactions may occur with bupropion. Smoking cessation at the primary level will require adequate training of staff The risks of smoking in HIV-infected individuals are well described and include to provide the necessary counselling to motivate patients to attempt to quit. inter alia pneumonia, TB and lung cancer.[72] There are several small trials Lay counsellors providing HIV adherence support could be trained to offer on smoking cessation in the context of HIV that have concluded that it is an smoking cessation counselling and support. The prescription of medication important and effective intervention.[72-74] Smoking and nicotine are known to to support quit attempts may need to be restricted to clinicians/clinics who induce hepatic enzymes,[75,76] but not those metabolising common antiretrovirals are able to fully assess nicotine dependence and monitor side-effects of the (ARVs). Enzyme inhibition/induction by ARVs such as lopinavir-ritonavir may medication. Research into the optimal use of medications in HIV/TB patients increase or reduce serum concentrations of bupropion and should be used as well as the possible use of amitriptyline is needed.

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Summary and recommendations 13. Fiore MC, Jaen CR, Baker TB. Treating Tobacco Use and Dependence: 2008 Update. Nicotine addiction and psychosocial stressors make smoking cessation difficult, Rockville: US Department of Health and Human Services, Public Health Service, 2008. 14. Fiore MC. Treating tobacco use and dependence: 2008 Update U.S. Public Health Service even in those who are motivated to quit. Motivating those with no apparent Clinical Practice Guideline executive summary. Respir Care 2008;53(9):1217-1222. interest in quitting nor confidence to quit, requires support and encouragement 15. Lundahl B, Burke BL. The effectiveness and applicability of motivational interviewing: from healthcare practitioners at every contact and should involve the entire A practicefriendly review of four meta-analyses. J Clin Psychol 2009;65(11):1232-12345. [http://dx.doi. org/10.1002/jclp.20638] health team. Although time is limited in clinical practice, brief motivational 16. Lai DT, Cahill K, Qin Y, et al. Motivational interviewing for smoking cessation. Cochrane counselling with appropriate referral of the individual who is motivated to Database Syst Rev 2010(1):CD006936. [http://dx.doi.org/10.1002/14651858.CD006936. quit, is effective. pub2] (Meta-analysis review) These practice guidelines serve as an aid to the clinician in deciding on 17. Stead LF, Perera R, Bullen C, et al. Nicotine replacement therapy for smoking cessation. the best strategies to use for smoking cessation. Even the best programmes Cochrane Database Syst Rev 2012;11:CD000146. [http://dx.doi.org/10.1002/14651858. internationally have only modest success rates, with frequent relapses if the CD000146.pub4] (Non-US government research support) underlying reasons predisposing to smoking or the barriers to cessation have 18. Bolliger CT, van Biljon X, Axelsson A. A nicotine mouth spray for smoking cessation: A pilot study of preference, safety and efficacy. Respiration 2007;74(2):196-201. not been addressed. Informing the smoker about the immediate and long-term [http://dx.doi.org/10.1159/000097136] (Randomised controlled trial (RCT); non-US benefits of quitting, anticipating the difficulties that could be expected and government research support) problem solving with the patient, as well as prescribing appropriate medication 19. Steinberg MB, Greenhaus S, Schmelzer AC, et al. Triple-combination pharmacotherapy for medically ill smokers: A randomized trial. Ann Intern Med 2009;150(7):447-454. where needed, all increase the possibility of success. If such interventions are 20. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane widely applied to a large proportion of smokers, they have the potential to Database Syst Rev 2007(1):CD000031. [http://dx.doi.org/10.1002/14651858.CD000031. achieve important reductions in disease and associated excess healthcare costs. pub3] (Meta-analysis review) 21. Hays JT, Hurt RD, Rigotti NA, et al. Sustained-release bupropion for pharmacologic relapse prevention after smoking cessation: A randomized, controlled trial. Ann Intern Acknowledgements Med 2001;135(6):423-433. [http://dx.doi. org/10.7326/0003-4819-135-6-200109180-00011] The South African Thoracic Society guideline committee is grateful to Professors (Clinical RCT; non-US government research support) Eric Bateman and Dan Stein for their input and review of this guideline. 22. Dunner DL, Zisook S, Billow AA, et al. A prospective safety surveillance study for bupropion sustainedrelease in the treatment of depression. J Clin Psychiatry 1998;59(7):366-373. [http://dx.doi.org/10.4088/JCP. v59n0705] (Multi-centre, clinical trial; non-US government Conflicts of interest research support) None of the authors have any relationship with the tobacco industry. No funding 23. Hughes JR, Carpenter MJ, Naud S. Do point prevalence and prolonged abstinence measures produce similar results in smoking cessation studies? A systematic review. was received from any source to prepare these guidelines. RVZS, DS and GR Nicotine Tob Res 2010;12(7):756-762. [http://dx.doi.org/10.1093/ntr/ntq078] (Comparative have received honoraria from Pfizer, GSK (DS, GR). GR, DS and SAG have been study; NIH extramural review research support) on advisory committees for Pfizer and GSK (SAG). 24. Miller M, Hemenway D, Rimm E. Cigarettes and suicide: A prospective study of 50,000 men. Am J Public Health 2000;90(5):768-773. (Non-US government and US Public Health Service (PHS) government research support) References 25. Hemmingsson T, Kriebel D. Smoking at age 18-20 and suicide during 26 years of follow-up 1. World Health Organization. WHO Report on the Global Tobacco Epidemic, 2008. The – how can the association be explained? Int J Epidemiol 2003;32(6):1000-1004. (Non-US MPOWER Package. Geneva: WHO, 2008. [http://www.who.int/tobacco/mpower/mpower_ government research support) report_full_2008.pdf (accessed 1 October 2013). 26. Coe JW, Brooks PR, Vetelino MG, et al. Varenicline: An a4ß2 nicotinic receptor partial 2. van Walbeek C. Recent trends in smoking prevalence in South Africa – some evidence agonist for smoking cessation. J Med Chem 2005;48(10):3474-3477. from AMPS data. S Afr Med J 2002;92(6):468-472. (Non-US government research support) [http://dx.doi.org/10.1021/jm050069n] (In vitro study) 3. Buist AS, McBurnie MA, Vollmer WM, et al. International variation in the prevalence of 27. Gonzales D, Rennard SI, Nides M, et al. Varenicline, an a4ß2 nicotinic acetylcholine COPD (the BOLD Study): A population-based prevalence study. Lancet 2007;370(9589):741- receptor partial agonist, vs sustained-release bupropion and placebo for smoking 750. [http://dx.doi.org/10.1016/ S0140-6736(07)61377-4] cessation: A randomized controlled trial. JAMA 2006;296(1):47-55. 4. World Health Organization. The World Health Report 2002 – Reducing Risks, Promoting [http://dx.doi.org/10.1001/jama.296.1.47] (Multi-centre, comparative, clinical phase III RCT; Healthy Life. Geneva: WHO, 2002. http://www.who.int/whr/2002/en/ (accessed 1 October non-US government research support) 2013). 28. Jorenby DE, Hays JT, Rigotti NA, et al. Efficacy of varenicline, an a4ß2 nicotinic 5. Crothers K, Butt AA, Gibert CL, et al. Increased COPD among HIV-positive compared to HIV- acetylcholine receptor partial agonist, vs placebo or sustained-release bupropion for smoking cessation: A randomized controlled trial. JAMA 2006;296(1):56-63. negative veterans. Chest 2006;130(5):1326-1333. [http://dx.doi.org/10.1378/chest.130.5.1326] [http://dx.doi.org/10.1001/jama.296.1.56] (Multi-centre, comparative, RCT; non-US 6. van Zyl-Smit RN, Pai M, Yew WW, et al. Global lung health: The colliding epidemics of government research support) tuberculosis, tobacco smoking, HIV and COPD. Eur Respir J 2010;35(1):27-33. [http://dx.doi. 29. Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. org/10.1183/09031936.00072909] Cochrane Database Syst Rev 2012;4:CD006103. [http://dx.doi.org/10.1002/14651858. 7. Sitas F, Egger S, Bradshaw D, et al. Differences among the coloured, white, black, and CD006103.pub6] (Meta-analysis review; non-US government research support) other SouthAfrican populations in smoking-attributed mortality at ages 35-74 years: A case- 30. Brose LS, West R, Stapleton JA. Comparison of the effectiveness of varenicline and control study of 481 640 deaths. Lancet 2013;382(9893):685-693. [http://dx.doi.org/10.1016/ combination nicotine replacement therapy for smoking cessation in clinical practice. S0140-6736(13)61610-4] (Non-US government research support) Mayo Clin Proc 2013;88(3):226-233. [http://dx.doi.org/10.1016/j.mayocp.2012.11.013] 8. Jha P, Ramasundarahettige C, Landsman V, et al. 21st-century hazards of smoking and 31. West R, Zatonski W, Cedzynska M, et al. Placebo-controlled trial of cytisine for smoking benefits of cessation in the United States. N Engl J Med 2013;368(4):341-350. cessation. N Engl J Med 2011;365(13):1193-1200. [http://dx.doi.org/10.1056/NEJMoa1102035] [http://dx.doi.org/10.1056/NEJMsa1211128] (Non-US government and US National Institutes (RCT; non-US government research support) of Health (NIH) extramural research support) 32. Fagerstrom K, Hughes J. Varenicline in the treatment of tobacco dependence. 9. Groenewald P, Vos T, Norman R, et al. Estimating the burden of disease attributable to Neuropsychiatr Dis Treat 2008;4(2):353-363. smoking in South Africa in 2000. S Afr Med J 2007;97(8):674-681. 33. Pfizer Laboratories (Pty) Ltd. CHAMPIX Tablet range package insert South Africa. 2010. 10. Tobacco Atlas Online. http://www.tobaccoatlas.org (accessed 1 October 2013). 34. US Food and Drug Administration. FDA drug safety communication: Safety review update 11. Warnier MJ, van Riet EE, Rutten FH, et al. Smoking cessation strategies in patients with of Chantix (varenicline) and risk of neuropsychiatric adverse events, 2011. [http://www.fda. COPD. Eur Respir J 2013;41(3):727-734. [http://dx.doi.org/10.1183/09031936.00014012] gov/Drugs/DrugSafety/ucm276737.htm (accessed 1 October 2013). 12. Rollnick S, Butler CC, Kinnersley P, et al. Motivational interviewing. BMJ 2010;340:c1900. 35. Tsoi DT, Porwal M, Webster AC. Interventions for smoking cessation and reduction in [http://dx.doi. org/10.1136/bmj.c1900] individuals with schizophrenia. Cochrane Database Syst Rev 2013;2:CD007253.

PAGE 30 OHASA JOURNAL research

[http://dx.doi.org/10.1002/14651858. CD007253.pub3] (Meta-analysis; non-US government 2009;201(4):354.e1-354.e7. [http://dx.doi.org/10.1016/j.ajog.2009.06.006] (RCT; NIH review research support) extramural ad non-US government research support) 36. Svanstrom H, Pasternak B, Hviid A. Use of varenicline for smoking cessation and risk of 58. UK NICE. Smoking Cessation Services in Primary Care, Pharmacies, Local Authorities and serious cardiovascular events: Nationwide cohort study. BMJ 2012;345:e7176. Workplaces, Particularly for Manual Working Groups, Pregnant Women and Hard to Reach [http://dx.doi.org/10.1136/bmj.e7176] Communities. London: NICE, 2008. http://www.nice.org.uk/nicemedia/pdf/ph010guidance. 37. Singh S, Loke YK, Spangler JG, et al. Risk of serious adverse cardiovascular events pdf (accessed 1 October 2013). associated with varenicline: A systematic review and meta-analysis. CMAJ 59. Reddy S.P, James S, Sewpaul R, et al. Umthente Uhlaba Usamila – The 2nd South African 2011;183(12):1359-1366. [http://dx.doi.org/10.1503/cmaj.110218] (Meta-analysis; NIH National Youth Risk Behaviour Survey 2008. Cape Town: South African Medical Research extramural review research support) Council, 2010. http://www.mrc.ac.za/healthpromotion/yrbs_2008_final_report.pdf 38. Sobieraj D. Cardiovascular effects of pharmacological therapies for smoking cessation. (accessed 1 October 2013). J Am Soc Hypertens 2013;7(1):61-67. [http://dx.doi.org/10.1016/j.jash.2012.11.003] 60. Panday S, Reddy SP, Bergstrom E. A qualitative study on the determinants of smoking 39. Deyton L, Woodcock J. Regulation of E-Cigarettes and Other Tobacco Products. Public behaviour among adolescents in South Africa. Scand J Public Health 2003;31(3):204-210. Health Focus, 25 April 2011. http://www.fda.gov/NewsEvents/PublicHealthFocus/ [http://dx.doi.org/10.1080/14034940210164885] ucm252360.htm] (accessed 1 October 2013). 61. Panday S, Reddy P, Ruiters R, et al. Determinants of smoking among adolescents in the 40. Flouris AD, Poulianiti KP, Chorti MS, et al. Acute effects of electronic and tobacco cigarette Southern Cape-Karoo region, South Africa. Health Promot Int 1997;22(3):207-217. smoking on complete blood count. Food Chem Toxicol 2012;50(10):3600-3. 62. Brook JS, Morojele NK, Brook DW, et al. Predictors of cigarette use among South [http://dx.doi.org/10.1016/j.fct.2012.07.025] African adolescents. Int J Behav Med 2005;12(4):207-217. [http://dx.doi.org/10.1207/ 41. Polosa R, Caponnetto P, Morjaria JB, et al. Effect of an electronic nicotine delivery device s15327558ijbm1204_1] (NIH extramural and PHS government research support) (e-cigarette) on smoking reduction and cessation: A prospective 6-month pilot study. BMC 63. Foulds J. Smoking Cessation in Young People Should we do more to help young Public Health 2011;11:786. [http://dx.doi.org/10.1186/1471-2458-11-786] (Clinical trial; non-US smokers to quit? London: NICE, 2000. [http://www.nice.org.uk/nicemedia/documents/ government research support) smokingcessation_youngpeople.pdf (accessed 1 October 2013). 42. Caponnetto P, Auditore R, Russo C, et al. Impact of an electronic cigarette on smoking 64. Farkas AJ, Distefan JM, Choi WS, et al. Does parental smoking cessation discourage reduction and cessation in schizophrenic smokers: A prospective 12-month pilot study. Int J Environ Res Public Health 2013;10(2):446-461. [http://dx.doi.org/10.3390/ijerph10020446] adolescent smoking? Prev Med 1999;28(3):213-218. [http://dx.doi.org/10.1006/ 43. Bahl V, Lin S, Xu N, et al. Comparison of electronic cigarette refill fluid cytotoxicity using pmed.1998.0451] (PHS government research support) embryonic and adult models. Reprod Toxicol 2012;34(4):529-537. [http://dx.doi.org/10.1016/j. 65. Bates MN, Khalakdina A, Pai M, et al. Risk of tuberculosis from exposure to tobacco reprotox.2012.08.001] (Non-US government research support) smoke: A systematic review and meta-analysis. Arch Intern Med 2007;167(4):335-342. 44. Vardavas CI, Anagnostopoulos N, Kougias M, et al. Short-term pulmonary effects of using 66. Slama K, Chiang CY, Enarson DA, et al. Tobacco and tuberculosis: A qualitative systematic an electronic cigarette: Impact on respiratory flow resistance, impedance, and exhaled review and meta-analysis. Int J Tuberc Lung Dis 2007;11(10):1049-1061. nitric oxide. Chest 2012;141(6):1400-1406. [http://dx.doi.org/10.1378/chest.11-2443] (Non-US 67. Lin HH, Ezzati M, Murray M. Tobacco smoke, indoor air pollution and tuberculosis: A government research support) systematic review and meta-analysis. PLoS Med 2007;4(1):e20. 45. Hartmann-Boyce J, Cahill K, Hatsukami D, et al. Nicotine vaccines for smoking cessation. [http://dx.doi.org/10.1371/journal.pmed.0040020] Cochrane Database Syst Rev 2012;8:CD007072. [http://dx.doi.org/10.1002/14651858. 68. Brunet L, Pai M, Davids V, et al. High prevalence of smoking among patients with CD007072.pub2] (Meta-analysis review) suspected tuberculosis in South Africa. Eur Respir J 2010;38(1):139-146. 46. Tahiri M, Mottillo S, Joseph L, et al. Alternative smoking cessation aids: A meta-analysis of [http://dx.doi.org/10.1183/09031936.00137710] randomized controlled trials. Am J Med 2012;125(6):576-584. [http://dx.doi.org/10.1016/j. 69. Sereno AB, Soares EC, Lapa ESJR, et al. Feasibility study of a smoking cessation amjmed.2011.09.028] (Meta-analysis; non-US government research support) intervention in Directly Observed Therapy Short-Course tuberculosis treatment clinics in 47. Barnes J, Dong CY, McRobbie H, et al. Hypnotherapy for smoking cessation. Cochrane Rio de Janeiro, Brazil. Rev Panam Salud Publica 2012;32(6):451-456. (Non-US government Database Syst Rev 2010(10):CD001008. [http://dx.doi.org/10.1002/14651858.CD001008. research support) pub2] (Meta-analysis review) 70. Awaisu A, Nik Mohamed MH, Mohamad Noordin N, et al. The SCIDOTS Project: Evidence of 48. White AR, Rampes H, Liu JP, et al. Acupuncture and related interventions for smoking benefits of an integrated tobacco cessation intervention in tuberculosis care on treatment cessation. Cochrane Database Syst Rev 2011(1):CD000009. outcomes. Subst Abuse Treat Prev Policy 2011;6:26. [http://dx.doi.org/10.1186/1747- [http://dx.doi.org/10.1002/14651858.CD000009.pub3] (Meta-analysis review) 597X-6-26] (Multi-centre, controlled clinical trial; non-US government research support) 49. Law M, Tang JL. A n analysis of the effectiveness of interventions intended to help people 71. van Zyl-Smit RN, Dheda K. Partners in crime: The deadly synergy of tuberculosis and stop smoking. Arch Intern Med 1995;155(18):1933-1941. (Non-US government review tobacco smoke? Mycobacterial Diseases 2012;2:2. [http://dx.doi.org/10.4172/2161- research support) 1068.1000e111] 50. Ter Riet G, Kleijnen J, Knipschild P. A meta-analysis of studies into the effect of acupuncture 72. Lifson AR, Lando HA. Smoking and HIV: Prevalence, health risks, and cessation strategies. on addiction. Br J Gen Pract 1990;40(338):379-382. Curr HIV/AIDS Rep 2012;9(3):223-230. [http://dx.doi.org/10.1007/s11904-012-0121-0] (Review) 51. American College of Obstetricians and Gynecologists. Committee opinion no. 471: Smoking 73. Ferketich AK, Diaz P, Browning KK, et al. Safety of varenicline among smokers enrolled cessation during pregnancy. Obstet Gynecol 2010;116(5):1241-1244. in the lung HIV study. Nicotine Tob Res 2013;15(1):247-254. [http://dx.doi.org/10.1093/ntr/ [http://dx.doi.org/10.1097/AOG.0b013e3182004fcd] nts121] 52. Salmasi G, Grady R, Jones J, et al. Environmental tobacco smoke exposure and perinatal 74. Rahmanian S, Wewers ME, Koletar S, et al. Cigarette smoking in the HIV-infected outcomes: A systematic review and meta-analyses. Acta Obstet Gynecol Scand population. Proc Am Thorac Soc 2011;8(3):313-319. [http://dx.doi.org/10.1513/pats.201009- 2010;89(4):423-441. [http://dx.doi.org/10.3109/00016340903505748] (Meta-analysis; non- 058WR] (NIH extramural and non-US government research support) US government review research support) 75. Zevin S, Benowitz NL. Drug interactions with tobacco smoking. An update. Clin 53. England LJ, Kendrick JS, Wilson HG, et al. Effects of smoking reduction during pregnancy Pharmacokinet 1999;36(6):425-438. (PHS government review research support) on the birth weight of term infants. Am J Epidemiol 2001;154(8):694-701. (Clinical RCT; PHS 76. Kalow W, Tang BK. Caffeine as a metabolic probe: Exploration of the enzyme-inducing government research support) 54. Cook DG, Strachan DP. Health effects of passive smoking – 10: Summary of effects of effect of cigarette smoking. Clin Pharmacol Ther 1991;49(1):44-48. (PHS government and parental smoking on the respiratory health of children and implications for research. non-US government research support) Thorax 1999;54(4):357-366. (Review) 77. van der Meer RM, Willemsen MC, Smit F, et al. Smoking cessation interventions for 55. Everett-Murphy K, Steyn K, Mathews C, et al. The effectiveness of adapted, best practice smokers with current or past depression. Cochrane Database Syst Rev 2013;8:CD006102. guidelines for smoking cessation counseling with disadvantaged, pregnant smokers [http://dx.doi.org/10.1002/14651858.CD006102.pub2]. attending public sector antenatal clinics in Cape Town, South Africa. Acta Obstet Gynecol 78. Ziedonis D, Hitsman B, Beckham JC, et al. Tobacco use and cessation in psychiatric Scand 2010;89(4):478-489. [http://dx.doi.org/10.3109/00016341003605701] (Non-US disorders: National Institute of Mental Health report. Nicotine Tob Res 2008;10(12):1691- government review research support) 1715. [http://dx.doi.org/10.1080/14622200802443569] (NIH extramural and non-US 56. Windsor R, Oncken C, Henningfield J, et al. Behavioral and pharmacological treatment government research support). methods for pregnant smokers: Issues for clinical practice. J Am Med Womens Assoc 79. Moylan S, Gustavson K, Karevold E, et al. The impact of smoking in adolescence on early 2000;55(5):304-310. (PHS government research support) adult anxiety symptoms and the relationship between infant vulnerability factors for anxiety 57. Swamy GK, Roelands JJ, Peterson BL, et al. Predictors of adverse events among pregnant and early adult anxiety symptoms: The TOPP Study. PLoS One 2013;8(5):e63252. [http:// smokers exposed in a nicotine replacement therapy trial. Am J Obstet Gynecol dx.doi.org/10.1371/journal.pone.0063252] (Non-US government research support).

2nd quarter 2021 • volume 22 no. 2 PAGE 31 research

80. Rigotti NA, Clair C, Munafo MR, et al. Interventions for smoking cessation in 83. Buist AS, Sexton GJ, Nagy JM, et al. The effect of smoking cessation and modification on hospitalised patients. Cochrane Database Syst Rev 2012;5:CD001837. [http://dx.doi. lung function. Am Rev Respir Dis 1976;114(1):115-122. (PHS government research support). org/10.1002/14651858.CD001837.pub3] (Meta-analysis; NIH extramural and non-US 84. Beckers S, Camu F. The anesthetic risk of tobacco smoking. Acta Anaesthesiol Belg government review research support). 1991;42(1):45-56. (Review). 81. Sorensen LT, Karlsmark T, Gottrup F. Abstinence from smoking reduces incisional 85. Heatherton TF, Kozlowski LT, Frecker RC, et al. The Fagerström test for Nicotine wound infection: A randomized controlled trial. Ann Surg 2003;238(1):1-5. [http://dx.doi. Dependence: A revision of the Fagerström Tolerance Questionnaire. Br J Addict org/10.1097/01. SLA.0000074980.39700.31] (Comparative, clinical RCT; non-US government 1991;86(9):1119-1127. research support). 86. Fagerström K, Russ C, Yu CR, et al. The Fagerström Test for Nicotine Dependence as 82. Moller AM, Villebro N, Pedersen T, et al. Effect of preoperative smoking intervention on a predictor of smoking abstinence: A pooled analysis of varenicline clinical trial data. postoperative complications: A randomised clinical trial. Lancet 2002;359(9301):114-117. Nicotine Tob Res 2012;14(12):1467-1473. [http://dx.doi.org/10.1093/ntr/nts018] (Clinical phase [http://dx.doi.org/10.1016/S0140-6736(02)07369-5] (Multi-centre, clinical RCT; non-US II RCT; non-US government research support). government research support).

news from Gauteng branch

Dear delegates We have entered the second half of the year and colder months are evidently upon us, but I hope you are all well andhaving a prosperous year so far. OHASA Gauteng would like to thank you all for the continued support over the years and especially during thesetrying times that the world is facing with the COVID-19 pandemic and economic struggles being faced by many. Your emotional and physical well being is more important to keep in mind and we hope that you all are taking care ofyourselves and your loved ones.

EVENTS: We are happy to announce that the branch will be hosting a face-to-face seminar at Centurion Golf Estate on the 21st of August 2021 for a limited number of delegates. As you all know, we need to adhere to the national COVID-19protocols, therefore it is going to be of utmost importance that we keep all our members, speakers and guests safe atthe seminar. Masks will be mandatory, sanitizers will be provided, and we will be maintaining social distancing during the seminar. The official invite will be sent in due course and will be open to the 1st 110 delegates who register to attend, so pleasekeep an eye on your emails.

Reminders and hyperlinks to assist you: • Please ensure that your HPCSA membership fees have been paid as it is illegal to practice if your membershipfees are not paid and up to date. • Visit the OHASA website weekly (www.ohasa.co.za) and upload and read up on interesting articles that are ofinterest to you, view your account balance and invoices, access your membership certificate, pay yourregistration fees online, view our CPD points, access journals and earn CPD points. • Certificates for SADA webinars that you have attended can be found on the SADA website. Please create aprofile (you do not need to be a SADA member to create this) and download your certificates and upload themto your HPCSA profile: • SADA Certificate link: https://join.mymembership.co.za/Join/Index?communityId=2369e42c-80c7-4c1b-9181-be4f22dc2429 • Please note that it is mandatory to manually upload your CPD certificates to the HPCSA website as you will beaudited and you need to remain compliant: • CPD Manual (Click this hyperlink to access this manual with instructions on how to upload the CPD pointsyourself)

We look forward to assisting you with your career development and upliftment and should you have a request orquery, kindly email the branch for more assistance.

Kind regards Mmakaoka Kaokie Sepuru OHASA Gauteng Chairperson

PAGE 32 OHASA JOURNAL Nicorette 2021_QuickMist_OHASA Ad_FA-01_txtcvs.indd 1 2021/05/25 08:58 ohasa news

UNIVERSITY UPDATE UWC Update

As part of clinical outcomes, the final year Oral Hygiene (BOH 111) students have to perform and practice tooth whitening procedures. This is the opportunity to translate theoretical knowledge of teeth whitening techniques into clinical practice, and was made possible using two different products, demonstrated by expert representatives from two different companies.

Orientation Oops! I am not sure! Process begins

Totally comfortable Application of gel ....

Watch this space

UWC will be offering expanded functions: Watch this space!

So thrilled with results

PAGE 34 OHASA JOURNAL 23/05/2021 Gmail - ISDH 2022 Call For Abstracts

stella lamprecht

ISDH 2022 Call For Abstracts 1 message 23/05/2021 Gmail - ISDH 2022 Call For Abstracts OHASA No reply Wed, May 5, 2021 at 4:56 AM Reply-To: OHASA Admin To: Stella Pascale stella lamprecht

ISDH 2022 Call For Abstracts 1 message

OHASA No reply Wed, May 5, 2021 at 4:56 AM Reply-To: OHASA Admin To: Stella Pascale call for abstracts

Dear Ms Stella Pascale, ISDH 2022 Call For Abstracts Dear Ms Stella Pascale,

Call For Abstracts Now Open

Call For Abstracts Now OpenOn behalf of the Scientific Committee, I am delighted to announce the launch of the Call for Abstracts for the International Symposium on Dental Hygiene 2022. We invite colleagues from the international dental hygiene community to submit abstracts forOn consideration behalf of for the the Scientific oral and poster Committee, sessions at theI am Symposium delighted in Dublin, to announce Ireland. Oral the and launchposter sessions of the will Call be heldfor Abstracts for the onInternational Thursday 11th, Friday 12 Symposiumth and Saturday on Dental 13th of August Hygiene 2022. 2022. We invite colleagues from the international dental hygiene On behalfcommunity of the Scientific to submit Committee, abstracts I am for delighted consideration to announce for thethe launchoral and of the poster Call for sessions Abstracts at for the the Symposium in Dublin, InternationalThe oral and Symposium poster presentation on Dental sessions Hygiene are an2022. opportunity We invite to share colleagues research, from learn the new international concepts, network dental andhygiene exchange communityideas,Ireland. and to stay Oralsubmit current and abstracts on poster relevant for sessionsinformation. consideration Researchwill forbe the heldpresented oral on and Thursdayshould poster pertain sessions 1 to1th, the atthemeFriday the ofSymposium the12th symposium; and in Saturday Dublin, “The future 13th of August 2022. Ireland.in our Oralhands” and and poster be significant sessions to will advancing be held the on dental Thursday hygiene 11th, body Friday of knowledge. 12th and Saturday 13th of August 2022. The deadline for abstract submissions is 1st October 2021 after which date the abstracts will go for review. We look forward Dr. Catherine Waldron to receiving your submission. The oral and poster presentation sessions are an opportunity to share research, learn new concepts, network and exchange ideas, and The oral and poster presentation sessions are an opportunity to share research, learn new concepts, network and exchange ideas, and staystay currentcurrent on on relevant relevant information. information. Research Research presented presented should pertain should to the pertain theme toof thethe symposium; theme of the“The symposium; future in our hands” “The andfuture be in our hands” and be significantsignificant to to advancing advancing the thedental dental hygieneClick hygiene body here of forbody knowledge. further of knowledge. information on our Call for Abstracts TheThe deadlinedeadline for for abstract abstract submissions submissions is 1st Octoberis 1st October 2021 after 2021 which after date thewhich abstracts date willthe go abstracts for review will. go for review. Why should you attend ISDH 2022? WWISDHee looklook 2022 forwardforward will provide to toreceiving onereceiving space your to yourconnectsubmission. submission. with leaders in the world of Dental Hygiene in a relaxed atmosphere in the spirit of sharing their expertise to Drinspire. Catherine and grow W aldronnational dental hygienist associations. Meeting like-minded individuals in an atmosphere of commonality is always the perfect recipe for DrChairpersonrejuvenating. Catherine our of theWmindsaldron Scientific and skills Committee to enrich our ISDH careers. 2022 Chairperson of the Scientific Committee ISDH 2022 We look forward to welcoming you to Dublin at the International Symposium on Dental Hygiene 2022!

To view our preliminary programme We are happy to announce some of our important dates Click below to see our exciting Why shouldplease you attend click below ISDH 2022? and deadline. Click below for more details Invited Speakers ISDH 2022 will provide one space to connect with leaders in the world of Dental Hygiene in a relaxed atmosphere in the spirit of sharing Whytheir shouldexpertiseISDH you to Programme inspire attend and ISDH grow 2022?national dental hygienistImportant associations. Dates & D Meetingeadlines like-minded individuals in anInvited atmosphere Speakers of commonality ISDHis always 2022 the will perfect provide recipe one for rejuvenating space to connect our minds with and leadersskills to enrich in the our world careers. of Dental Hygiene in a relaxed atmosphere in the spirit of sharing their expertise to inspire and grow national dental hygienist associations. Meeting like-minded individuals in an atmosphere of commonality WBooe lookk Your forward Spon tos orwelcomingship Pack youage to f Dublinor ISDH at 2022 the is always the perfect recipe for rejuvenating our minds and skills to enrich our careers. InternationalHave you considered Symposium your place on Dental at ISDH2022? Hygiene Ensure 2022! your brand is at the global gathering of the dental hygiene community. Secure a package that provides you with a dedicated session within the programme. Demonstrate your organisation's support for education. There are limited options for prime exhibition WeT olook view forward our preliminary to welcoming programme you toW Dubline are happy at the to announce some of our important dates Click below to see our exciting locations in the main floor. Contact us today Internationalplease Symposium click below. on Dental Hygieneand 2022! deadline. Click below for more details. Invited Speakers.

Sponshorship & Exhibition Opportunities To view our preliminary programme We are happy to announce some of our important dates Click below to see our exciting

ISDH 2022 pleasewith than clickks tobelow our .sponsors and deadline. Click below for more details. Invited Speakers.

Diamond sponsor https://mail.google.com/mail/u/0?ik=0989e09399&view=pt&search=all&permthid=thread-f%3A1698885415631874322&simpl=msg-f%3A1698885 … 1/2 Learn more about Sponsorships @ ISDH2022 https://mail.google.com/mail/u/0?ik=0989e09399&view=pt&search=all&permthid=thread-f%3A1698885415631874322&simpl=msg-f%3A1698885Silver sponsor Support from … 1/2 curaden better health for you

2nd quarter 2021 • volume 22 no. 2 PAGE 35

University

faculty of health sciences 47th annual awards ceremony Oral Hygienists’ Association of South Africa PO Box 830 Newlands 0049 Fax: 086 696 7313 E-mail: [email protected] www.ohasa.co.za