Interventions for tobacco cessation in the dental setting

Analysis of Tobacco Cessation Programs in Dental Settings

Background

Tobacco use is a leading cause of preventable diseases, including oral cancer and periodontal disease. Dental settings offer a unique opportunity for tobacco cessation interventions due to the frequent patient-dentist interactions.

Materials and Methods

A randomized controlled trial was conducted across 20 dental clinics. Participants included 400 adult tobacco users who were randomly assigned to either an intervention group (n = 200) or a control group (n = 200). The intervention group received a comprehensive tobacco cessation program consisting of behavioral counseling, nicotine replacement therapy, and follow-up sessions over 6 months. The control group received standard care, which included general advice on quitting tobacco. Data on tobacco use, quit rates, and oral health status were collected at baseline, 3 months, and 6 months. Statistical analysis was performed using SPSS 24.0, and significance was set at P < 0.05.

Results

At 6 months, the intervention group showed a significantly higher quit rate (45%) compared to the control group (20%) (P < 0.001). Additionally, participants in the intervention group exhibited significant improvements in oral health parameters, including reductions in periodontal pocket depths (a mean reduction of 2.5 mm) and improvements in gingival health scores. Satisfaction with the program was high among participants in the intervention group, with 85% reporting they would recommend the program to others.

Conclusion

The tobacco cessation program implemented in dental settings significantly increased quit rates and improved oral health outcomes compared to standard care. These findings suggest that integrating tobacco cessation programs into routine dental practice can effectively reduce tobacco use and enhance oral health.

Tooth loss mediates the association between smoking and an increased risk of dementia among older adults: The JAGES prospective cohort study

AIM

Tooth loss has various causes; however, its cause-specific effects on health outcomes remain unclear. This study evaluated whether the association between past/current smoking and risk of dementia was mediated by tooth loss.

MATERIALS AND METHODS

This 9-year-follow-up prospective cohort study targeted adults aged ≥65 years. Dementia incidence during 2013-2019, smoking status (never, past/current) in 2010 and the number of remaining teeth (≤19, ≥20) in 2013 were the outcome, exposure and mediator, respectively. We used causal mediation analysis to fit the Cox proportional hazards model and estimated the hazard ratio (HR) and 95% confidence interval (CI) of the natural indirect effect (NIE) of smoking on dementia incidence through tooth loss and their mediated proportions.

RESULTS

Among 32,986 participants (mean age 72.6 years [1 SD = 5.4]; men 48.4%), the dementia incidence during follow-up was 2.11/100 person-years. Tooth loss significantly mediated the association between past/current smoking and dementia incidence; the NIE of fewer remaining teeth for past/current smokers compared to never smokers was HR = 1.03 (95% CI: 1.02-1.05), and the mediated proportion was 18.0%.

CONCLUSIONS

Tooth loss significantly mediates the association between past/current smoking and an increased risk of dementia among older adults.

Impact of an educational intervention regarding tobacco counseling on dentists and dental students

The present study aimed to assess the knowledge, attitudes, and perceptions of dental professionals and students regarding tobacco cessation counseling (TCC) after their participation in a continuing education activity (CEA) entitled "Smoking cessation: How does the dentist participate in this decision?" at the Oral Cancer Seminar: Projeto Maio Vermelho 2021. This study utilized a pre-/post-intervention design, including a pre-intervention questionnaire with 20 close-ended questions, an educational intervention, and a post-intervention questionnaire with nine close-ended questions. Descriptive and statistical analyses were performed using SPSS 25 and GraphPad Prism 8 software. The significance level was set at p = 0.05. A total of 94 participants answered the pre-intervention questionnaire and 52 answered both the pre- and post-intervention questionnaires. Most participants reported regularly asking about smoking status (96.8%), providing advice on tobacco risks (96.8%), and offering some counseling to help patients stop smoking (84.0%). Although participants habitually ask about cigarette use, other forms of tobacco consumption are frequently overlooked. Most participants reported never having attended TCC training during their undergraduate studies (67.0%) or after graduation (71.2%). However, 96.2% showed interest in attending TCC training. The perception that motivational counseling by dentists can encourage patients to stop smoking rose from 87.5 to 98.2% (p<0.05) after the educational intervention. In addition, participants' self-confidence in conducting TCC increased from 8.9% to 23.3% (p<0.01). The brief CEA on TCC showed favorable outcomes, enhancing the perception of dentists and undergraduate dental students regarding the effectiveness of counseling for smoking cessation and boosting their self-confidence in providing tobacco counseling.

Smoking Cessation Counseling: Practices, Determinants, and Barriers in a Sample of Iranian Primary Care Dentists

Objectives: Despite the successful tobacco smoking cessation counseling (TSCC) efforts of dental professionals, Iranian primary care dentists have not fully utilized their potential for TSCC provision. Thus, this study assessed the TSCC practices and their associations with socio-professional attributes, knowledge, and attitude, and explored the TSCC barriers and their socio-professional determinants in a sample of Iranian primary care dentists. Materials and Methods: This cross-sectional study was conducted at Comprehensive Healthcare Centers (CHCs) in Tehran Province, Iran from March to June 2019. All dentists practicing in these centers (n=190) completed self-administered questionnaires regarding TSCC-related knowledge, attitude, practice, and barriers. Simple and multiple linear regression and multiple logistic regression tests were used for statistical analyses. Results: The respondents (n=180, response rate=93%) were predominantly females (81.6%), recent graduates (69.6%), and non-cigarette smokers (90.2%), with a mean age of 34±9.98 years. Most performed 'Ask' (90.6%) and 'Advise' (69.1%), while a few were engaged in 'Assess' (33.7%) and fewer in 'Assist,' with 21.3% making physician referrals and 31.5% making psychologist referrals. Non-smokers (B=0.80, 95% CI: 0.19 to 1.40; P=0.01), and those with a more positive attitude (B=0.06, 95% CI: 0.04 to 0.08; P< 0.001) were more likely to provide TSCC. The main identified barriers included "absence of educational resources for patients", "time constraints", and "lack of patient cooperation. Conclusion: Although the selected sample of Iranian primary care dentists performed "Ask" and "Advise" more frequently than their peers, their TSCC practice required further improvement through simplified guidelines, customized pathways, training, team work, and resource advocacy.

The Impact of Nicotine Patches on Gingival and Oral Health: A Narrative Review

Smoking significantly impacts oral health, causing periodontal disease, oral cancer, tooth discoloration, halitosis, and impaired wound healing. Nicotine replacement therapy (NRT), particularly nicotine patches, is widely used for smoking cessation. This review evaluates the literature regarding nicotine patches and their implications for oral and gum health. Nicotine patches deliver controlled nicotine doses transdermally, alleviating cravings and withdrawal symptoms. While nicotine can negatively affect oral health through vasoconstriction and reduced salivary flow, the overall impact of patches is generally positive compared to continued smoking. The primary benefit is the elimination of exposure to harmful chemicals and heat from cigarette smoke, significantly decreasing oral cancer risk and periodontal disease progression. Nicotine patches are associated with improved periodontal treatment outcomes, better wound healing, and potential anti-inflammatory effects. They may also promote improved oral hygiene practices. However, limitations include uncertain long-term effects and potential side effects like xerostomia. In conclusion, while nicotine patches may have some oral health effects, their use generally leads to significant improvements compared to continued smoking, making them valuable for promoting better oral health in individuals quitting smoking.

How to have healthy conversations: Contemporary Evidence and Behaviour Change Tools in support of Delivering Better (Oral) Health

The aim of this paper is to provide dental professionals with insight into how the science of behaviour change can be used to support patients to change their oral health behaviours. The paper describes how the fourth version of Delivering Better Oral Health (DBOHv4) published in November 2021, brings together the theory plus key principles and practical tools in Chapter 3 "Behaviour change", to help front-line clinicians achieve the best effect. DBOH is freely available to all online at gov.uk and is a key resource for dental teams for the prevention of oral diseases.

The ISAC Paradigm to Tame Oral Cancer in Saudi Arabia: A Quasi-experimental Study

Late detection of oral cancer (OC) cases in Saudi Arabia is concerning. It reduces survival rate and complicates treatment. The ISAC intervention was developed to bridge the gaps observed in dentists' practice of OC examination and patient education. The ISAC stands for I, informing patients of OC screenings; S, screening for OC; A, advising high-risk patients to quit risk factors; and C, connecting patients to advanced services. This study tested the potential effect of the ISAC in influencing dentists' cognitive and behavioral skills, to enhance early detection and prevention of OC. A quasi-experimental study was conducted among dental interns (DIs) at dental setting to test the effect on comprehensive oral cancer examination score (COCE), awareness, self-efficacy, descriptive-norms, and self-reported behavior. Data were collected through triangulation of methods pre and post the intervention at two-months. Multiple linear mixed effects regression models were utilized for data analysis. Between October 2020 and April 2021, 47 DIs participated in the study. The final model showed the significant effects of time (ISAC) on COCE (95% CI = 25.12-29.42, P < .001). DIs had a significant improvement in awareness, self-efficacy, descriptive norms, and self-reported behavior. The findings showed promising effects of the intervention toward the early detection and prevention of OC. Dentists, dental organizations, and policymakers in areas with a high risk of OC could benefit from the current intervention which contributes to capacity building and improved community health. A pragmatic study with a robust design is needed to test the effectiveness of the intervention on a wider scale.

Behavioural interventions for tobacco cessation in India: A systematic review and meta-analysis

Tobacco consumption is an area of public health concern in India. One of the unmet needs of many low-resource countries is to provide cost-effective tobacco cessation interventions for reducing tobacco-related mortality. This article reviews studies on non-pharmacological interventions for tobacco cessation in India. A systematic review by PICO (population, intervention, comparison, outcome) of behavioural intervention-based tobacco cessation studies that met the inclusion criteria, with a minimum 1-month follow-up, reporting outcomes in terms of frequencies or percentages published between 2010 and 2020 was performed. Following the review stages, 16 studies comprising 9,613 participants were included in the review. A pooled estimate was derived using both fixed-effects and random-effects models. The intervention showed good overall efficacy for any tobacco user (relative risk [RR] = 1.73 [95% confidence interval [CI]: 1.58-1.90) (fixed-effect model)] and (RR = 2.02 [95% CI: 1.64-2.48] [random-effects model]). Behavioural intervention studies targeted towards only smokers (RR of 1.81 [95% CI: 1.55-2.11] and 1.96 [95% CI: 1.52-2.53]) and combined smoking and smokeless tobacco users (RR of 1.69 [95% CI: 1.50-1.90] and 2.12 [95% CI: 1.49-3.01]) were equally efficacious. The review provides the effectiveness of behavioural interventions in quitting tobacco among users of both smoking and smokeless forms of tobacco. The review findings are of particular significance to inform health policy decisions on the integration of cost-effective brief behavioural intervention into existing health care services in resource-constrained countries.

Smoking cessation in dental setting: a narrative review on dental professionals' attitude, preparedness, practices and barriers

Integration of smoking cessation program into routine oral health care has been advocated by World Health Organization since it brings extensive benefits to oral health. By tobacco cessation, patients are less prone to progression of periodontal disease, have less future tooth loss, have reduced risks of oral mucosal lesions and head and neck cancers. Evidence indicates that dentists are in a favorable position to deliver effective smoking cessation advice to improve patients' oral health. This article aims to present the current situation of smoking cessation in dental setting, including dental management of smoking patients, perceptions of dentists and dental students towards smoking cessation, challenges dental professionals face when carrying out cessation interventions. Patients' perspectives are also evaluated to provide a clearer picture of smoking cessation practice in the dental field. Review of past surveys show most patients welcome smoking cessation advice from dental practitioners. Meanwhile dentists may have wrong assumption that patients would disapprove them if they advise patient to quit smoking. On top of that, main obstacles identified are lack of training, inadequate treatment time and insufficient knowledge towards smoking cessation guidelines and referral routes. With regard to the potential barriers, evidence demonstrates that more trainings on smoking cessation strategies are needed. Future research in this aspect is also indicated to further foster the practice of smoking cessation counselling in dental setting.

Behavioural and cognitive-behavioural theories in oral health research: Current state and future directions

OBJECTIVES

Behavioural and cognitive-behavioural theories, models and frameworks have been incorporated for decades in behavioural and social oral health sciences, oral health care, and education of dentists, hygienists, and other oral healthcare professionals.

METHODS

While a myriad of these conceptualizations have been incorporated in this work, there are six of them that have had the greatest impact in the oral health arena: (a) Health Belief Model; (b) Theory of Reasoned Action, Theory of Planned Behavior and Integrated Behavioral Model, which are considered in unison; (c) Social Learning Theory and Social Cognitive Theory which are considered together; (d) Transtheoretical Model/Stages of Change Model; (e) Salutogenesis Model/Theory and Sense of Coherence Framework; and the (f) Behavior Change Wheel, Capability-Opportunity-Motivation-Behavior Model and Theoretical Domains Framework, which are categorized together.

RESULTS

An analysis of nomenclature (i.e. theories, models, frameworks and conceptualizations) is provided in the context of a description of each of these theories and models, with discussion about their aspects that particularly relate to oral health. Additionally, a quantitative, longitudinal view is provided of the frequency of use of these theories and models in the oral health arena. Given the benefits of theory-based intervention development, dissemination and implementation, it is important to consider these theories and models in a collective context.

CONCLUSIONS

At a basic level, these theories and models help in identifying and acting on mechanisms, both of behaviour itself and behaviour change. Future directions are discussed in terms of need for theory evolution and development.

Behaviour change intervention for smokeless tobacco (ST) cessation delivered through dentists within a dental setting: a feasibility study protocol

Objectives/Aim

To adapt a structured behavioural support intervention for smokeless tobacco (ST) cessation and to assess the feasibility and acceptability of delivering the intervention via dentists within dental settings in Pakistan.

Material and methods

The study will have 3 phases: (1) Adapt a previously developed intervention to make it suitable for delivery in a clinical/dental setting through qualitative interviews with dental patients and dentists; (2) A multi-centre, pilot randomised control trial in two teaching dental hospitals in Pakistan. Participants (dental patients) will be randomly assigned to intervention or control group in a 1:1 allocation ratio to receive either a structured behavioural support intervention involving face to face counselling or self-help material plus usual care. Each participant will be in the study for approximately 6 months and the overall study is expected to run for 12 months; (3) An embedded qualitative process evaluation. All trial participants will be followed up at 3 and 6 months to assess self-reported ST use. Outcome measures will include: rates of eligibility, recruitment and retention, randomisation group cross-over rates, the provision of data on ST use behaviour, fidelity to the intervention and qualitative assessment of acceptability and feasibility.

Discussion

Despite the high use of ST in Pakistan, users are offered negligible cessation support. The findings of this multi-centre, mixed-method feasibility study will inform the scope for a larger trial on ST cessation delivered through the existing dental health system.

Effectiveness of Behavioral Counseling in Smokeless Tobacco Cessation Among Adult Users Reporting to a Dental Hospital in Pune: A Randomized Controlled Trial

Aim To assess the effectiveness of behavioral counseling for smokeless tobacco cessation among adult users in a dental hospital setting. Methods A total of 200 patients visiting a dental hospital who were exclusively using smokeless tobacco (SLT) were enrolled in the study. A randomized controlled trial with a concurrent parallel study design, which consisted of two arms, was conducted. Fagerstrom test for nicotine dependence level and the transtheoretical stage of change was assessed at the baseline. Behavioral cessation counseling and motivational interviewing were provided in the study arm and brief advice was given to those in the control arm. The counseling was provided at baseline and followed up till six months through telephone to assess the change in the frequency of use of SLT products and abstinence from SLT use. A biochemical validation with a urine cotinine test was done to confirm abstinence. Results At six months, there was a significant difference within and between the study and control groups, indicating the role played by behavioral tobacco cessation in reducing the frequency of consumption. About 24.4% of participants in the study group and 10% in the control group abstained from the habit at the sixth month, with an odd's ratio (OR)=2.91 and with a loss to follow-up of 10% in each of the groups. The cotinine test, which was used for validation, revealed a significant difference between the study and the control group. The number needed to treat (NNT) shows that to motivate one additional person to give up the SLT habit, we need to intervene with about seven people. Conclusion Behavior intervention with motivational interviewing was considered an effective method in promoting smokeless tobacco cessation among adults. Transtheoretical stages of change have proven to be an effective model to assess the stage of behavior change of the population toward SLT use and was also helpful for changing the behavior.

Systematic overview of systematic reviews and clinical guidelines: assessment and prevention of behavioural risk factors associated with oral cancer to inform dental professionals in primary care dental practices

Aims/objectives Tobacco and alcohol are recognised as the major modifiable risk factors for oral cancer, the incidence of which is rising globally and predicted to increase. This paper aimed to: 1) appraise and synthesise best practice evidence for assessing the major behavioural risk factors for oral cancer and delivering behaviour change interventions (for example, advice, counselling, signposting/referral to preventive services); and 2) assess appropriateness for implementation by dental professionals in primary care.Methods A systematic overview was undertaken of systematic reviews and international clinical guidelines. This involved: systematically searching and collating the international literature on assessing oral cancer risk and delivering preventive interventions within primary care; quality appraising and assessing the risk of bias using validated tools; synthesising the evidence for best practice; and assessing application of key findings to the dental setting.Results and conclusions There is clear evidence for the effectiveness of a 'brief', in-person, motivational intervention for sustained tobacco abstinence or reduced alcohol consumption, following risk factor assessment. Evidence for combined behavioural interventions is lacking. There is no firm conclusion with regards to optimal duration of brief interventions (range 5-20 minutes). For tobacco users, longer (10-20 minutes) and intensive (more than 20 minutes, with follow-up visits) interventions are more effective in increasing quit rates compared to no intervention; very brief (less than five minutes) interventions in a single session show comparable effectiveness to the longer/more intensive interventions. For alcohol users, 10-15-minute multi-contact interventions were most effective, compared to no intervention or very brief (less than five minutes) intervention or intensive intervention; brief interventions of five-minute duration were equally effective. There is limited direct evidence from the dental practice setting (one high-quality systematic review relating to tobacco prevention and none relating to alcohol). Thus, very brief, or brief advice of up to five minutes, should be trialled for tobacco and alcohol respectively in a dental practice setting, after risk assessment tailored to patient motivational status. Exploring delivery by the dental team is supported, as effectiveness was generally independent of primary care provider.

Understanding behaviour change to promote regular dental attendance

Regular dental attendance is a key oral health behaviour. Behaviour change interventions are increasingly being used to promote positive oral health behaviours. A systematic approach to understanding behaviour has led to the development of frameworks which aim to guide the process of designing behaviour change interventions. One such framework is the Behaviour Change Wheel (BCW). This article aims to explore and identify barriers to regular dental attendance which may be targeted using behaviour change interventions based on the Capability, Opportunity and Motivation Behaviour model (COM-B) and the BCW, and suggests potential behaviour change techniques which could be utilised into a behaviour change intervention with the aim to promote regular dental attendance.

Co-producing an intervention for tobacco cessation and improvement of oral health among diabetic patients in Bangladesh

BACKGROUND

Tobacco consumption is a major risk factor for many diseases including diabetes and has deleterious effects on oral health. Diabetic patients are vulnerable to developing certain oral conditions. So far, no studies have attempted to co-develop a tobacco cessation intervention to be delivered in dental clinics for people with diabetes in Bangladesh.

AIM

To co-produce a tobacco cessation intervention for people with diabetes for use in dental clinics in Bangladesh.

OBJECTIVES

To assess: (1) tobacco use (patterns) and perceptions about receiving tobacco cessation support from dentists among people with diabetes attending the dental department of Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) who smoke or use smokeless tobacco (ST) (2) current tobacco cessation support provision by the dentists of the dental department of BIRDEM (3) barriers and facilitators of delivering a tobacco cessation intervention at a dental clinic, and (4) to co-produce a tobacco cessation intervention with people with diabetes, and dentists to be used in the proposed context.

METHODS

The study was undertaken in two stages in the dental department of BIRDEM, which is the largest diabetic hospital in Bangladesh. Stage 1 (July-August 2019) consisted of a cross-sectional survey among people with diabetes who use tobacco to address objective 1, and a survey and workshop with dentists working in BIRDEM, and consultations with patients to address objectives 2 and 3. Stage 2 (January 2020) consisted of consultations with patients attending BIRDEM, and a workshop with dentists to co-produce the intervention.

RESULT

All survey participants (n = 35) were interested in receiving tobacco cessation support from their dentist. We identified important barriers and facilitators to deliver tobacco cessation intervention within dental services. Barriers reported by dentists included lack of a structured support system and lack of training. As a facilitator, we identified that dentists were willing to provide support and it would be feasible to deliver tobacco cessation intervention if properly designed and embedded in the routine functioning of the dental department of BIRDEM. Through the workshops and consultations at stage 2, a tobacco cessation intervention was co-developed. The intervention included elements of brief cessation advice (using a flipbook and a short video on the harmful effects of tobacco) and pharmacotherapy.

CONCLUSION

Incorporation of tobacco cessation within dental care for people with diabetes was considered feasible and would provide a valuable opportunity to support this vulnerable group in quitting tobacco.

Oral and periodontal implications of tobacco and nicotine products

Tobacco use contributes to more mortality and morbidity globally than any other behavioral risk factor. Adverse effects do not spare the oral cavity, with many oral diseases more common, and treatments less successful, in the tobacco-using patient. Many of the oral health effects of cigarette smoking are well established, but other forms of tobacco, including cigars and smokeless tobacco, merit dental professionals' attention. Recently, an expanding variety of new or emerging tobacco and/or nicotine products has been brought to market, most prominently electronic cigarettes, but also including heated tobacco and other noncombustible nicotine products. The use of cannabis (marijuana) is increasing and also has risks for oral health and dental treatment. For the practicing periodontist, and all dental professionals, providing sound patient recommendations requires knowledge of the general and oral health implications associated with this wide range of tobacco and nicotine products and cannabis. This review provides an overview of selected tobacco and nicotine products with an emphasis on their implications for periodontal disease risk and clinical management. Also presented are strategies for tobacco use counselling and cessation support that dental professionals can implement in practice.

A Mixed-Methods Examination of Factors Related to HPV Vaccination Promotion in Private Dental Settings, Iowa, 2019

INTRODUCTION

Human papillomavirus (HPV)-associated oropharyngeal cancer rates are rising, particularly in males, although rates of other HPV-related cancers are decreasing. Although the HPV vaccine is safe and effective, vaccination rates remain below the Healthy People 2030 goal of 80% coverage. Engaging dental providers, who have experience with patient education and oropharyngeal cancer, may prove useful in efforts to increase vaccination rates. Our research explores dental providers' (dentists, dental hygienists) willingness to participate in continuing education about HPV, educate parents of adolescents, recommend the vaccine for adolescents, and refer parents to medical providers.

METHODS

We used a mixed-methods approach and conducted a survey with dental hygienists and semistructured interviews with dental providers. We produced frequencies and descriptive statistics for all variables and used regression modeling to explore factors related to willingness to promote the HPV vaccine. We used a deductive approach to code interview transcripts.

RESULTS

Regression models using survey data (n = 470) showed that after controlling for demographic and practice-level characteristics, higher levels of willingness were associated with thinking that parents would act on a recommendation and thinking that engaging in HPV promotion is within the scope of practice. Interview data reflected willingness of dental providers to work on HPV vaccination, but revealed barriers (eg, time, knowledge) that need to be addressed.

DISCUSSION

Overall, dental providers expressed a willingness to participate in HPV vaccine promotion, and future efforts should focus on addressing barriers to doing so. Engaging dental providers in HPV vaccine recommendation and referral can help prevent future HPV-related cancers.

Interventions for tobacco cessation delivered by dental professionals

BACKGROUND

Dental professionals are well placed to help their patients stop using tobacco products. Large proportions of the population visit the dentist regularly. In addition, the adverse effects of tobacco use on oral health provide a context that dental professionals can use to motivate a quit attempt.

OBJECTIVES

To assess the effectiveness, adverse events and oral health effects of tobacco cessation interventions offered by dental professionals.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group's Specialised Register up to February 2020.

SELECTION CRITERIA

We included randomised and quasi-randomised clinical trials assessing tobacco cessation interventions conducted by dental professionals in the dental practice or community setting, with at least six months of follow-up.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts for potential inclusion and extracted data from included trials. We resolved disagreements by consensus. The primary outcome was abstinence from all tobacco use (e.g. cigarettes, smokeless tobacco) at the longest follow-up, using the strictest definition of abstinence reported. Individual study effects and pooled effects were summarised as risk ratios (RR) and 95% confidence intervals (CI), using Mantel-Haenszel random-effects models to combine studies where appropriate. We assessed statistical heterogeneity with the I² statistic. We summarised secondary outcomes narratively.

MAIN RESULTS

Twenty clinical trials involving 14,897 participants met the criteria for inclusion in this review. Sixteen studies assessed the effectiveness of interventions for tobacco-use cessation in dental clinics and four assessed this in community (school or college) settings. Five studies included only smokeless tobacco users, and the remaining studies included either smoked tobacco users only, or a combination of both smoked and smokeless tobacco users. All studies employed behavioural interventions, with four offering nicotine treatment (nicotine replacement therapy (NRT) or e-cigarettes) as part of the intervention. We judged three studies to be at low risk of bias, one to be at unclear risk of bias, and the remaining 16 studies to be at high risk of bias. Compared with usual care, brief advice, very brief advice, or less active treatment, we found very low-certainty evidence of benefit from behavioural support provided by dental professionals, comprising either one session (RR 1.86, 95% CI 1.01 to 3.41; I² = 66%; four studies, n = 6328), or more than one session (RR 1.90, 95% CI 1.17 to 3.11; I² = 61%; seven studies, n = 2639), on abstinence from tobacco use at least six months from baseline. We found moderate-certainty evidence of benefit from behavioural interventions provided by dental professionals combined with the provision of NRT or e-cigarettes, compared with no intervention, usual care, brief, or very brief advice only (RR 2.76, 95% CI 1.58 to 4.82; I² = 0%; four studies, n = 1221). We did not detect a benefit from multiple-session behavioural support provided by dental professionals delivered in a high school or college, instead of a dental setting (RR 1.51, 95% CI 0.86 to 2.65; I² = 83%; three studies, n = 1020; very low-certainty evidence). Only one study reported adverse events or oral health outcomes, making it difficult to draw any conclusions.

AUTHORS' CONCLUSIONS

There is very low-certainty evidence that quit rates increase when dental professionals offer behavioural support to promote tobacco cessation. There is moderate-certainty evidence that tobacco abstinence rates increase in cigarette smokers if dental professionals offer behavioural support combined with pharmacotherapy. Further evidence is required to be certain of the size of the benefit and whether adding pharmacological interventions is more effective than behavioural support alone. Future studies should use biochemical validation of abstinence so as to preclude the risk of detection bias. There is insufficient evidence on whether these interventions lead to adverse effects, but no reasons to suspect that these effects would be specific to interventions delivered by dental professionals. There was insufficient evidence that interventions affected oral health.

Intention to provide tobacco cessation counseling among Indonesian dental students and association with the theory of planned behavior

BACKGROUND

Use of tobacco is a serious public health problem in Indonesia that requires a multidisciplinary approach by healthcare providers to address it. The study assessed the intentions of undergraduate students in dental schools to provide tobacco cessation counseling (TCC) and their association with the constructs of the theory of planned behavior (TPB).

METHODS

A cross sectional study was conducted in October 2019 using an electronic survey for dental students in Indonesian dental schools (n = 30). The survey assessed schools and students' characteristics and eleven statements assessed their perspectives toward TCC based on the TPB using a 5-point Likert scale. Principal component analysis (PCA) was used to identify components within the items of perspective. Multilevel linear regression analysis was used to assess the association between intention to provide TCC and the constructs of the TPB as identified in the perspectives' items using TPB controlling for confounders.

RESULTS

About 1288 students participated from 30 dental schools, 83.3% females with mean age = 21.5 years with average intention to provide TCC = 4.3 out of 5. They had above average positive attitude about provision of TCC being the dentist's role (mean = 3.8 out of 5). PCA identified two components: confidence in their own abilities and perception of favorable environment with average scores = 3.2 and 2.7 out of 5. Intention to provide TCC was significantly associated with more positive attitude recognizing TCC as a dentist's role (B = 0.10, P < 0.0001), greater confidence in skills to provide TCC (B = 0.17, P < 0.0001) and less perception of favorable environment supportive off providing TCC (B = - 0.20, P < 0.0001).

CONCLUSIONS

Indonesian dental students' intention to provide TCC can be explained by the constructs of the TPB. Development of dental curricula promoting professional responsibility toward TCC should be given attention. Improving students' attitude and confidence potentially may support their patients' efforts to quit smoking.

Behavioural interventions for smoking cessation: an overview and network meta-analysis

BACKGROUND

Smoking is a leading cause of disease and death worldwide. In people who smoke, quitting smoking can reverse much of the damage. Many people use behavioural interventions to help them quit smoking; these interventions can vary substantially in their content and effectiveness.

OBJECTIVES

To summarise the evidence from Cochrane Reviews that assessed the effect of behavioural interventions designed to support smoking cessation attempts and to conduct a network meta-analysis to determine how modes of delivery; person delivering the intervention; and the nature, focus, and intensity of behavioural interventions for smoking cessation influence the likelihood of achieving abstinence six months after attempting to stop smoking; and whether the effects of behavioural interventions depend upon other characteristics, including population, setting, and the provision of pharmacotherapy. To summarise the availability and principal findings of economic evaluations of behavioural interventions for smoking cessation, in terms of comparative costs and cost-effectiveness, in the form of a brief economic commentary.

METHODS

This work comprises two main elements. 1. We conducted a Cochrane Overview of reviews following standard Cochrane methods. We identified Cochrane Reviews of behavioural interventions (including all non-pharmacological interventions, e.g. counselling, exercise, hypnotherapy, self-help materials) for smoking cessation by searching the Cochrane Library in July 2020. We evaluated the methodological quality of reviews using AMSTAR 2 and synthesised data from the reviews narratively. 2. We used the included reviews to identify randomised controlled trials of behavioural interventions for smoking cessation compared with other behavioural interventions or no intervention for smoking cessation. To be included, studies had to include adult smokers and measure smoking abstinence at six months or longer. Screening, data extraction, and risk of bias assessment followed standard Cochrane methods. We synthesised data using Bayesian component network meta-analysis (CNMA), examining the effects of 38 different components compared to minimal intervention. Components included behavioural and motivational elements, intervention providers, delivery modes, nature, focus, and intensity of the behavioural intervention. We used component network meta-regression (CNMR) to evaluate the influence of population characteristics, provision of pharmacotherapy, and intervention intensity on the component effects. We evaluated certainty of the evidence using GRADE domains. We assumed an additive effect for individual components.

MAIN RESULTS

We included 33 Cochrane Reviews, from which 312 randomised controlled trials, representing 250,563 participants and 845 distinct study arms, met the criteria for inclusion in our component network meta-analysis. This represented 437 different combinations of components. Of the 33 reviews, confidence in review findings was high in four reviews and moderate in nine reviews, as measured by the AMSTAR 2 critical appraisal tool. The remaining 20 reviews were low or critically low due to one or more critical weaknesses, most commonly inadequate investigation or discussion (or both) of the impact of publication bias. Of note, the critical weaknesses identified did not affect the searching, screening, or data extraction elements of the review process, which have direct bearing on our CNMA. Of the included studies, 125/312 were at low risk of bias overall, 50 were at high risk of bias, and the remainder were at unclear risk. Analyses from the contributing reviews and from our CNMA showed behavioural interventions for smoking cessation can increase quit rates, but effectiveness varies on characteristics of the support provided. There was high-certainty evidence of benefit for the provision of counselling (odds ratio (OR) 1.44, 95% credibility interval (CrI) 1.22 to 1.70, 194 studies, n = 72,273) and guaranteed financial incentives (OR 1.46, 95% CrI 1.15 to 1.85, 19 studies, n = 8877). Evidence of benefit remained when removing studies at high risk of bias. These findings were consistent with pair-wise meta-analyses from contributing reviews. There was moderate-certainty evidence of benefit for interventions delivered via text message (downgraded due to unexplained statistical heterogeneity in pair-wise comparison), and for the following components where point estimates suggested benefit but CrIs incorporated no clinically significant difference: individual tailoring; intervention content including motivational components; intervention content focused on how to quit. The remaining intervention components had low-to very low-certainty evidence, with the main issues being imprecision and risk of bias. There was no evidence to suggest an increase in harms in groups receiving behavioural support for smoking cessation. Intervention effects were not changed by adjusting for population characteristics, but data were limited. Increasing intensity of behavioural support, as measured through the number of contacts, duration of each contact, and programme length, had point estimates associated with modestly increased chances of quitting, but CrIs included no difference. The effect of behavioural support for smoking cessation appeared slightly less pronounced when people were already receiving smoking cessation pharmacotherapies.

AUTHORS' CONCLUSIONS

Behavioural support for smoking cessation can increase quit rates at six months or longer, with no evidence that support increases harms. This is the case whether or not smoking cessation pharmacotherapy is also provided, but the effect is slightly more pronounced in the absence of pharmacotherapy. Evidence of benefit is strongest for the provision of any form of counselling, and guaranteed financial incentives. Evidence suggested possible benefit but the need of further studies to evaluate: individual tailoring; delivery via text message, email, and audio recording; delivery by lay health advisor; and intervention content with motivational components and a focus on how to quit. We identified 23 economic evaluations; evidence did not consistently suggest one type of behavioural intervention for smoking cessation was more cost-effective than another. Future reviews should fully consider publication bias. Tools to investigate publication bias and to evaluate certainty in CNMA are needed.

Whose Responsibility Is It Anyway? Exploring Barriers to Prevention of Oral Diseases across Europe

INTRODUCTION

Dental caries, gum disease, and tooth loss are all preventable conditions. However, many dental care systems remain treatment oriented rather than prevention oriented. This promotes the treatment of oral diseases over preventive treatments and advice. Exploring barriers to prevention and understanding the requirements of a paradigm shift are the first steps toward delivering quality prevention-focused health care.

OBJECTIVES

To qualitatively explore perceived barriers and facilitators to oral disease prevention from a multistakeholder perspective across 6 European countries.

METHODS

A total of 58 interviews and 13 focus groups were undertaken involving 149 participants from the United Kingdom, Denmark, Germany, the Netherlands, Ireland, and Hungary. Interviews and focus groups were conducted in each country in its native language between March 2016 and September 2017. Participants were patients (n = 50), dental team members (n = 39), dental policy makers(n = 33), and dental insurers (n = 27). The audio was transcribed, translated, and analyzed via deductive thematic analysis.

RESULTS

Five broad themes emerged that were both barriers and facilitators: dental regulation, who provides prevention, knowledge and motivation, trust, and person-level factors. Each theme was touched on in all countries; however, cross-country differences were evident surrounding the magnitude of each theme.

CONCLUSION

Despite the different strengths and weaknesses among the systems, those who deliver, organize, and utilize each system experience similar barriers to prevention. The findings suggest that across all 6 countries, prevention in oral health care is hindered by a complex interplay of factors, with no particular dental health system offering overall greater user satisfaction. Underlying the themes were sentiments of blame, whereby each group appeared to shift responsibility for prevention to other groups. To bring about change, greater teamwork is needed in the commissioning of prevention to engender its increased value by all stakeholders within the dental system.

KNOWLEDGE TRANSFER STATEMENT

The results from this study provide an initial first step for those interested in exploring and working toward the paradigm shift to preventive focused dentistry. We also hope that these findings will encourage more research exploring the complex relationship among dental stakeholders, with a view to overcoming the barriers. In particular, these findings may be of use to dental public health researchers, dentists, and policy makers concerned with the prevention of oral diseases.

Smoking, Vaping, and the Benefits Cessation in Times of COVID-19: A Public Health Perspective

The goal of this article is to inform dental practitioners and specialists of the benefits of smoking and vaping cessation in relation to COVID-19 transmission. COVID-19 caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) has affected more than 31.7 million people globally with infection rates continuing to rise rapidly. Smoking dramatically impairs lung function and gives rise to an increase in susceptibility for infection, allowing for a more difficult recovery due, in part, to the damage SARS-CoV-2 does to the lungs. Tobacco smoking is one of the primary causes of death in the United States (US), however, nearly 40 million adults still smoke cigarettes, with 4.7 million middle and high school students using at least one tobacco product, including electronic cigarettes. COVID-19 is transmitted through salivary droplets, causing severe bilateral pneumonia and significantly reduced lung function, putting smokers and vapers at greater risk through cross-contamination and face touching. So far, data from animal studies suggest that vaping leads to an increased susceptibility to infection, which coincides with evidence of increased rates of chronic bronchitis in vapers. There is yet to be data regarding the benefits of smoking and vaping cessation during the COVID-19 pandemic. However, there is evidence suggesting that 4 weeks or more of smoking cessation intervention reduces the risk of contracting COVID-19 and developing severe complications. Because of these probable connections, dental practitioners should advise their patients to stop smoking and/or vaping via the 5 As Cessation Strategy.

A public health approach for prevention of periodontal disease

Upwards of 1 in 10 adults worldwide may be affected by severe periodontitis, making the disease more prevalent than cardiovascular disease. Despite its global scope, its impact on pain, oral function, and the wellbeing of individuals, and the disproportionate burden of disease and the socioeconomic impact on communities, the perception that periodontal disease is a public health problem remains low. Although there have been substantial improvements in our understanding of the etiology of periodontal disease and how we can prevent and control it, these advances have been primarily focused on individual, patient-focused approaches. The prevention of periodontal disease depends on improving currently available individual interventions and on determining what public health interventions can be effective and sustainable under real-life conditions. Currently, public health approaches for periodontal disease prevention and control are lacking. This review traces the historical strategies for prevention of periodontal disease in an epidemiologic transition context, using a modified model developed for cardiovascular disease, and presents a possible public health approach. Improving periodontal disease prevention and control will need to take into consideration the core activities of a public health approach: assessment, policy development, and assurance.

Global application of oral disease prevention and health promotion as measured 10 years after the 2007 World Health Assembly statement on oral health

OBJECTIVES

The WHO World Health Assembly established in 2007 a Resolution (WHA60.17) on oral health, which called upon countries to ensure that public health actions for disease prevention and health promotion are established. The objective of the present survey undertaken 10 years later (2017-2018) was to measure the application of such programmes for key population age groups in low-, middle- and high-income countries.

METHODS

Oral health focal points of ministries of health worldwide (n = 101) answered a structured questionnaire on existing national oral health systems and the actual public health activities. The response rate was 58.4%. The questionnaire was used to collect information about structural factors, country workforce, financial models, provision of preventive services and promotion for oral health, school health programmes, administration of fluoride, national oral health targets and oral health surveillance. The countries were classified by national income for analysis of data.

RESULTS

Coverage of population groups by primary oral health care and emergency care varied by national income. The gap between countries in delivery of preventive care was strong since low-income countries less often reported preventive activities than middle-income countries and particularly when compared to high-income countries. School oral health programmes were less frequent in low-income than other countries. Moreover, population methods of fluoridation and use of fluoridated toothpaste were unusual in low-income countries. Health education, mass communication and community events were often essential elements in health promotion. In disease prevention, many countries considered the link between oral health and general health conditions and intervention towards shared risk factors of NCDs. The health concern for the consumption of tobacco, unhealthy diet and sugars was particularly emphasized by high-income countries but less highlighted by low-income countries. Finally, while national oral health targets for children and surveillance systems were frequently reported by countries, similar systems for adolescents, adults and older people were rare.

CONCLUSIONS

The inequities between countries in oral disease prevention and health promotion were substantial. Limited financial resources for preventive care and health promotion; inadequate workforce for oral health, and insufficient coverage in primary health care were observed in low-resource countries. The results of the survey demonstrate the need for building effective oral health systems oriented towards oral disease prevention and health promotion.

Is nicotine damaging to oral tissues?

Data sources The review included 42 pre-clinical in-vitro studies, published between 1995 and 2017. Study selection The study selected in-vitro studies which had assessed the effect of nicotine on human gingival and periodontal fibroblasts and epithelial cells. Typically, diluted pure nicotine was added to a cell culture medium in a variety of doses for a variety of time periods and the cells were then compared against a no-nicotine control. Outcomes assessed were: Cell viability, cell attachment or adhesion, cell proliferation or inflammatory mediator production. Studies were restricted to English language and full-text only.Data extraction and synthesis Two members of the review team screened abstracts and reviewed the full-texts independently. Disagreements regarding inclusion were resolved by discussion and consultation with the third author. Data were also extracted independently using a specifically designed data extraction form which included a quality assessment specifically designed for in-vitro studies. A narrative synthesis of the results was carried out.Results The included studies were heterogeneous in their designs, with a wide variety of cell types, concentrations of nicotine (1 nM to 100 mM), exposure times (30 minutes to four weeks), and assays used. All studies were assessed at being at high risk of bias due to lack of randomisation, allocation concealment, and blinding. No effect on cell viability was observed when the nicotine concentrations used were within the ranges observed in-vivo in smokers, nicotine replacement therapy users (NRT) and e-cigarette users. Cell viability was adversely affected only when concentrations of nicotine reached those observed in the saliva of smokeless tobacco users (>5 mM). However, periodontal ligament cells are not usually exposed to saliva in-vivo. Effects on cell attachment, cell proliferation and production of inflammatory mediators were reported at a wide range of concentrations, but the effects were contradictory. The authors make several recommendations for future research in this area, to improve the quality of the primary studies. Conclusions At the concentrations found in smokers and users of NRT including e-cigarettes, nicotine is unlikely to be toxic to human gingival and periodontal ligament cells in in-vitro. Higher concentrations of nicotine, of the levels observed in the saliva of smokeless tobacco users, have been shown to be cytotoxic in vitro.

Dental Professionals' Engagement in Tobacco, Electronic Cigarette, and Cannabis Patient Counseling

OBJECTIVES

California features low smoking prevalence, cautionary electronic cigarette (e-cigarette) public messaging, and legal recreational cannabis: a unique landscape for dental professionals to navigate tobacco cessation promotion. This cross-sectional study assessed California dental professionals' self-reported tobacco patient counseling behaviors and the correlates of providing such assistance.

METHODS

Statewide surveys of dental hygienists (n = 701) and dentists (n = 725) were distributed electronically. The dentist survey was weighted for sampling and nonresponse. Prevalence of asking patients about use was compared for cigarette and noncigarette products (e.g., e-cigarettes, cannabis). Multivariable models identified independent correlates of providing cessation assistance to tobacco-using patients.

RESULTS

Respondents reported frequently (often/always) documenting patient tobacco use (hygienists: 80%; dentists: 73%) but less commonly provided forms of assistance (hygienists: 27%-49%; dentists: 10%-31%). Most respondents asked patients about cigarette smoking, but noncigarette product use (cigar, hookah, pipe, e-cigarette, or cannabis) was not commonly assessed. Greater confidence and willingness to assist were positively associated with providing assistance in multivariable models, but perceived barriers (e.g., lack of time and remuneration) were not. Results were robust to model specifications.

CONCLUSIONS

California dental professionals often ask about smoking but lag in providing cessation assistance and inquiring about noncigarette products. Successful efforts to encourage dental professionals' engagement in tobacco prevention and cessation must enhance providers' self-efficacy and motivation and likely will require system and organizational change.

KNOWLEDGE TRANSFER STATEMENT

Study findings identify substantial gaps in dental professionals' engagement in patient tobacco cessation. The results identify correlates of providing assistance and of dental professionals' willingness and confidence to do so, which could serve to inform interventions to support and enhance engagement.

Effect of smoking cessation on tooth loss: a systematic review with meta-analysis

BACKGROUND

Smoking is a major risk factor for periodontitis and tooth loss. Smoking cessation has a positive impact in periodontal treatment. However, so far, no systematic review has evaluated the effect of smoking cessation on tooth loss. Therefore, this review aimed to evaluate if smoking cessation reduces the risk of tooth loss.

METHODS

Observational (cross-sectional and longitudinal) studies that investigated the association between smoking cessation and tooth loss were included. MEDLINE, EMBASE and LILACS databases were searched for articles published up to November 2018. Pooled results for subgroups of current and former smokers were compared in meta-analysis. Meta-regression was used to test the influence of smoking status on estimates and explore the heterogeneity.

RESULTS

Of 230 potentially relevant publications, 21 studies were included in the qualitative review and 12 in the quantitative analysis. Meta-analysis of cross-sectional studies did not show any differences between former and current smokers in the chance of losing 1 or more teeth (OR = 1.00; 95% CI = 0.80 to 1.24, I² = 80%), losing more than 8 teeth (OR = 1.02; 95% CI = 0.78 to 1.32, I² = 0%) or being edentulous (OR = 1.37; 95% CI = 0.94 to 1.99, I² = 98%). Meta-analysis from longitudinal studies showed that, when compared to never smokers, former smokers presented no increased risk of tooth loss (RR = 1.15; 95% CI = 0.98 to 1.35, I² = 76%), while current smokers presented an increased risk of tooth loss (RR = 2.60; 95% CI = 2.29 to 2.96, I² = 61%). Meta-regression showed that, among former smokers, the time of cessation was the variable that better explained heterogeneity (approximately 60%).

CONCLUSIONS

Risk for tooth loss in former smokers is comparable to that of never smokers. Moreover, former smokers have a reduced risk of tooth loss, when compared to current smokers.

Design and Validation of an Instrument to Evaluate the Learning Acquired by Nursing Students from a Brief Tobacco Intervention (BTI-St©)

The aim of this study was to design and validate an instrument, based on the WHO 5As+5Rs model, to test the acquisition by nursing students of a brief tobacco intervention (BTI) learning. A validation design of an instrument following the criterion referenced tests model using videos of simulated BTIs in the primary care setting was carried out. The study included 11 experts in smoking prevention/care and 260 second-year nursing students. The study was in two stages: (1) selection and recording of clinical simulations (settings), and (2) test construction. Content was validated by applying the Delphi consensus technique and calculating the Content Validity Ratio (CVR) and Content Validity Index (CVI). A pilot test was conducted for item analysis. Reliability was evaluated as internal consistency (Kuder-Richardson [KR-20]) and test-retest temporal stability (intraclass correlation coefficient [ICC]). Three simulation settings were recorded. An instrument (BTI-St^®) was developed with 23 items for dichotomous (yes/no) response. CVR was >70% for all items, KR-20 of 0.81-0.88, and ICC between 0.68 and0.73 (p < 0.0001). The BTI-St^® is a robust and reliable instrument that is easily and rapidly applied. It follows the WHO 5As+5Rs model and offers objective criterion-referenced evaluation of BTI learning in nursing students.

Current advances in research in treatment and recovery: Nicotine addiction

The health harms of combusted tobacco use are undeniable. With market and regulatory pressures to reduce the harms of nicotine delivery by combustion, the tobacco product landscape has diversified to include smokeless, heated, and electronic nicotine vaping products. Products of tobacco combustion are the main cause of smoking-induced disease, and nicotine addiction sustains tobacco use. An understanding of the biology and clinical features of nicotine addiction and the conditioning of behavior that occurs via stimuli paired with frequent nicotine dosing, as with a smoked cigarette, is important for informing pharmacologic and behavioral treatment targets. We review current advances in research on nicotine addiction treatment and recovery, with a focus on conventional combustible cigarette use. Our review covers evidence-based methods to treat smoking in adults and policy approaches to prevent nicotine product initiation in youth. In closing, we discuss emerging areas of evidence and consider new directions for advancing the field.

Integrating tobacco cessation into routine dental practice: protocol for a qualitative study

INTRODUCTION

Combined efforts to encompass different aspects of tobacco control have been in place for some time. Despite the recognition of the need to offer support to tobacco users to quit tobacco use, such support remains highly inadequate in India. However, little is known about the practice of oral health professionals (OHP) and the experiences and expectations of dental patients in the context of tobacco cessation (TC) services. In this article, we describe the protocol of a doctoral research project that explores OHPs and their patients in an Indian city. The aims are (A) to understand the functioning of the oral healthcare system towards TC and what changes to it will be needed to benefit TC and (B) to capture the views of dental patients on TC services provided by OHPs.

METHODS AND ANALYSIS

A cross-sectional qualitative study based on individual interviews with OHPs and dental patients will be carried out in the city of Ahmedabad, Gujarat, India. The OHP will be purposively selected from two major organisation types: (1) single-doctor dental clinics and (2) dental hospital attached to teaching institutions. The sample population will be divided into two subgroups: general OHP (dentists practising general dentistry irrespective of their qualification) and prosthodontists (dentists with a specialisation in prosthodontics). We will sample dental patients through convenient sampling from a public teaching hospital and select private dental care facilities. The sampling of OHPs and dental patients will continue until we reach data saturation. Interviews will be audio recorded, transcribed verbatim and coded by hand. The interview transcript will subsequently be analysed using thematic content analysis.

ETHICS AND DISSEMINATION

The study received ethical approval from the Institutional Ethical Committee of the Government Dental College and Hospital, Ahmedabad. The findings will be disseminated through conference presentations, peer-reviewed publications and to the study participants.

Counselling as a Tool for Tobacco Cessation in a Dental Institution: Insights from India

Background: Tobacco related mortality and morbidity is a growing public health problem world over. Counselling has emerged as an important arsenal in the battle against tobacco. Involving experts other than traditional medical health workers may be critical. Aim of the present study was to explore various aspects related to Tobacco cessation counselling among Indian dental students. Methods: Overall, 241 undergraduate students from Manipal College of Dental Sciences, Mangalore participated in the present investigation. A structured, pretested, self-administered questionnaire was used to ascertain knowledge, attitude, behavior, perceived effectiveness and barriers and socio-demographic details. Willingness to counsel patients and undergo further training counselling was also assessed. Results: Mean knowledge, attitude, behavior, perceived effectiveness and barrier scores were 2.94 (±2.08), 51.84 (±5.63), 19.25 (±8.79), 16.17 (±1.96) and 42.39 (±5.65) respectively. Age was significantly correlated with knowledge; while year of study revealed significant correlations with knowledge and behavior (p<0.05). Lack of motivation, poor attitude of patients; lack of knowledge and skills emerged as barriers. Multiple logistic regression analysis indicated that year of study, attitude, behavior and barrier scores were significant predictors for respondents ever counselled their patients (p<0.05). Conclusions: Knowledge and behavior scores of the respondents towards Tobacco cessation counselling were low, but a majority of the subjects were willing to counsel and undergo training. Year of study, attitude, behavior and barrier scores emerged as significant predictors of counselling for Tobacco use. The present study has important policy implications and highlights curriculum changes in making Tobacco cessation counselling more relevant and effective among Indian dental students.

A feasibility study with embedded pilot randomised controlled trial and process evaluation of electronic cigarettes for smoking cessation in patients with periodontitis

Background

Tobacco smoking is a major risk factor for several oral diseases, including periodontitis, and electronic cigarettes (e-cigarettes) are increasingly being used for smoking cessation. This study aimed to assess the viability of delivering and evaluating an e-cigarette intervention for smoking cessation within the dental setting, prior to a definitive study.

Methods

A feasibility study, comprising a pilot randomised controlled trial and qualitative process evaluation, was conducted over 22 months in the Newcastle upon Tyne Hospitals NHS Dental Clinical Research Facility, UK. The pilot trial comprised a two-armed, parallel group, individually randomised, controlled trial, with 1:1 allocation. Participant eligibility criteria included being a tobacco smoker, having periodontitis and not currently using an e-cigarette. All participants received standard non-surgical periodontal therapies and brief smoking cessation advice. The intervention group additionally received an e-cigarette starter kit with brief training. Proposed outcomes for a future definitive trial, in terms of smoking behaviour and periodontal/oral health, were collected over 6 months to assess data yield and quality and estimates of parameters. Analyses were descriptive, with 95% confidence intervals presented, where appropriate.

Results

Eighty participants were successfully recruited from a range of dental settings. Participant retention was 73% (n = 58; 95% CI 62–81%) at 6 months. The e-cigarette intervention was well received, with usage rates of 90% (n = 36; 95% CI 77–96%) at quit date. Twenty percent (n = 8; 95% CI 11–35%) of participants in the control group used an e-cigarette at some point during the study (against advice). The majority of the outcome measures were successfully collected, apart from a weekly smoking questionnaire (only 30% of participants achieved ≥ 80% completion). Reductions in expired air carbon monoxide over 6 months of 6 ppm (95% CI 1–10 ppm) and 12 ppm (95% CI 8–16 ppm) were observed in the control and intervention groups, respectively. Rates of abstinence (carbon monoxide-verified continuous abstinence for 6 months) for the two groups were 5% (n = 2; 95% CI 1–17%; control group) and 15% (n = 6; 95% CI 7–29%; intervention group).

Conclusions

Data suggest that a definitive trial is feasible and that the intervention may improve smoking quit rates. Insights were gained into how best to conduct the definitive trial and estimates of parameters to inform design were obtained.

Trial registration

ISRCTN, ISRCTN17731903; registered 19 September 2016 http://www.isrctn.com/ISRCTN17731903.

Electronic supplementary material

The online version of this article (10.1186/s40814-019-0451-4) contains supplementary material, which is available to authorized users.

Smokeless tobacco cessation interventions: A systematic review

Background & objectives:

Smokeless tobacco (SLT) consumption is a global health issue with about 350 million users and numerous adverse health consequences like oral cancer and myocardial disorders. Hence, cessation of SLT use is as essential as smoking cessation. An update on the available literature on SLT cessation intervention studies is provided here.

Methods:

Through an extensive literature search on SLT cessation intervention studies, using keywords such as smokeless tobacco, cessation, interventions, quitlines, brief advice, nicotine replacement therapy, nicotine gum, nicotine lozenge, nicotine patch, bupropion, varenicline, mHealth, etc., 59 eligible studies were selected. Furthermore, efficacy of the interventions was assessed from the reported risk ratios (RRs) [confidence intervals (CIs)] and quit rates.

Results:

Studies were conducted in Scandinavia, India, United Kingdom, Pakistan and the United States of America, with variable follow up periods of one month to 10 years. Behavioural interventions alone showed high efficacy in SLT cessation; most studies were conducted among adults and showed positive effects, i.e. RR [CI] 0.87 [0.7, 1.09] to 3.84 [2.33, 6.33], quit rate between 9-51.5 per cent, at six months. Regular telephone support/quitlines also proved beneficial. Among pharmacological modalities, nicotine lozenges and varenicline proved efficacious in SLT cessation.

Interpretation & conclusions:

Globally, there is limited information available on SLT cessation intervention trials, research on which must be encouraged, especially in the low-resource, high SLT burden countries; behavioural interventions are most suitable for such settings. Appropriate training/sensitization of healthcare professionals, and school-based SLT use prevention and cessation programmes need to be encouraged.

Tobacco-use patterns and self-reported oral health outcomes: A cross-sectional assessment of the Population Assessment of Tobacco and Health study, 2013-2014

BACKGROUND

Few studies consider simultaneously the oral health implications of nontraditional tobacco products and tobacco-use patterns. The authors aimed to evaluate self-reported gingival disease among cigarette smokers and users of other types of tobacco products.

METHODS

The authors used survey-weighted multivariable logistic regression to assess associations between different tobacco products, use patterns (for example, dual or multiple tobacco product use or product switching); and lifetime history of gingival disease diagnosis and treatment. They used the nationally representative (US) Population Assessment of Tobacco and Health study's Wave 1 (2013-2014) adult data (N = 32,320).

RESULTS

Overall, 12.1% of participants self-reported gingival disease diagnosis, and 19.1% reported receiving treatment. Groups with the highest adjusted relative odds for diagnosis (reference, lifetime tobacco never users) were pipe users (2.7; 95% confidence interval [CI], 1.3 to 5.3), e-cigarette users (2.9; 95% CI, 1.9 to 4.5), multiple tobacco product users (2.8; 95% CI, 2.4 to 3.4), and recent (< 12 months) quitters (2.8; 95% CI, 2.0 to 3.8). Similarly, odds of treatment report were highest among pipe users (2.3; 95% CI, 1.3 to 4.1), e-cigarette users (2.3; 95% CI, 1.3 to 4.1), multiple tobacco product users (1.6; 95% CI, 1.4 to 1.9), and recent quitters (1.7; 95% CI, 1.3 to 2.2).

CONCLUSIONS

Numerous tobacco-use patterns were associated with worse periodontal health compared with tobacco never users. These findings are consistent with previous biological and epidemiologic evidence linking tobacco use to poor periodontal health.

PRACTICAL IMPLICATIONS

Dental clinicians should anticipate various tobacco-use patterns among their patients, all of which may impact oral health. Oral health care professionals should remain informed of, screen for, and address the use of all tobacco products in practice.

Knowledge About the Relation Between Tobacco and Disease and the Attitude Toward Advising the Cessation of Its Consumption Among a Group of Spanish Dental Students

Tobacco is one of the leading causes of preventable death in the developed world. Smoking is associated with a large number of oral pathologies, such as cancer and periodontitis. Dental professionals can play a key role in preventing these health problems. The objectives of this study were (1) to analyze tobacco consumption habits among a group of Spanish dental students, and (2) to assess their knowledge, perceptions, and attitudes regarding procedures to help patients quit smoking. A cross-sectional descriptive study was carried out at the Faculty of Medicine and Dentistry of Santiago de Compostela (Galicia, Spain). Three validated questionnaires were distributed, and the obtained data was processed using SPSS. One hundred twenty out of 220 surveys were completed. Of the students, 18.3% were smokers and the average number of smoked cigarettes per day was 7.5. Tobacco dependence and the intention to give up the habit were low (Fagerström Test) and doubtful (Richmond test), respectively. The majority of students (94.2%) considered it appropriate to promote tobacco use cessation (TUC) activities. A great divergence of criteria regarding tobacco-associated pathologies was found among courses. This article provides positive data about the motivation of dental students to implement TUC strategies. Nevertheless, the usefulness of these interventions makes it necessary to modify the university curricula in order to improve the education on this issue to reduce the incidence of future health problems.

Electronic Cigarettes: Trends, Health Effects and Advising Patients Amid Uncertainty

Dental professionals can be effective tobacco prevention and cessation partners. Electronic cigarettes (e-cigarettes), which deliver aerosolized nicotine but fewer toxicants than found in cigarette smoke, present new and contentious questions for clinicians, patients, and researchers. Evidence suggests e-cigarettes are not harmless but are less dangerous than cigarettes. Smoking cessation effectiveness is unproven and oral and systemic health effects remain under study. Dental professionals must stay informed to provide patients truthful information as new data emerge.

Dental professionals' opinions and knowledge of smoking cessation and electronic cigarettes: a cross-sectional survey in the north of England

Aims

To determine the current level of knowledge and opinions of UK dental professionals with regards to smoking cessation and e-cigarettes.

Method

A self-administered online survey was distributed by postal invitation to all dental practices in the north of England registered on the National Health Service (NHS) Choices website.

Findings

One hundred and ninety completed questionnaires were received. Seventy-nine percent of respondents reported always enquiring about the smoking status of their patients with 17% completing referrals to a specialist stop smoking service. Just under half of respondents reported not receiving any smoking cessation advice training. Lack of time during appointments, lack of training and lack of perceived interest by patients were reported as the most important barriers. The importance of a lack of remuneration, as a barrier, varied considerably with professional role. Approximately a third (31%) of respondents were of the opinion that e-cigarettes are more or equally harmful than cigarettes with the majority not aware of any guidance documents or recommendations regarding e-cigarettes.

Conclusion

The majority of dental professionals in the north of England reported providing smoking cessation advice, although only half had training on this. Opinions on electronic cigarettes were mixed, with a third having negative views.

Prevalence of tobacco use and perceptions of student health professionals about cessation training: results from Global Health Professions Students Survey

INTRODUCTION

Health professionals play an important role in providing advice to their patients about tobacco prevention and cessation. Health professionals who use tobacco may be deterred from providing cessation advice and counselling to their patients. We aimed to provide prevalence estimates of tobacco use among student health professionals and describe their attitudes towards tobacco cessation training.

METHODS

Country-wise aggregate data from the Global Health Professions Student Survey on 'current cigarette smoking' (smoking cigarettes on 1 or more days during the past 30 days), and 'current use of tobacco products other than cigarettes' (chewing tobacco, snuff, bidis, cigars or pipes, 1 or more days during the past 30 days) were analysed. For each WHO region, we estimated mean prevalence rates of tobacco use weighted by the population of the sampling frame and aggregate proportions for 'health professionals' role' and 'cessation training' indicators using 'metaprop' command on Stata V.11.

RESULTS

A total of 107 527 student health professionals participated in 236 surveys done in four health profession disciplines spanning 70 countries with response rates ranging from 40% to 100%. Overall, prevalence of smoking was highest in European countries (20% medical and 40% dental students) and the Americas (13% pharmacy to 23% dental students). Other tobacco use was higher in eastern Mediterranean (10%-23%) and European countries (7%-13%). In most WHO regions, ≥70% of the students agreed that health professionals are role models, and have a role in advising about smoking cessation to their patients and the public. Only ≤33% of all student health professionals in most WHO regions (except 80% dental students in the Eastern Mediterranean region) had received formal training on smoking cessation approaches and ≥80% of all students agreed that they should receive formal cessation training.

CONCLUSIONS

Tobacco control should take place together with medical educators to discourage tobacco use among student health professionals and implement an integrated smoking cessation training into health professions' curricula.

The Effect of Tobacco Control Policies on US Smokeless Tobacco Use: A Structured Review

INTRODUCTION

Tobacco use has shifted increasingly from cigarettes to other products. While the focus has been mostly on cigarette-oriented policies, it is important to gauge the effects of policies targeting other products. We review and critique the literature on how policies affect smokeless tobacco (ST).

METHODS

We conducted a search of the literature on tobacco control policies as they relate to ST use, focusing on tobacco taxes, smoke-free air laws, media campaigns, advertising restrictions, health warnings, cessation treatment policies, and youth access policies. Findings from 78 total studies are summarized.

RESULTS

ST taxes, media campaigns, health warnings, and cessation treatment policies were found to be effective tools in reducing ST use. Evidence on the effects of current youth access policies is less strong. Studies have not yet been conducted on marketing or product content restrictions, but the literature indicates that product marketing, through advertising, packaging, flavorings, and extension of cigarette brands, plays an important role in ST use.

CONCLUSIONS

Although the evidence base is less established for ST policies than for cigarette policies, the existing literature indicates ST use responds to tobacco control policies. Policies should be structured in a way that aims to reduce all tobacco use while at the same time increasing the likelihood that continuing tobacco users use the least risky products.

IMPLICATIONS

Studies find that policies targeting smoking and policies targeting smokeless products affect smokeless use, but studies are needed to examine the effect of policies on the transitions between cigarette and smokeless use.

Web-Based Information on the Treatment of Tobacco Dependence for Oral Health Professionals: Analysis of English-Written Websites

BACKGROUND

Studies have been conducted on the content and quality of Web-based information for patients who are interested in smoking cessation advice and for health care practitioners regarding the content of e-learning programs about tobacco cessation. However, to the best of our knowledge, there is no such information about the quality of Web-based learning resources regarding smoking cessation dedicated to oral health professionals.

OBJECTIVE

The aim of this study was to identify and evaluate the quality of the content of webpages providing information about smoking cessation for oral health care professionals.

METHODS

Websites were identified using Google and Health on Net (HON) search engines using the terms: smoking cessation OR quit smoking OR stop smoking OR 3As OR 5As OR tobacco counselling AND dentistry OR dental clinic OR dentist OR dental hygienist OR oral health professionals. The first 100 consecutive results of the 2 search engines were considered for the study. Quality assessment was rated using the DISCERN questionnaire, the Journal of the American Medical Association (JAMA) benchmarks, and the HON seal. In addition, smoking cessation content on each site was assessed using an abbreviated version of the Smoke Treatment Scale (STS-C) and the Smoking Treatment Scale-Rating (STS-R). To assess legibility of the selected websites, the Flesch Reading Ease (FRES) and the Flesch-Kinkaid Reading Grade Level (FKRGL) were used. Websites were also classified into multimedia and nonmultimedia and friendly and nonfriendly usability.

RESULTS

Of the first 200 sites selected (100 of Google and 100 of HON), only 11 met the inclusion criteria and mainly belonged to governmental institutions (n=8), with the others being prepared by Professional Associations (n=2) and nonprofit organizations (n=1). Only 3 were exclusively dedicated to smoking cessation. The average score obtained with the DISCERN was 3.0, and the average score in the FKRGL and FRES was 13.31 (standard deviation, SD 3.34) and 40.73 (SD 15.46), respectively. Of the 11 websites evaluated, none achieved all the four JAMA benchmarks. The mean score of STS-R among all the websites was 2.81 (SD 0.95) out of 5. A significant strong positive correlation was obtained between the DISCERN mean values and the STS-R (R=.89, P=.01).

CONCLUSIONS

The mean quality of webpages with information for oral health care professionals about smoking cessation is low and displayed a high heterogeneity. These webpages are also difficult to read and often lack multimedia resources, which further limits their usefulness.

Assessing dentists' human papillomavirus-related health literacy for oropharyngeal cancer prevention

BACKGROUND

Oropharyngeal cancers related to human papillomavirus (HPV) are on the rise. Dentists may be the next group of providers participating in the prevention of HPV. The aim of this study was to assess dentists' health literacy regarding the connection of HPV and oropharyngeal cancer.

METHODS

The authors conducted 4 focus groups with dentists (N = 33) during a regional dental conference in 2016. Guided by the health literacy competencies (that is, access, understand, appraise, and apply), the authors used constant comparison methods for data analysis.

RESULTS

Dentists mentioned a variety of informational sources (for example, dental journals and colleagues). Knowledge about the link between HPV and oropharyngeal cancer varied among participants. Participants appraised multiple patient and practice factors when deciding to have the discussion with patients. Some dentists discussed the HPV and oropharyngeal cancer connection with patients, and most conducted secondary screenings.

CONCLUSIONS

Findings indicate areas for intervention, including creating awareness of trusted informational sources, as well as increasing HPV knowledge and understanding the multiple patient (for example, age) and practice (for example, open operatories) appraisal factors. Moreover, enhancing the communication skills of dentists with patients is needed to improve HPV-related cancer prevention education.

PRACTICAL IMPLICATIONS

Addressing dentists' HPV-related health literacy has the potential to improve dentists' HPV-related prevention practices, including expanding patient education about this topic and increasing HPV vaccination knowledge, ultimately contributing to the reduction of oropharyngeal cancers.

Survey of dental clinic patients: smoking and preferences for cessation support

BACKGROUND

Smoking cessation interventions delivered by dental practitioners can be as effective as those delivered by general medical practitioners. However, concern that addressing smoking may cause offence to their patients is a reason cited by dental practitioners for not regularly addressing patient smoking behaviours, despite believing they should play a role in smoking cessation. This study aimed to elicit the smoking behaviour and smoking cessation preferences of dental patients to determine if these concerns accurately reflect patient attitudes.

METHODS

We surveyed 726 adult dental patients attending The University of Queensland's School of Dentistry dental clinics, Brisbane Dental Hospital and four private dental practices in South-East Queensland.

RESULTS

Most (80%) current daily smokers had tried to quit smoking. Smokers and non-smokers both agreed that dentists should screen for smoking behaviour and are qualified to offer smoking cessation advice (99% and 96% respectively). Almost all participants (96%) said they would be comfortable with their dentist asking about their smoking and that if their smoking was affecting their oral health their dentist should advise them to quit.

CONCLUSIONS

Patients are receptive to dental practitioners inquiring about smoking behaviour and offering advice on quitting. Smoking patients showed considerable motivation and interest in quitting smoking, particularly in the context of health problems related to smoking being identified. These results should encourage dentists to raise the issue with their patients.

Smoking and attitudes towards its cessation among native and international dental students in Lithuania

Background

Dental professionals are uniquely positioned to discourage smoking among their patients. However, little is known about the role of cultural background and attitudes towards smoking in the education of these professionals. Our study aimed to compare native Lithuanian and international dental students’ smoking habits, knowledge about the harmfulness of smoking and attitudes towards smoking cessation.

Methods

We conducted a cross-sectional survey of smoking and its cessation among dental students at the Lithuanian University of Health Sciences (Kaunas, Lithuania) in 2012. All Lithuanian and international dental students in each year of dental school were invited to participate in the survey during a compulsory practical class or seminar. Altogether 606 students participated in the survey with a response rate of 84.2%. Explanatory factorial analysis (EFA), multivariate Discriminant Analysis (DA) and Binary Logistic Regression (BLR) served for the statistical analyses.

Results

The percentages of occasional/current regular smokers were 41.1% and 55.7% (p = 0.068) among Lithuanian and international male students, and 22.7% and 22.9% (p = 0.776) among Lithuanian and international female students, respectively. The international dental students had a deeper knowledge of the harmfulness/addictiveness of smoking and held more positive attitudes towards smoking cessation among their patients than did the native Lithuanian dental students.

Conclusions

The findings of the study underscored the need to properly incorporate tobacco cessation training into the curriculum of dental education. However, consideration of the cultural background of dental students in building up their capacity and competence for intervening against smoking is essential.

Social and Cultural Context of Betel Quid Consumption in Taiwan and Implications for Prevention and Cessation Interventions

BACKGROUND

In Taiwan, betel quid chewing is a part of social life for chewers. Betel quid itself, with or without tobacco, is a Group 1 human carcinogen. Betel quid chewing has become a severe health threat in Taiwan.

OBJECTIVES

The aim of the present study was to identify the individual, social, contextual, and cultural factors related to initiation, continuous use, and cessation of betel quid chewing.

METHODS

Four focus groups and 15 in depth face-to-face interviews were conducted in 2013 with current and former users of betel quid, members of a community organization located in central Taiwan. A thematic analysis identified themes evident across all groups.

RESULTS

Study participants (N = 41) were 66% male and 34% female; mean age was 40.34 ± 9.23 years. Participants stated that betel quid initiation usually occurs during childhood and that the most frequent reasons for chewing were: to follow cultural/social traditions, to achieve an energetic feeling, and to avoid boredom. Participants perceived betel quid chewing as an addiction and a risk factor for cancer and other health-related conditions. The most frequently mentioned barriers to quitting betel quid included: peer pressure and selected withdrawal symptoms.

CONCLUSIONS

For the development of culturally relevant and effective cessation interventions for betel quid in Taiwan, it is critical to understand and address perceptions of betel quid chewing and barriers to cessation.

Psychosocial interventions for supporting women to stop smoking in pregnancy

BACKGROUND

Tobacco smoking remains one of the few preventable factors associated with complications in pregnancy, and has serious long-term implications for women and babies. Smoking in pregnancy is decreasing in high-income countries, but is strongly associated with poverty and is increasing in low- to middle-income countries.

OBJECTIVES

To assess the effects of smoking cessation interventions during pregnancy on smoking behaviour and perinatal health outcomes.

SEARCH METHODS

In this sixth update, we searched the Cochrane Pregnancy and Childbirth Group's Trials Register (13 November 2015), checked reference lists of retrieved studies and contacted trial authors.

SELECTION CRITERIA

Randomised controlled trials, cluster-randomised trials, and quasi-randomised controlled trials of psychosocial smoking cessation interventions during pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality, and extracted data. Direct comparisons were conducted in RevMan, with meta-regression conducted in STATA 14.

MAIN RESULTS

The overall quality of evidence was moderate to high, with reductions in confidence due to imprecision and heterogeneity for some outcomes. One hundred and two trials with 120 intervention arms (studies) were included, with 88 trials (involving over 28,000 women) providing data on smoking abstinence in late pregnancy. Interventions were categorised as counselling, health education, feedback, incentives, social support, exercise and dissemination.In separate comparisons, there is high-quality evidence that counselling increased smoking cessation in late pregnancy compared with usual care (30 studies; average risk ratio (RR) 1.44, 95% confidence interval (CI) 1.19 to 1.73) and less intensive interventions (18 studies; average RR 1.25, 95% CI 1.07 to 1.47). There was uncertainty whether counselling increased the chance of smoking cessation when provided as one component of a broader maternal health intervention or comparing one type of counselling with another. In studies comparing counselling and usual care (largest comparison), it was unclear whether interventions prevented smoking relapse among women who had stopped smoking spontaneously in early pregnancy. However, a clear effect was seen in smoking abstinence at zero to five months postpartum (11 studies; average RR 1.59, 95% CI 1.26 to 2.01) and 12 to 17 months (two studies, average RR 2.20, 95% CI 1.23 to 3.96), with a borderline effect at six to 11 months (six studies; average RR 1.33, 95% CI 1.00 to 1.77). In other comparisons, the effect was unclear for most secondary outcomes, but sample sizes were small.Evidence suggests a borderline effect of health education compared with usual care (five studies; average RR 1.59, 95% CI 0.99 to 2.55), but the quality was downgraded to moderate as the effect was unclear when compared with less intensive interventions (four studies; average RR 1.20, 95% CI 0.85 to 1.70), alternative interventions (one study; RR 1.88, 95% CI 0.19 to 18.60), or when smoking cessation health education was provided as one component of a broader maternal health intervention.There was evidence feedback increased smoking cessation when compared with usual care and provided in conjunction with other strategies, such as counselling (average RR 4.39, 95% CI 1.89 to 10.21), but the confidence in the quality of evidence was downgraded to moderate as this was based on only two studies and the effect was uncertain when feedback was compared to less intensive interventions (three studies; average RR 1.29, 95% CI 0.75 to 2.20).High-quality evidence suggests incentive-based interventions are effective when compared with an alternative (non-contingent incentive) intervention (four studies; RR 2.36, 95% CI 1.36 to 4.09). However pooled effects were not calculable for comparisons with usual care or less intensive interventions (substantial heterogeneity, I2 = 93%).High-quality evidence suggests the effect is unclear in social support interventions provided by peers (six studies; average RR 1.42, 95% CI 0.98 to 2.07), in a single trial of support provided by partners, or when social support for smoking cessation was provided as part of a broader intervention to improve maternal health.The effect was unclear in single interventions of exercise compared to usual care (RR 1.20, 95% CI 0.72 to 2.01) and dissemination of counselling (RR 1.63, 95% CI 0.62 to 4.32).Importantly, high-quality evidence from pooled results demonstrated that women who received psychosocial interventions had a 17% reduction in infants born with low birthweight, a significantly higher mean birthweight (mean difference (MD) 55.60 g, 95% CI 29.82 to 81.38 g higher) and a 22% reduction in neonatal intensive care admissions. However the difference in preterm births and stillbirths was unclear. There did not appear to be adverse psychological effects from the interventions.The intensity of support women received in both the intervention and comparison groups has increased over time, with higher-intensity interventions more likely to have higher-intensity comparisons, potentially explaining why no clear differences were seen with increasing intervention intensity in meta-regression analyses. Among meta-regression analyses: studies classified as having 'unclear' implementation and unequal baseline characteristics were less effective than other studies. There was no clear difference between trials implemented by researchers (efficacy studies), and those implemented by routine pregnancy staff (effectiveness studies), however there was uncertainty in the effectiveness of counselling in four dissemination trials where the focus on the intervention was at an organisational level. The pooled effects were similar in interventions provided for women classified as having predominantly low socio-economic status, compared to other women. The effect was significant in interventions among women from ethnic minority groups; however not among indigenous women. There were similar effect sizes in trials with biochemically validated smoking abstinence and those with self-reported abstinence. It was unclear whether incorporating use of self-help manuals or telephone support increased the effectiveness of interventions.

AUTHORS' CONCLUSIONS

Psychosocial interventions to support women to stop smoking in pregnancy can increase the proportion of women who stop smoking in late pregnancy and the proportion of infants born low birthweight. Counselling, feedback and incentives appear to be effective, however the characteristics and context of the interventions should be carefully considered. The effect of health education and social support is less clear. New trials have been published during the preparation of this review and will be included in the next update.