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.

Enhancing identification and counseling skills of dental undergraduate students using a customized Tobacco Counseling Training Module (TCTM) - A piloting of the process using ADDIE framework

Background

Tobacco use has emerged as a major public health problem. But, most graduates in medical and dental schools receive limited systematic training. The objective of this education innovation project was to enhance dental undergraduate student's ability to identify tobacco users through oral manifestations and improve their counseling skills using a customized Tobacco Counseling Training Module (TCTM).

Methods

A TCTM for students of dentistry was developed using ADDIE framework as a guide. Content and construct validation of the module was done by six subject experts using Delphi technique for obtaining consensus. Pilot testing was done on 20 students of third year BDS. Pre- and post-intervention assessment of knowledge, attitude, self-confidence was done using learning outcomes questionnaire. Ability to correctly identify oral manifestations was assessed using extended item MCQs and tobacco counseling skills using a modified KEECC. The difference in mean scores were computed and subjected to further statistical analysis using SPSS version 22.

Results

There was a significant improvement in post intervention scores for mean knowledge (5.5 ± 1.4 to 13.2 ± 1.1), attitude (5.6 ± 0.9 and 8.5 ± 0.5), self-confidence (1.5 ± 0.5 and 3.1 ± 0.2), ability to correctly identify oral manifestations (5.2 ± 1.4 and 9.4 ± 0.8) and tobacco counseling skills.

Conclusion

It is possible to introduce the module in the existing curriculum and its effectiveness evaluation shows benefit in terms of Kirkpatrick's Level 1, 2, 3 (improvement in knowledge, attitude, self-confidence, ability to identify oral manifestations, and tobacco counseling skills) of training effectiveness.

The Effectiveness of Tobacco Dependence Education in Health Professional Students' Practice: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The objective of this study was to perform a systematic review to examine the effectiveness of tobacco dependence education versus usual or no tobacco dependence education on entry-level health professional student practice and client smoking cessation. Sixteen published databases, seven grey literature databases/websites, publishers’ websites, books, and pertinent reference lists were searched. Studies from 16 health professional programs yielded 28 RCTs with data on 4343 healthcare students and 3122 patients. Two researchers independently assessed articles and abstracted data about student knowledge, self-efficacy, performance of tobacco cessation interventions, and patient smoking cessation. All forms of tobacco were included. We did not find separate interventions for different kinds of tobacco such as pipes or flavoured tobacco. We computed effect sizes using a random-effects model and applied meta-analytic procedures to 13 RCTs that provided data for meta-analysis. Students’ counseling skills increased significantly following the 5As model (SMD = 1.03; 95% CI 0.07, 1.98; p < 0.00001, I² 94%; p = 0.04) or motivational interviewing approach (SMD = 0.90, 95% CI 0.59, 1.21; p = 0.68, I² 0%; p < 0.00001). With tobacco dependence counseling, 78 more patients per 1000 (than control) reported quitting at 6 months (OR 2.02; 95% CI 1.49, 2.74, I² = 0%, p = 0.76; p < 0.00001), although the strength of evidence was moderate or low. Student tobacco cessation counseling improved guided by the above models, active learning strategies, and practice with standardized patients.

Effects of Trained Health Professionals' Behavioral Counseling Skills on Smoking Cessation Outcomes

Background

There is evidence that training health professionals in behavioral counseling skills can lead to greater success in helping their smokers to quit. However, it is still unknown how counseling skills relate to counseling effects.

Purpose

We established a method of skills evaluation of health professionals for smoking cessation counseling based on videotaped counseling sessions with a standardized smoker, and examined the relationship between skill levels and smoking cessation outcomes.

Methods

Twenty-three health professionals at Japanese workplaces underwent a training program. Their counseling skills were evaluated before and after the program using a structured evaluation form-based analysis of videotaped interactions between participants and a standardized smoker. A total of 858 smokers then received individual smoking cessation counseling by the trained health professionals at an annual health checkup. These patients were followed-up through surveys after 1 year.

Results

On a scale from 0 to 24, Total skill scores, which ranged from 0 to 24, were significantly higher after the training than before the training (p < .001). Multiple two-level logistic regression analysis adjusted for smokers' characteristics showed that the odds ratios of skill scores after the training for point prevalence and sustained abstinence rates among smokers who received counseling were 1.21 (95% confidence interval: 1.03-1.42) and 1.26 (1.05-1.50), respectively.

Conclusions

This study demonstrates that higher behavioral counseling skills were associated with better smoking cessation outcomes. This research is of clinical importance in that it provides a tool for assessing counselling skills in a way that is demonstrably relevant to outcomes.

Tobacco-Nicotine Education and Training for Health-Care Professional Students and Practitioners: A Systematic Review

Introduction

The objective of this systematic review was to investigate what education and training characteristics prepares and supports health-care professionals (HCPs) in the delivery of competent and effective care to clients who use tobacco-nicotine.

Aims and Methods

A search of eight bibliographic databases for English-language peer-reviewed publications from January 2006 to March 2015. Studies were included if they met the a priori inclusion criteria, which consisted of: (1) quantitative study design and (2) focus on tobacco-nicotine education or training for HCP students and practitioners. All studies were independently screened for inclusion by two reviewers. Data from included studies were extracted for study characteristics and key outcomes then critically appraised for methodological quality.

Results

Fifty-nine studies were included for narrative synthesis. Two categories emerged: (1) curriculum characteristics (n = 10) and (2) education and training interventions (n = 49). Included curriculum studies identified the following themes: content, intensity, competencies evaluation, and barriers. Study findings about education and training interventions were grouped by level of education (prelicensure, post-licensure, and faculty training), teaching modality, health discipline, and the associated HCP and client outcomes.

Conclusions

This comprehensive review suggests that there is a lack of consistency in HCP tobacco-nicotine education and training characteristics. This paper provides valuable categorization of the most frequently utilized components of academic curriculum and discusses the interventions in relation to HCP and client outcomes. Gaps in the literature are highlighted, and the need for standardization of tobacco-nicotine training competencies and evaluation is discussed. Future research investigating the most effective approaches to training is needed.

Implications

This systematic review summarizes existing tobacco-related curriculum components (content, intensity, competency evaluation, and barriers) and training interventions for health-care professionals worldwide and demonstrates that they are associated with positive health-care professional outcomes (knowledge, attitudes, behaviors, and skills) and client outcomes (quit attempts and smoking abstinence).

Understanding the impact of simulated patients on health care learners' communication skills: a systematic review

CONTEXT

Effective communication skills are at the core of good health care. Simulated patients (SPs) are increasingly engaged as an interactive means of teaching, applying and practising communication skills with immediate feedback. There is a large body of research into the use of manikin-based simulation but a gap exists in the body of research on the effectiveness of SP-based education to teach communication skills that impact patient outcomes. The aim of this systematic review was to critically analyse the existing research, investigating whether SP-based communication skills training improves learner-patient communication, how communication skill improvement is measured, and who measures these improvements.

METHODS

The databases Medline, ProQuest (Health & Medical Complete, Nursing and Allied Health Source) and CINAHL (EBSCOhost) Education Resources Information Centre (ERIC) were searched for articles that investigated the effects of SP-based education on the communication skills of medical, nursing and allied health learners.

RESULTS

There were 60 studies included in the review. Only two studies reported direct patient outcomes, one reporting some negative impact, and no studies included an economic analysis. Many studies reported statistically significant third-party ratings of improved communication effectiveness following SP-based education; however, studies were unable to be pooled for meta-analysis because of the outcome collection methods. There were a small number of studies comparing SP with no training at all and there were no differences between communication skills, contradicting the results from studies reporting benefits. Of the 60 studies included for analysis, 54 (90%) met the minimum quality score of 7/11, with four articles (7%) scoring 11/11.

CONCLUSION

SP-based education is widely accepted as a valuable and effective means of teaching communication skills but there is limited evidence of how this translates to patient outcomes and no indication of economic benefit for this type of training over another method.

Global tobacco prevention and control in relation to a cardiovascular health promotion and disease prevention framework: A narrative review

The purpose of this review is to emphasize the role of tobacco prevention and control in cardiovascular health (CVH) promotion and cardiovascular disease (CVD) prevention, including the importance of these endpoints for measuring the full impact of tobacco-related policies, programs, and practices. In this review, we describe an overview of tobacco control interventions that have led to substantial declines in tobacco use and the relationship between these declines with CVH and CVD. We review interventions that have had success in high-income countries (HICs) as well as those that are gaining traction in low- and middle-income countries (LMICs). We emphasize the challenges to comprehensive tobacco prevention and control strategies faced by LMICs, and highlight the special role of cardiovascular health professionals in achieving CVH promotion and CVD prevention endpoints through tobacco control. Tobacco prevention and control strategies have a strong scientific basis, yet a distinct gap remains between this evidence and implementation of tobacco control policies, particularly in LMICs. Health professionals can contribute to tobacco control efforts, especially through patient-level clinical interventions, when supported by a health care system and government that recognize and support tobacco control as a critical strategy for CVH promotion and CVD prevention. Understanding, supporting, and applying current and evolving policies, programs, and practices in tobacco prevention and control is the province of all health professionals, especially those concerned with CVH promotion and CVD prevention. A new tobacco control roadmap from the World Heart Federation provides a strong impetus to the needed interdisciplinary collaboration.

Effectiveness of tobacco intervention education in health professional students' practice: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to examine the effectiveness of entry-level education on smoking cessation or prevention and tobacco-dependence interventions on health professional student practice in promoting client health and on client smoking cessation behaviors.The specific review question to be addressed: what is the effect of entry-level tobacco dependence education on: (1) health professional students' knowledge and skills and self-efficacy, (2) performance of tobacco prevention and cessation interventions, and (3) client smoking cessation behaviors?

Awareness and support for anti-tobacco policies among health professional students in Pakistan: findings from the Global Health Professional Students Survey, 2011

Background

Health professional (HP) students may have an important role in controlling future tobacco use of their patients, and public at large. It is important to understand their existing level of awareness and support for national anti-tobacco policies. We thus aim to explore Pakistani HP students’ existing attitudes towards national anti-tobacco policy and examine factors associated with lack of awareness, and support amongst them.

Methods

Secondary data analysis of the Global Health Professional Students Survey, Pakistan, 2011 was performed. Study population included 4,235 health professional students enrolled in third year of graduate level HP programs. The policy support metrics were developed using six questions from the survey. Univariate and multivariate analyses were conducted to analyze association between HP students’ awareness, and support for anti-tobacco policy (outcome variables), and various socio-demographic, attitudinal, and knowledge related factors. Descriptive statistics are reported as proportions, and results of logistic regression analysis were reported as odds ratios with 95% confidence interval.

Results

Overall, among HP students, 10.8% (n = 391) were current smokers, and 26.7% (n = 965) of them were cigarette experimenters. Almost half, (46.1%, n = 1666) of the HP students did not have an awareness of the official policy banning tobacco use in their school buildings and clinics; and only one in ten (9.4%, n = 338) of them did not support anti-tobacco policies. Students were less likely to be aware if they had second hand exposure at home/work (OR = 0.73, 95% CI (0.57-0.92), p-value <0.01). Furthermore, students who were current smokers (OR = 0.21, 95% CI (0.08-0.56), or cigarette experimenters (OR = 0.42, 95% CI (0.26-0.70), p-value <0.01), were least likely to support anti-tobacco policies.

Conclusion

We found that HP students lack awareness of anti-tobacco policies; and were less likely to support such efforts if they were current smokers. These findings may help in understanding existing perceptions of the future care givers in Pakistan. Future anti-tobacco efforts and HP training programs may target the smoking HPs to enhance their full support in this regard.

Electronic supplementary material

The online version of this article (doi:10.1186/s13011-015-0001-x) contains supplementary material, which is available to authorized users.

Educating Physical Therapist Students in Tobacco Cessation Counseling: Feasibility and Preliminary Outcomes

BACKGROUND

Smoking is the leading preventable cause of chronic disease and premature morbidity. People with physical disabilities experience elevated smoking prevalence when compared with their non-disabled peers. The physical therapy profession is dedicated to meeting needs of people with physical disabilities, yet most physical therapists (PT) do not typically provide tobacco cessation interventions. Similar deficits exist among other health professions, creating a demand for improved services to address smoking-related health burdens. Within other health professions, insufficient tobacco cessation counseling (TCC) education has been linked to a lack of interventions and may account for similar deficits in physical therapy practice.

STUDY PURPOSE

Goals were to assess feasibility, implementation, and results of a tailored TCC educational program for entry-level physical therapist (PT) students.

SUBJECTS

Two cohorts of entry-level physical therapist (PT) students (n = 12 and n = 17).

METHODS

Educational objectives were established based on prior review of the literature, a survey of national PT education programs, and clinical guidelines for TCC established by the United States Public Health Service (USPHS). Based on these objectives, the team designed a 3-hour workshop involving didactic content and problem-based skills practice. A pre- and post-test survey was used to measure 6 dimensions: knowledge, perceived barriers, perceived facilitators, self-efficacy, outcome expectations, and self-rated skill in TCC. Within each cohort, changes in score were compared using a paired t test. The ability to apply clinical guidelines for TCC was assessed using case scenarios and structured observation. These outcomes were selected based on the Theory of Reasoned Action, which states that future behavior is determined by intention to act. Intention to act is a product of knowledge, a positive balance between perceived barriers and facilitators, strong self-efficacy, favorable outcome expectations, and necessary skills. Student satisfaction with training was assessed through anonymous written feedback. Feasibility was based on cost analysis, including material resources, as well as faculty time and effort.

RESULTS

Following participation, both cohorts improved in knowledge, perceived facilitators, outcome expectations, and self-rated skill. Cohort 2 also showed an increase in self-efficacy (P < .01). Structured observation revealed competencies in application of clinical guidelines for case-based scenarios. Mean student satisfaction ratings for the educational experience were 5/5, and cost-estimate for delivery of the 3-hour educational intervention was approximately $32 per student.

CONCLUSIONS

This research study demonstrated feasibility and impact of an evidence-based curricular model designed to increase likelihood of TCC by future PTs by enhancing factors known to promote TCC behaviors. The program was well-received by students, and objectives were achieved through efficient use of faculty time and resources. Subsequent research should examine the effects of training on the provision of TCC within clinical settings, as well as the impact of TCC on smoking quit rates for patients who have received this intervention as a component of their physical therapy plan of care.

Implementing tobacco dependence treatment during clinical consultations: a qualitative study of clinicians' experiences, perceptions and behaviours in a South African primary health care setting

Background

Evidence suggests that healthcare providers (HCPs) in South Africa do not consistently offer tobacco dependence treatment (TDT) during clinical consultations. In order to understand and explain this behaviour in a South African context, we conducted a qualitative exploration of HCPs’ experiences, perceptions and behaviours regarding TDT.

Methods

Individual qualitative interviews were conducted with physicians and nurses who were purposively selected. Themes were identified from interview transcripts using content analysis. Findings were triangulated and peer-reviewed, and were also verified by the participants.

Results

Fifteen physicians and four nurses were interviewed, none of whom used tobacco. These participants perceived TDT as an important task, but could not consistently implement it during clinical consultations due to health systems constraints (time-constraints because of patient-overload, the unavailability of cessation medications and a lack of support for referrals), misperceptions and misconceptions (negative outcome expectations about the effectiveness and feasibility of TDT), socio-cultural barriers (counselling older persons was perceived as challenging) and personal limitations (perceived low self-efficacy, poor knowledge and skills on implementing any evidence-based TDT framework). Patients are therefore selectively screened based on clinical relevance and offered only prescriptive brief advice. Participants recommended several systems changes, including academic detailing of tobacco status, training HCPs and incorporating tobacco cessation medications in the Essential Drug List.

Conclusion

The reported selective screening and limited TDT interventions offered by HCPs are related to interactions between health systems constraints, personal limitations, and misperceptions and misconceptions about the effectiveness and feasibility of TDT during clinical consultation. Implementing the recommended systems changes has the potential to improve the implementation of TDT in South African primary health care (PHC).

Feasibility of using a standardized patient encounter for training chiropractic students in tobacco cessation counseling

Objective : Although tobacco cessation training is included in many health profession programs, it is not yet routinely incorporated into chiropractic education. The purpose of this study was to assess the feasibility of incorporating a problem-based learning tobacco cessation activity into a lecture course for chiropractic students. Methods : Seventy-two students were assigned to participate in two 1-hour lectures on health promotion counseling and tobacco cessation followed by an experiential student-driven lab session using standardized patients at various stages of dependency and willingness to quit. The intervention was based on the transtheoretic model and the "5 A's" of counseling (ask, advise, assess, assist, arrange). Outcomes were assessed via (1) questionnaires completed by the standardized patients regarding the students' use of the 5A's, and (2) questionnaires completed by the students using a 5-point Likert scale of "strongly disagree" to "strongly agree" on the acceptability of this method of learning. Descriptive statistics were computed. Results : Sixty-eight students (94%) completed the activity, spending a median of 2.5 minutes with patients. Over 90% addressed 4 of the 5A's: 99% asked patients if they were smokers; 97% advised them to quit; 90% assessed if they were willing to quit; and 99% offered assistance in quitting. Only 79% arranged a follow-up visit. Overall, students expressed a positive response to the experience; 81% said it increased their confidence in being able to advise patients, and 77% felt it would be valuable for use in their future practice. Conclusion : This active learning exercise appeared to be a feasible way to introduce tobacco counseling into the curriculum.

A video feedback-based tobacco cessation counselling course for undergraduates-preliminary results

BACKGROUND

Hungary has one of the highest rates of tobacco use and decayed, missing and filled teeth in Europe, and the number of lung cancer-related deaths per annum is amongst the highest globally. As it is estimated that the rate of smokers who see their dentist or physician annually is about 70%, to involve all healthcare providers in tobacco intervention seems to be a promising strategy to reduce tobacco use in countries like Hungary. Such an intervention should obviously include the dental health team. It has already been suggested by experts on this topic that instruction in tobacco use prevention and cessation counselling for dental professionals and students of dentistry should be included in under- and postgraduate curricula.

OBJECTIVES

To present a novel, video feedback-based undergraduate cessation counselling programme, which has recently been introduced to the dental curriculum at the Faculty of Dentistry, Szeged, Hungary.

METHODS

Applying a problem-based learning approach, the programme consists of three main activities: a small-group interactive training session led by a faculty member, where students learn about the basic science and clinical aspects of tobacco use, including counselling skills; student interactions with professional actors (i.e. standardised patients) simulating real-life dental situations, which are recorded for post hoc evaluation; and finally an evaluation of the recorded performance of each student, with the participation of the actor, the student and a faculty member.

RESULTS

With the help of this new approach, students had the chance to learn about and develop a deeper understanding of tobacco-related professional dental communication in realistic, case-based dental scenarios. Students have reported increased confidence in tobacco counselling after having participated in this programme. Furthermore, this method appears to be an ideal tool for the evaluation of both verbal and non-verbal tobacco counselling skills.

CONCLUSION

To our knowledge, we are the first to have applied video feedback combined with behavioural modification methods in the teaching of tobacco cessation counselling. We conclude that teaching method can help dentists better understand smokers, gain confidence in tobacco cessation counselling and become more effective promoters of a smoke-free lifestyle. In addition, this method can be easily adapted to other healthcare educational settings, including other oral health training programmes.