Tobacco cessation in dental settings: research findings and future directions

The impact of smoking on oral health and patient assessment of tobacco cessation support from Turkish dentists

INTRODUCTION

Dentists are in a critical position to help patients quit smoking. This study analyses the effectiveness of Turkish dentists in smoking cessation as part of routine patient care.

METHODS

An in-person cross-sectional survey on previous dental visit experiences was completed by 226 patients recruited from the Department of Periodontology, Eskisehir Osmangazi University, Turkey, from March 2019 to September 2019. The questionnaire included topics on patient's smoking/quit characteristics, experiences on smoking cessation from their dentists, and willingness for the implementation of smoking cessation advice by dentists.

RESULTS

In all, 38% of the patients were current smokers, 8% were former smokers, and 68% tried to quit previously. Smokers demonstrated consistently higher scores for plaque index, gingival index, and probing depth, than former/non-smokers (p<0.05). Patients' knowledge of adverse effects was high, and the patients presented a positive attitude toward receiving cessation activities from dentists (86.7%). A total of 89% responded positively to be asked about their smoking behavior. However, the dentists' approach for cessation discussions did not go any further than listing the harmful effects. Only 32% of the patients were informed about side effects of smoking and one-third were encouraged to quit. In general, offering smoking cessation advice was relatively infrequent, and the majority of patients tried to quit smoking by themselves (76%) without using any nicotine replacement product (84%).

CONCLUSIONS

Smoking leads to oral health problems. Dentists in Turkey may ask their patients' about their smoking habits but less frequently offer practical help to quit.

The effectiveness of guideline implementation strategies in the dental setting: a systematic review

BACKGROUND

Guideline implementation has been an ongoing challenge in the dental practice setting. Despite this, there are no reviews summarising the existing evidence regarding effective guideline implementation strategies in this setting. In order to address this, this systematic review examines the effectiveness of guideline implementation strategies in the dental practice setting.

METHODS

A systematic search was undertaken according to the PRISMA statement across nine electronic databases, targeting randomised controlled trials and quasi-experimental studies which evaluated the effectiveness of guideline implementation strategies in improving guideline adherence in the dental setting. All records were independently examined for relevance and appraised for study quality by two authors, with consensus achieved by a third author. Data were extracted from included studies using a standardised data extraction pro forma.

RESULTS

A total of 15 records were eligible for inclusion in this review, which focused on the effects of audit and feedback, reminders, education, patient-mediated interventions, pay for performance and multifaceted interventions. Although there were some conflicting evidence, studies within each category of implementation strategy indicated a positive effect on guideline adherence.

CONCLUSIONS

This study has identified education, reminders and multifaceted interventions as effective implementation strategies for the dental practice setting. Although this is similar to research findings from other health sectors, there is some evidence to suggest patient-mediated interventions may be less effective and pay for performance may be more effective in the dental setting. These findings can inform policy makers, professional associations, colleges and organisations in the future adoption of clinical guidelines in the dental practice setting.

TRIAL REGISTRATION

This systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration ID CRD42018093023.

Feasibility of Collecting Saliva for Biological Verification of Tobacco Use Status in Dental Practices and Patients' Homes: Results from the National Dental PBRN

OBJECTIVE

To evaluate the feasibility of collecting and analyzing saliva samples from dental practices and patients' homes for biochemical verification of tobacco use status.

BASIC RESEARCH DESIGN

Sub-study within single-arm, multi-center, longitudinal clinical study.

CLINICAL SETTING

Dental practices in the South Central region of the United States National Dental Practice-Based Research Network and patients' homes.

PARTICIPANTS

Fifty-five patients recruited from 30 dental practices.

INTERVENTIONS

Participants in the sub-study were instructed on saliva collection for cotinine analysis in dental practices where they enrolled in the primary study. Saliva was collected at the practices and then from patients' homes.

MAIN OUTCOME MEASURES

Feasibility for dental practice collection was define as 80% of enrolled participants having analyzable samples. For patients' home collection, feasibility was defined as 70%.

RESULTS

Forty-seven samples (i.e., 86% of those enrolled) collected in dental practices were analyzable. Twenty-one samples (i.e. 38% of those enrolled) collected in patients' homes were analyzable.

CONCLUSIONS

Collecting saliva samples for cotinine analysis from dental practices, but not from patients' homes, was feasible. Dental practices may provide an advantageous setting for biochemically verifying tobacco use status as part of clinical trials for tobacco cessation.

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.

Tobacco screening and cessation efforts by dental providers: A quality measure evaluation

OBJECTIVES

The purpose of this study was to adapt, test, and evaluate the implementation of a primary care "Preventive care and Screening" meaningful use quality measure for tobacco use, in dental institutions. We determined the percentage of dental patients screened for tobacco use, and the percentage of tobacco users who received cessation counseling.

METHODS

We implemented the dental quality measure (DQM), in three dental schools and a large dental accountable care organization. An automated electronic health record (EHR) query identified patients 18 years and older who were screened for tobacco use one or more times within 24 months, and who received cessation counseling intervention if identified as a tobacco user. We evaluated EHR query performance with a manual review of a subsample of charts.

RESULTS

Across all four sites, in the reporting calendar year of 2015, a total of 143,675 patients met the inclusion criteria for the study. Within 24 months, including 2014 and 2015 calendar years, percentages of tobacco screening ranged from 79.7 to 99.9 percent, while cessation intervention percentages varied from 1 to 81 percent among sites. By employing DQM research methodology, we identified intervention gaps in clinical practice.

CONCLUSIONS

We demonstrated the successful implementation of a DQM to evaluate screening rates for tobacco use and cessation intervention. There is substantial variation in the cessation intervention rates across sites, and these results are a call for action for the dental profession to employ tobacco evidence-based cessation strategies to improve oral health and general health outcomes.

Dental Students' Attitudes Toward Tobacco Cessation in the Dental Setting: A Systematic Review

Many dental schools have integrated tobacco cessation into their predoctoral curricula. However, dental students' perceptions should be taken into consideration when designing those curricula. The aim of this study was to systematically review the published literature on dental students' attitudes and perceptions regarding tobacco cessation. The research team conducted a search for articles through April 2016 using the following electronic databases: Medline, PsychInfo, Cochrane Library, and CINAHL. Each abstract and/or article was reviewed for inclusion. Data were extracted from all included articles. Each was rated for quality appraisal by two reviewers. The initial search identified 2,035 articles, and 38 of those were included in the review. The majority were cross-sectional and sampled students from one dental school. There was wide variation in the measurement of dental student attitudes. Overall, the majority of students in these studies reported believing it is within the scope of dental practice to address tobacco use with patients, but there was variability in terms of the practice of specific tobacco cessation strategies. The most common perceived barrier was patient resistance/lack of motivation. In most of the studies, the majority of students were interested in being trained in tobacco cessation. The findings suggest that dental students will respond positively to receiving tobacco cessation education while in dental school and that educators should include strategies to help future dentists deal with patient resistance. Future studies should focus on the development of a validated measure of dental student attitudes toward tobacco cessation and longitudinal, multi-institutional research that can provide more generalizable findings.

Evaluation of a Web-Based Training in Smoking Cessation Counseling Targeting U.S. Eye-Care Professionals

Background. Smoking causes blindness-related diseases. Eye-care providers are uniquely positioned to help their patients quit smoking. Aims. Using a pre-/postevaluation design, this study evaluated a web-based training in smoking cessation counseling targeting eye-care providers. Method. The training was developed based on the 3A1R protocol: “Ask about smoking, Advise to quit, Assess willingness to quit, and Refer to tobacco quitlines,” and made available in the form of a web-based video presentation. Providers ( n = 654) at four academic centers were invited to participate. Participants completed pretraining, posttraining, and 3-month follow-up surveys. Main outcomes were self-reported improvement in their motivation, confidence, and counseling practices at 3-month follow-up. Generalized linear mixed models for two time-points (pretraining and 3-month) were conducted for these outcomes. Results. A total of 113 providers (54.0% males) participated in the study (17.7% response rate). At the 3-month evaluation, 9.8% of participants reported improvement in their motivation. With respect to the 3A1R, 8% reported improvement in their confidence for Ask, 15.5% for Advise, 28.6% for Assess, and 37.8% for Refer. Similarly, 25.5% reported improvement in their practices for Ask, 25.5% for Advise, 37.2% for Assess, and 39.4% for Refer to tobacco quitlines ( p < .001 for all except for Refer confidence p = .05). Discussion. Although participation rate was low, the program effectively improved providers’ smoking cessation counseling practices. Conclusions. Including training in smoking cessation counseling in ophthalmology curriculums, and integrating the 3A1R protocol into the electronic medical records systems in eye-care settings, might promote smoking cessation practices in these settings.

Assessing dental professionals' understanding of tobacco prevention and control: a qualitative study in Västerbotten County, Sweden

Aim:

To assess dental professionals’ understanding of tobacco prevention and control.

Materials and methods:

In Sweden dental hygienists receive training in tobacco prevention and control. The study setting is Västerbotton County in the north of Sweden where a number of successful tobacco control initiatives have been established. A purposeful sample comprising five male and four female dental professionals and trainees was selected. Data were collected through in-depth semi-structured individual interviews and analysed using content analysis.

Results:

Informants acknowledged limited adherence to tobacco prevention. They were not confident of their knowledge of tobacco and non-communicable disease prevention and had limited awareness of global oral health policies. Reasons for poor adherence included professional fragmentation, lack of training, and the absence of reimbursement for time spent on prevention activities.

Discussion:

The success of efforts to reduce smoking in Västerbotton County is attributed to the network of local public health initiatives with very limited involvement by local dental professionals.

Conclusions:

The findings highlight the need to more actively engage the dental workforce in tobacco control and prevention. Moreover, it is important to recognise that dental professionals can be public health advocates for tobacco control and prevention at global, national and local levels.

The tobacco-using periodontal patient: role of the dental practitioner in tobacco cessation and periodontal disease management

Although the prevalence of tobacco use has declined in some parts of the world, tobacco use remains a persistent and, in some cases, growing problem that will continue to be a fundamental challenge facing dental practitioners in the decades ahead. Dental practitioners have a unique opportunity and professional obligation to be a positive influence in reducing the economic and social burden inflicted by tobacco use on dental and general health. In this article, the current noninvasive, evidence-based approaches are presented for dental practitioners to help patients avoid initiating tobacco use, to encourage and assist patients in ceasing tobacco use and to address tobacco-induced damage to periodontal supporting tissues.

Receipt of evidence-based brief cessation interventions by health professionals and use of cessation assisted treatments among current adult cigarette-only smokers: National Adult Tobacco Survey, 2009-2010

Background

Helping tobacco smokers to quit during a medical visit is a clinical and public health priority. Research suggests that most health professionals engage their patients in at least some of the ‘5 A’s’ of the brief cessation intervention recommended in the U.S. Public Health Service Clinical Practice Guideline, but information on the extent to which patients act on this intervention is uncertain. We assessed current cigarette-only smokers’ self-reported receipt of the 5 A’s to determine the odds of using optimal cessation assisted treatments (a combination of counseling and medication).

Methods

Data came from the 2009–2010 National Adult Tobacco Survey (NATS), a nationally representative landline and mobile phone survey of adults aged ≥18 years. Among current cigarette-only smokers who visited a health professional in the past 12 months, we assessed patients’ self-reported receipt of the 5 A’s, use of the combination of counseling and medication for smoking cessation, and use of other cessation treatments. We used logistic regression to examine whether receipt of the 5 A’s during a recent clinic visit was associated with use of cessation treatments (counseling, medication, or a combination of counseling and medication) among current cigarette-only smokers.

Results

In this large sample (N = 10,801) of current cigarette-only smokers who visited a health professional in the past 12 months, 6.3 % reported use of both counseling and medication for smoking cessation within the past year. Other assisted cessation treatments used to quit were: medication (19.6 %); class or program (3.8 %); one-on-one counseling (3.7 %); and telephone quitline (2.6 %). Current cigarette-only smokers who reported receiving all 5 A’s during a recent clinic visit were more likely to use counseling (odds ratio [OR]: 11.2, 95 % confidence interval [CI]: 7.1–17.5), medication (OR: 6.2, 95 % CI: 4.3–9.0), or a combination of counseling and medication (OR: 14.6, 95 % CI: 9.3–23.0), compared to smokers who received one or none of the 5 A’s components.

Conclusions

Receipt of the ‘5 A’s’ intervention was associated with a significant increase in patients’ use of recommended counseling and medication for cessation. It is important for health professionals to deliver all 5 A’s when conducting brief cessation interventions with patients who smoke.

Dental patients' perceptions and motivation in smoking cessation activities

OBJECTIVE

The aim of the present study was to investigate smokers' perceptions of and motivation for smoking cessation activities in dentistry. MATERIALS AND METHODS PATIENTS: who smoked were consecutively recruited from general as well as specialist dental care clinics in Sweden. After a dental visit the patients completed a questionnaire about self-perceived oral health, smoking habits, motivation, reasons to quit and not to quit smoking, support to quit, smoking cessation activities and questions about smoking asked by dentists and dental hygienists.

RESULTS

The sample consisted of 167 adult patients (≥ 20 years) who smoked daily. During the last 6 months, 81% of the patients had experienced oral health problems. The most common complaints were discolourations of the teeth, periodontal problems and dry mouth (38%, 36% and 33%, respectively). Improved general health was a major reason to quit smoking (89%). It was also stated that it was important to avoid oral health problems. 71% of the patients preferred to quit by themselves and 16% wanted support from dentistry. High motivation to quit smoking was reported by 20%. Occurrence of periodontitis during the last 6 months was significantly associated with being highly motivated to stop smoking (OR = 3.0, 95% CI = 1.03-8.55).

CONCLUSIONS

This study revealed that, although it was important to quit smoking to avoid oral health problems, the patients were not aware that tobacco cessation activities can be performed in dentistry. Periodontal problems seem to be the most motivating factor among the patients who were highly motivated to stop smoking.

Survey of Australian oral health practitioners and their smoking cessation practices

BACKGROUND

Smoking is a significant health and economic burden in Australia. Studies of smoking cessation practices in dental settings have primarily concentrated on dentists rather than other oral health practitioner (OHP) groups (dental hygienists, dental therapists and oral health therapists). The aim of this study was to measure Australian OHPs' attitudes, behaviours, interest and barriers to delivering smoking cessation interventions.

METHODS

Members of the two peak professional bodies representing Australian OHPs were invited to participate in an anonymous online questionnaire.

RESULTS

There were discrepancies between practitioner attitudes and current smoking cessation practices. While the majority of practitioners (90.1%) frequently screened for smoking behaviour, fewer (51.1%) assisted patients to quit smoking. The principal form of assistance was referral to Quitline (45.7%) or to a general medical practitioner (44.4%). The most prevalent barriers identified were lack of knowledge of pharmacological treatments (45.8%) and lack of access to smoking cessation resources (44.2%). Contrary to international studies, time and financial incentive were not commonly cited barriers to delivering smoking cessation interventions.

CONCLUSIONS

This survey identifies a need for continuing education in smoking cessation practice. Dissemination of policies, guidelines and resources may assist OHPs to become more engaged and confident in delivering smoking cessation interventions as part of their routine practice.

Enrolling Smokers from Health Systems into Quitline Services: ‘Results of two enrollment strategies’

Objective: To determine the effects of motivational interviewing (MI) counselling versus a minimal intervention control on the enrollment of smokers in the Minnesota QUITPLAN Helpline.

Study design: Two-group randomized controlled trial of 235 community-dwelling adult smokers. Participants were randomly assigned to receive either a three-session phone based motivational interviewing intervention (n = 118) or the control (n = 117) consisting of mailed printed materials about the Minnesota QUITPLAN helpline services.

Data collection: Participants completed demographic and smoking-related survey questionnaire at baseline (by mail) and at weeks 4 and 26 (by phone) follow-up. Quitline enrollment status data was provided by the Minnesota QUITPLAN Helpline.

Principal findings: At week 4 follow-up, a higher proportion of participants in the MI group (22.3%) had enroled in the Minnesota QUITPLAN Helpline compared to those in the control arm (13.6%; p = 0.098). At week 26 follow-up, enrollment rates were similar for MI (28.0%) and control (26.5%) arms. Of those who enroled in the Helpline, participants in the MI group reported completing more Helpline sessions than those in control group (4.9 vs. 3.2; p = 0.087).

There was no significant interaction between readiness to quit and intervention for the outcome of enrollment in the Helpline.

Conclusions: A minimal intensity control such as mailing printed materials resulted in quitline enrollment rates similar to a more resource intensive intervention like motivational interviewing and several folds higher than the current state or national averages. We recommend that health plans should consider mailing smoking cessation promotional messages to encourage smokers to enrol in quitlines.

Dentists' self-perceived role in offering tobacco cessation services: results from a nationally representative survey, United States, 2010-2011

Introduction

Dental visits represent an opportunity to identify and help patients quit smoking, yet dental settings remain an untapped venue for treatment of tobacco dependence. The purpose of this analysis was to assess factors that may influence patterns of tobacco-use–related practice among a national sample of dental providers.

Methods

We surveyed a representative sample of general dentists practicing in the United States (N = 1,802). Multivariable analysis was used to assess correlates of adherence to tobacco use treatment guidelines and to analyze factors that influence providers’ willingness to offer tobacco cessation assistance if reimbursed for this service.

Results

More than 90% of dental providers reported that they routinely ask patients about tobacco use, 76% counsel patients, and 45% routinely offer cessation assistance, defined as referring patients for cessation counseling, providing a cessation prescription, or both. Results from multivariable analysis indicated that cessation assistance was associated with having a practice with 1 or more hygienists, having a chart system that includes a tobacco use question, having received training on treating tobacco dependence, and having positive attitudes toward treating tobacco use. Providers who did not offer assistance but who reported that they would change their practice patterns if sufficiently reimbursed were more likely to be in a group practice, treat patients insured through Medicaid, and have positive attitudes toward treating tobacco dependence.

Conclusion

Findings indicate the potential benefit of increasing training opportunities and promoting system changes to increase involvement of dental providers in conducting tobacco use treatment. Reimbursement models should be tested to assess the effect on dental provider practice patterns.

Dentists United to Extinguish Tobacco (DUET): a study protocol for a cluster randomized, controlled trial for enhancing implementation of clinical practice guidelines for treating tobacco dependence in dental care settings

BACKGROUND

Although dental care settings provide an exceptional opportunity to reach smokers and provide brief cessation advice and treatment to reduce oral and other tobacco-related health conditions, dental care providers demonstrate limited adherence to evidence-based guidelines for treatment of tobacco use and dependence.

METHODS/DESIGN

Guided by a multi-level, conceptual framework that emphasizes changes in provider beliefs and organizational characteristics as drivers of improvement in tobacco treatment delivery, the current protocol will use a cluster, randomized design and multiple data sources (patient exit interviews, provider surveys, site observations, chart audits, and semi-structured provider interviews) to study the process of implementing clinical practice guidelines for treating tobacco dependence in 18 public dental care clinics in New York City. The specific aims of this comparative-effectiveness research trial are to: compare the effectiveness of three promising strategies for implementation of tobacco use treatment guidelines-staff training and current best practices (CBP), CBP + provider performance feedback (PF), and CBP + PF + provider reimbursement for delivery of tobacco cessation treatment (pay-for-performance, or P4P); examine potential theory-driven mechanisms hypothesized to explain the comparative effectiveness of three strategies for implementation; and identify baseline organizational factors that influence the implementation of evidence-based tobacco use treatment practices in dental clinics. The primary outcome is change in providers' tobacco treatment practices and the secondary outcomes are cost per quit, use of tobacco cessation treatments, quit attempts, and smoking abstinence.

DISCUSSION

We hypothesize that the value of these promising implementation strategies is additive and that incorporating all three strategies (CBP, PF, and P4P) will be superior to CBP alone and CBP + PF in improving delivery of cessation assistance to smokers. The findings will improve knowledge pertinent to the implementation, dissemination, and sustained utilization of evidence-based tobacco use treatment in dental practices.

TRIAL REGISTRATION

NCT01615237.

Association of strong smoke-free laws with dentists' advice to quit smoking, 2006-2007

OBJECTIVES

We examined the association of smoke-free laws with dentists' advice to quit smoking and referral to a quit line, among smokers who reported visiting the dentist in the past 12 months.

METHODS

We used the 2006 to 2007 Tobacco Use Supplement of the Current Population Survey merged with the American Nonsmokers' Rights Foundation Local Ordinance Database of smoke-free laws. The dependent variables were advice from a dentist to quit smoking and referral to a quit line, and the independent variable of interest was 100% smoke-free law coverage. We controlled for respondent demographics and an index of state-level smoking ban attitudes (included to ensure that the effect detected was not the result of social attitudes).

RESULTS

Smoke-free law coverage was associated with dental advice to quit smoking (odds ratio [OR] = 1.27; 95% confidence interval [CI] = 1.01, 1.59; P = .041), but not with referral to a quit line (OR = 1.33; 95% CI = 0.79, 2.25; P = .283).

CONCLUSIONS

Interventions with dentists are needed to increase referrals to quit lines and other smoking cessation efforts.

Tobacco cessation in India: how can oral health professionals contribute?

Tobacco use is described as the single most preventable cause of morbidity and mortality globally, with the World Bank predicting over 450 million tobacco-related deaths in the next fifty years. In India, the proportion of all deaths that can be attributed to tobacco use is expected to rise from 1.4% in 1990 to 13.3% in 2020 of which smoking alone will cause about 930,000 adult deaths by 2010. Many studies have shown that counseling from a health professional is an effective method of helping patients quit the tobacco habit. Tobacco cessation needs to be urgently expanded by training health professionals in providing routine clinical interventions, increasing availability and subsidies of pharmacotherapy, developing wide-reaching strategies such as quitlines, and cost- effective strategies, including group interventions. The WHO Framework Convention on Tobacco Control (FCTC) emphasizes the vital contribution of participation of health professional bodies, as well as training and healthcare institutions in tobacco control efforts. Dentists can play an important role in helping patients quit using tobacco. One of the key strategies to reduce tobacco-related morbidity and mortality is to encourage the involvement of health professionals in tobacco-use prevention and cessation counselling. The dental office is an ideal setting for tobacco cessation services since preventive treatment services, oral screening, and patient education have always been a large part of the dental practice.

Substance-use screening and interventions in dental practices: survey of practice-based research network dentists regarding current practices, policies and barriers

BACKGROUND

Dental visits represent an opportunity to identify and assist patients with unhealthy substance use, but little is known about how dentists are addressing patients' use of tobacco, alcohol and illicit drugs. The authors surveyed dentists to learn about the role their practices might play in providing substance-use screening and interventions.

METHODS

The authors distributed a 41-item Web-based survey to all 210 dentists active in the Practitioners Engaged in Applied Research and Learning Network, a practice-based research network. The questionnaire assessed dental practices' policies and current practices, attitudes and perceived barriers to providing services for tobacco, alcohol and illicit drug use.

RESULTS

One hundred forty-three dentists completed the survey (68 percent response rate). Although screening was common, fewer dentists reported that they were providing follow-up counseling or referrals for substance use. Insufficient knowledge or training was the most frequently cited barrier to intervention. Many dentists reported they would offer assistance for use of tobacco (67 percent) or alcohol or illicit drugs (52 percent) if reimbursed; respondents who treated publicly insured patients were more likely to reply that they would offer this assistance.

CONCLUSIONS

Dentists recognize the importance of screening for substance use, but they lack the clinical training and practice-based systems focused on substance use that could facilitate intervention. Practical Implications. The results of this study indicate that dentists may be willing to address substance use among patients, including use of alcohol and illicit drugs in addition to tobacco, if barriers are reduced through changes in reimbursement, education and systems-level support.

Implementation of tobacco use cessation counseling among oral health professionals in Finland

OBJECTIVES

Clinical guidelines for tobacco use cessation (TUC) counseling recommend that healthcare professionals should provide brief tobacco counseling for all tobacco users. Widespread implementation of these guidelines seems to be insufficient. To enhance adherence to TUC counseling guidelines, it is essential to identify provider behaviors related to a successful implementation. This study aims to assess adherence to TUC counseling guidelines and factors that are associated with counseling behaviors.

METHODS

A 41-item questionnaire relevant to the implementation of TUC counseling guidelines among healthcare professionals was administered. This questionnaire included items used to evaluate TUC counseling behaviors as well Theoretical Domains Framework (TDF)-based behavior change items. Of the 95 oral health professionals invited from 34 community dental clinics in Finland, 73 professionals (76.8 percent) participated. The TDF factors and their associations to TUC counseling behaviors were analyzed using correlations and logistic regression analyses.

RESULTS

Adherence to TUC counseling guidelines, especially for providing advice to quit, assisting in quitting and arranging follow-up services, were low. In addition, only 15.1 percent of the providers reported asking about tobacco use and 8.2 percent assessed interest in quitting among the majority (>75 percent) of their patients. Of the behavior change domains, "Memory, Attention and Decision Processes" and "Professional Role and Identity" were found to be significantly associated with TUC counseling behavior among oral health professionals.

CONCLUSIONS

Regarding the adherence to TUC counseling guidelines, there is room for improvement. The identified TDF factors related to TUC behaviors provide an avenue for targeted interventions to improve guideline implementation.

Impact of educational intervention on implementation of tobacco counselling among oral health professionals: a cluster-randomized community trial

OBJECTIVES

Tobacco use adversely affects oral health. Clinical guidelines recommend that oral health professionals promote tobacco abstinence and provide patients who use tobacco with brief tobacco use cessation counselling. Research shows that these guidelines are seldom implemented successfully. This study aimed to evaluate two interventions to enhance tobacco use prevention and cessation (TUPAC) counselling among oral health professionals in Finland.

METHODS

We used a cluster-randomized community trial to test educational and fee-for-service interventions in enhancing TUPAC counselling among a sample of dentists (n=73) and dental hygienists (n=22) in Finland. Educational intervention consisted of 1 day of training, including lectures, interactive sessions, multimedia demonstrations and a role play session with standard patient cases. Fee-for-service intervention consisted of monetary compensation for providing tobacco use prevention or cessation counselling. TUPAC counselling procedures provided were reported and measured using an electronic dental records system. In data analysis, intent-to-treat principles were followed at both individual and cluster levels. Descriptive analysis included chi-square and t-tests. A general linear model for repeated measures was used to compare the outcome measures by intervention group.

RESULTS

Of 95 providers, 73 participated (76.8%). In preventive counselling, there was no statistically significant time effect or group-by-time interaction. In cessation counselling, statistically significant group-by-time interaction was found after a 6-month follow-up (F=2.31; P=0.007), indicating that counselling activity increased significantly in intervention groups. On average, dental hygienists showed greater activity in tobacco prevention (F=12.13; P=0.001) and cessation counselling (F=30.19; P<0.001) than did dentists. In addition, cessation counselling showed a statistically significant provider-by-group-by-time interaction (F=5.95; P<0.001), indicating that interventions to enhance cessation counselling were more effective among dental hygienists.

CONCLUSIONS

Educational intervention yielded positive short-term effects on cessation counselling, but not on preventive counselling. Adding a fee-for-service to education failed to significantly improve TUPAC counselling performance. Other approaches than monetary incentives may be needed to enhance the effectiveness of educational intervention. Further studies with focus on how to achieve long-term changes in TUPAC counselling activity among oral health professionals are needed.

The effect of training on the use of tobacco-use cessation guidelines in dental settings

BACKGROUND

An increase in the number of dentists conducting tobacco-use cessation treatment is needed. The authors assessed the effects of high-intensity training (HIT) or low-intensity training (LIT) and reimbursement on general dentists' tobacco-use-related attitudes and treatment behaviors.

METHODS

The authors randomly selected 265 dentists in three states and assigned them to one of five groups: HIT workshop groups with and without tobacco-use cessation counseling reimbursement, LIT mailed self-study groups with and without reimbursement or a control group. Outcomes at follow-up were dentists' self-reported tobacco-use-related attitudes and behaviors and patients' reports of dentists' behaviors.

RESULTS

Significantly more dentists in the intervention groups reported having positive attitudes and behaviors at follow-up than did dentists in the control group. Dentists in the HIT groups, however, reported assessing patients' willingness to quit and assisting them with the quitting process significantly more often than did dentists in the LIT groups. Significantly more patients of dentists in the intervention groups who used tobacco reported receiving advice and assistance from their dentists than did patients of dentists in the control group. Adding reimbursement to HIT or LIT conditions did not provide additional intervention effect.

CONCLUSION

Dentists trained by means of a workshop or self-study program used components of a recommended guideline more frequently and felt more positive toward tobacco-use cessation counseling than did dentists in the control group.

CLINICAL IMPLICATIONS

Although the workshop training was more successful than the self-study training, the latter's reach among dentists could have a more significant public health impact. The effect of reimbursement needs further study.

Reimbursing dentists for smoking cessation treatment: views from dental insurers

INTRODUCTION

Screening and delivery of evidence-based interventions by dentists is an effective way to reduce tobacco use. However, dental visits remain an underutilized opportunity for the treatment of tobacco dependence. This is, in part, because the current reimbursement structure does not support expansion of dental providers' role in this arena. The purpose of this study was to interview dental insurers to assess attitudes toward tobacco use treatment in dental practice, pros and cons of offering dental provider reimbursement, and barriers to instituting a tobacco use treatment-related payment policy for dental providers.

METHODS

Semi-structured interviews were conducted with 11 dental insurance company executives. Participants were identified using a targeted sampling method and represented viewpoints from a significant share of companies within the dental insurance industry.

RESULTS

All insurers believed that screening and intervention for tobacco use was an appropriate part of routine care during a dental visit. Several indicated a need for more evidence of clinical and cost-effectiveness before reimbursement for these services could be actualized. Lack of purchaser demand, questionable returns on investment, and segregation of the medical and dental insurance markets were cited as additional barriers to coverage.

CONCLUSIONS

Dissemination of findings on efficacy and additional research on financial returns could help to promote uptake of coverage by insurers. Wider issues of integration between dental and medical care and payment systems must be addressed in order to expand opportunities for preventive services in dental care settings.

Long-term effectiveness of adolescent brief tobacco intervention: a follow-up study

Background

Brief tobacco intervention has been used in promoting smoking cessation and preventing the initiation of smoking. We used a cohort born in 1979 (n = 2 586) from four cities in Finland. Those born on odd days received up to four brief tobacco interventions during their annual school dental check-ups in 1992-1994 (at the age of 13-15). Those who were born on even days were used as a control group. In 2008 a follow-up questionnaire was sent to the cohort. The aim of this study was to ascertain the long-term effectiveness of brief tobacco intervention given in dental health care during school age.

Findings

Responses were received from 529 people in the intervention group and 491 in the control group. In the intervention group and control group by the age of 29 there were 15.3% and 18.5% smokers respectively. This difference was not statistically significant. The difference between groups was similar to that observed when they were 14 years old.

Conclusions

Brief tobacco intervention performed in dental health care in adolescence did not show effectiveness in the long-term follow-up. This type of intervention alone is insufficient to prevent smoking but supports other anti-smoking activities.

Trial Registration

This study was registered at http://clinicaltrials.gov (NCT01348646).

Cognitive mapping tobacco control advice for dentistry: a dental PBRN study

OBJECTIVE

To identify facilitative strategies that could be used in developing a tobacco cessation program for community dental practices.

METHODS

Nominal group technique (NGT) meetings and a card-sort task were used to obtain formative data. A cognitive mapping approach involving multidimensional scaling and hierarchical cluster analysis was used for data analysis.

RESULTS

Three NGT meetings conducted with 23 dental professionals yielded 27 nonredundant facilitative strategies. A 2-dimensional 4-cluster cognitive map provided an organizational framework for understanding these strategies.

CONCLUSION

Views of the target population solicited in a structured format provided clear direction for designing a tobacco cessation intervention.

Are oral health complaints related to smoking cessation intentions?

OBJECTIVE

Smoking influences oral health in several ways (such as the occurrence of periodontitis, teeth discolouration and oral cancer); therefore, smoking behaviour should be addressed in dental care. Dentists can play a role in primary and secondary prevention of tobacco dependence. They see their patients repeatedly over time. This study investigates whether oral health complaints can be seized as an opportunity to start smoking cessation counselling.

METHODS

A structured patient questionnaire in a sample of 1101 smokers (52.1% women, mean age 40.4 years) in a convenience sample of 87 primary care dental practices. The I-change model was used to describe factors influencing behavioural change. Dependent factors such as intention to quit smoking and related factors (attitude, social support and self-efficacy) were analysed in relation to independent factors such as oral health complaints (gingiva problems, gingiva inflammation, oral cancer and discoloured teeth) using a general linear model (univariate analysis), multinomial logistic regression analysis and multiple linear regression analysis.

RESULTS

A total of 56.3% had discoloured teeth, 27% of the smokers had a problem with their gums and 15.7% had gingiva inflammation. We found no direct relation between oral health complaints and the intention to quit smoking. However, teeth discolouration was positively related to attitudes towards smoking cessation [β, Confidential interval (95%); 1.92 (1.45-2.40 for advantages and -0.86(-1.18 to -0.53) for disadvantages] and negatively to self-efficacy regarding quitting [-2.69 (-3.49 to 1.88)].

CONCLUSIONS

We found no direct relation between oral health complaints and the intention to quit smoking, but oral health complaints and especially teeth discolouration were related to factors influencing the quit intention. Patients with discoloured teeth are more likely to have a positive attitude towards smoking cessation but are uncertain to persist smoking cessation. It is suggested that teeth discolouration can be a good entrance for addressing smoking cessation in daily dental practice.

Do faxed quitline referrals add value to dental office-based tobacco-use cessation interventions?

BACKGROUND

The Ask, Advise, Refer (AAR) model of intervening with patients who use tobacco promotes a brief office-based intervention plus referral to a tobacco quitline. However, there is little evidence that this model is effective. The primary aim of this study was to evaluate the effects on patients' tobacco use of two levels of a dental office-based intervention compared with usual care.

METHODS

The authors randomly assigned 68 private dental clinics to one of three conditions: 5 As (Ask, Advise, Assess, Assist, Arrange); 3 As (AAR model); or usual care, and they enrolled 2,160 participants.

RESULTS

At the 12-month assessment, compared with those in usual care, participants in the two intervention conditions combined were more likely to report cessation of tobacco use, as measured by nine-month prolonged abstinence (3 percent versus 2 percent; F(1,66) = 3.97, P < .10) and 12-month point prevalence (12 percent versus 8 percent; F(1,66) = 7.32, P < .01). There were no significant differences between participants in the clinics using the 5 As and 3 As strategies.

CONCLUSIONS

The results of this study are inconclusive as to whether referrals to a quitline add value to brief dental office-based interventions. Patients receiving telephone counseling quit tobacco use at higher rates, but only a small percentage of those proactively referred actually received counseling.

CLINICAL IMPLICATIONS

The results confirm those of previous research: that training dental practitioners to provide brief tobacco-use cessation advice and assistance results in a change in their behavior, and that these practitioners are effective in helping their patients to quit using tobacco.

A cessation program for snuff-dippers with long-term, extensive exposure to Swedish moist snuff: A 1-year follow-up study

OBJECTIVE

Smokeless tobacco (Swedish moist 'snus') users are often strongly addicted to nicotine. Compared to the large number of smoking-cessation studies, there have been few evaluated clinical cessation programs in conjunction with nicotine replacement therapy (NRT). The aim of this study was to evaluate a cessation program for snus users with a weekly use of >2 cans/week for >10 years.

MATERIAL AND METHODS

A prospective, open, non-randomized intervention trial was undertaken including baseline oral examination and soft tissue biopsy, minor physical examination, brief cessation advice, NRT recommendations and five prospective follow-up visits within 12 months. Individual cessation counseling was given, together with oral examination in the dental office. Fifty snus users with a minimum consumption of 100 g/week who were actively seeking cessation treatment were recruited through advertising. Self-reported abstaining, including random-sample biochemical verification, and NRT use were evaluated at 6 weeks and 3, 6 and 12 months.

RESULTS

At the 3-, 6- and 12-month visits, 58%, 46% and 30% of subjects, respectively were tobacco-abstinent. All nicotine abstinence was randomly controlled during the study except at 12 months, where all subjects claiming abstinence were confirmed biochemically and clinically.

CONCLUSION

Smokeless tobacco cessation achieved together with suitable NRT seems a promising way to improve a persistent tobacco-free condition.

Smoking cessation quitlines: an underrecognized intervention success story

Quitlines providing telephone counseling for smoking cessation derive from behavioral research and theory, have been shown to be effective, and have been adopted and then institutionalized at both the state and national levels. Although psychologists have made seminal contributions to quitline development and evaluation, this accomplishment has gone largely unnoticed by the practice and research communities in clinical, counseling, and health psychology. This article summarizes the development, content, structure, empirical status, and current reach of cessation quitlines. We note the rich research opportunities afforded by quitlines, describe some recent approaches to improving their effectiveness, and suggest that an understanding of how quitlines work could also improve their effectiveness. The implications for practitioners and the potential application of telephone counseling to other disorders are also considered.

Tobacco cessation education for dentists: an evaluation of the lecture format

Dentists with tobacco cessation training perform more interventions, report increased self-efficacy, preparedness and fewer barriers than those without training. The aim of this study was to assess changes in knowledge, attitudes and behavior of dentists (CE group) at six months following presentation of a standardized tobacco cessation lecture module. These data were compared to those from age and gender-matched controls who did not receive training. The CE group was more likely to feel cessation was very important, score higher on knowledge questions, update tobacco use of continuing patients, ask former smokers about relapse and ask about daily consumption. The CE group was also more likely to discuss the personal relevance of quitting, roadblocks and setting quit dates, identify triggers, discuss pharmacotherapy and provide follow-up. These results suggest that group education appears to be a cost-efficient and effective method of teaching dentists about the latest methods of tobacco cessation.

Randomized controlled trial of an interactive internet smoking cessation program with long-term follow-up

BACKGROUND

Internet programs for smoking cessation are widely available but few controlled studies demonstrate long-term efficacy.

PURPOSE

To determine the 13-month effectiveness of an Internet program presenting a set sequence of interactive steps, and the role of depressed affect.

METHODS

In a randomized controlled trial sponsored by the American Cancer Society, a treatment condition (n = 1,106) was compared to a control site (n = 1,047).

RESULTS

More treatment condition participants were abstinent (30-day point prevalence) than control site participants (12.9% vs. 10.1%, p < .05) at 13 months. This effect was greater among participants not reporting depressed affect (15.0% vs. 10.1%, p < .01). Among smokers who reported depressed affect, there was no difference in abstinence between the treatment and control conditions.

CONCLUSIONS

Data support the long-term efficacy of an Internet intervention for cessation modeled on a structured, in-person treatment approach, especially for participants not experiencing daily depressed affect.

Tobacco cessation via doctors of chiropractic: results of a feasibility study

INTRODUCTION

There is a sizeable and growing body of empirical literature on the effects of physician advice to quit smoking. Because of the association between tobacco use and the health problems that may provoke referral to chiropractic care, doctors of chiropractic (DCs) may be able to give patients personalized proximal health feedback that may motivate them to quit. However, DCs have not been utilized in this role. The primary aim of this study was to design and refine a brief office-based tobacco intervention for use within chiropractic settings.

METHODS

This study was conducted in 20 private chiropractic practices in 2 phases: (a) intervention development, in which we created and focus tested practitioner and patient materials, and (b) feasibility, in which we evaluated the impact of the intervention on 210 tobacco-using chiropractic patients.

RESULTS

Analyses were conducted on 156 patients who exclusively smoked cigarettes. Using an intent-to-treat approach, assuming all nonresponders to be smokers, 13 (8.3%) reported 7-day abstinence at 6 weeks, 22 (14.1%) at the 6-month follow-up, and 35 (22.4%) at the 12-month assessment. Eleven participants (7.1%) reported prolonged abstinence at the 6-month follow-up, and 15 (9.6%) reported prolonged abstinence at 12 months.

CONCLUSIONS

To our knowledge, this is the first study to refine a brief office-based treatment for tobacco dependence for use in chiropractic settings. The results of this study were promising and will lead to a randomized clinical trial. If found to be effective, this model could be disseminated to chiropractic practitioners throughout the United States.

What determines the provision of smoking cessation advice and counselling by dental care teams?

OBJECTIVE

To investigate determinants of the provision of smoking cessation advice and counselling by various dental professionals in the dental team (dentists, dental hygienists and prevention auxiliaries).

DESIGN

Cross-sectional design.

SETTING

Sixty-two general dental practices in the Netherlands.

METHODS

Multivariate logistic analyses of self-reported counselling behaviour collected from questionnaires for dentists (n = 72), dental hygienists (n = 31) and prevention auxiliaries (n = 50) in general dental practices.

MAIN OUTCOME MEASURES

Stimuli and barriers for smoking cessation counselling and advice behaviour to patients with or without oral health problems.

RESULTS

Dental hygienists provided more general cessation advice and counselling than dentists. However, when patients had oral complaints, dentists counselled more often compared to prevention auxiliaries. The support from experienced colleagues positively influenced the provision of advice and counselling as well as the perceived self-efficacy for all kinds of dental professionals.

CONCLUSIONS

The provision of general smoking cessation advice to patients with no acute oral complaints can be improved by more involvement of the dentist and/or task delegation to prevention auxiliaries and dental hygienists. Social support is important in encouraging more smoking cessation advice and counselling. Implementation strategies for support of smoking cessation in dental care should focus on creating a positive advice culture among colleagues.

Improving access to smoking cessation services for disadvantaged groups: a systematic review

BACKGROUND

Smoking is a main contributor to health inequalities. Identifying strategies to find and support smokers from disadvantaged groups is, therefore, of key importance.

METHODS

A systematic review was carried out of studies identifying and supporting smokers from disadvantaged groups for smoking cessation, and providing and improving their access to smoking-cessation services. A wide range of electronic databases were searched and unpublished reports were identified from the national research register and key experts.

RESULTS

Over 7500 studies were screened and 48 were included. Some papers were of poor quality, most were observational studies and many did not report findings for disadvantaged smokers. Nevertheless, several methods of recruiting smokers, including proactively targeting patients on General Physician's registers, routine screening or other hospital appointments, were identified. Barriers to service use for disadvantaged groups were identified and providing cessation services in different settings appeared to improve access. We found preliminary evidence of the effectiveness of some interventions in increasing quitting behaviour in disadvantaged groups.

CONCLUSIONS

There is limited evidence on effective strategies to increase access to cessation services for disadvantaged smokers. While many studies collected socioeconomic data, very few analysed its contribution to the results. However, some potentially promising interventions were identified which merit further research.

Health risk behaviors in relation to making a smoking quit attempt among adolescents

The primary aim of this study was to examine youth risk behaviors in relation to: (a) making a smoking quit attempt, and (b) successful cessation among adolescent smokers. Data were analyzed from the public use dataset of the 2003 national school-based Youth Risk Behavior Survey. The sample consisted of 2,033 students (weighted mean age of 16.3 years, 49.8% female, 73.6% White) who reported a history of daily smoking. While almost two-thirds (63.5%) of adolescent smokers reported making a quit attempt in the last year, only 10% of those were able to successfully quit. Factors associated with making a quit attempt included depression and participating in sports while high-risk sexual activity and engaging in substance use other than alcohol or marijuana were negatively related to making a quit attempt. Externalizing health behaviors (e.g., fighting, drug use, and high risk sexual activity) were associated with decreased likelihood of cessation. Findings from this study may inform efforts to develop more effective smoking prevention and treatment programs for youth.

The 5A's vs 3A's plus proactive quitline referral in private practice dental offices: preliminary results

AIMS

The primary aim of our randomised control trial (RCT) was to evaluate the relative efficacy of two dental office based interventions compared to usual care. One intervention consisted of a combination of dental practitioner advice to quit and proactive telephone counselling (3A's), and the other arm consisted of a dental practitioner delivered intervention based on the 5A's of the Clinical Practice Guideline (5A's).

METHOD

2177 tobacco using patients were enrolled from 68 dental practices in Mississippi. We collected 3-month outcome data from 76% (n = 1652) of participants.

RESULTS

Smokers in the two intervention conditions quit at a higher rate than those in usual care; chi2 (1, n = 1381) = 3.10, p<0.05. Although not significant, more patients in the 5A's condition quit than those in the 3A's. Of patients in the 3A's Condition, 50% reported being asked by their dentist or hygienists about fax referral to the quitline, and 35% were referred. Quitline counsellors contacted 143 (70%) referred participants.

CONCLUSION

These results suggest that there are both advantages and disadvantages to the use of quitlines as an adjunct to brief counselling provided by dental practitioners. Patients receiving quitline counselling quit at higher rates than those who did not; however, only a small percentage of patients received counselling from the quitline. Therefore, it appears that dental professionals may be most effective in helping their patients to quit by regularly providing the 5A's plus proactively referring only those patients who are highly motivated to a quitline for more intensive counselling.