Factors that influence delivery of tobacco cessation support in general dental practice: a narrative review

Barriers and facilitators to using an objective risk communication tool during primary care dental consultations: A Theoretical Domains Framework (TDF) informed qualitative study

OBJECTIVES

Objective risk communication tools can supplement clinical judgement and support the understanding of potential health risks. This study used the Theoretical Domains Framework (TDF) to identify barriers and facilitators to implementing a risk communication aid within primary care dental consultations.

METHODS

Dentists (N = 13), recruited via a dental practice database and through professional contacts were interviewed using a TDF-informed semi-structured interview schedule. Data were analysed inductively and deductively coding the themes using the TDF.

RESULTS

Eight theoretical domains (environmental context and resources; beliefs about consequences; goals; memory, attention, and decision processes; optimism; reinforcement; social influences and behavioural regulation) and thirteen sub-themes were identified. Insufficient resources and patient factors were commonly encountered barriers and led to increasing pressure to prioritise other tasks. Whilst dentists had a favourable view towards a risk communication aid and acknowledged its benefits, some were sceptical about its ability to facilitate behaviour change. Self-monitoring strategies and colleague support facilitated tool usage.

CONCLUSIONS

This study identified six barriers and seven facilitators to implementing a risk communication tool within primary care dental settings. Dentists appreciated the value of using a risk communication tool during dental consultations, although some required further support to integrate the tool into practice.

CLINICAL SIGNIFICANCE

Our findings provide a sound theoretical base for interventions aimed at facilitating patient behaviour change through the use of risk communication in dentistry. Further research should apply behavioural science to support the implementation of the tool in clinical practice.

Smokeless Tobacco Cessation Support in Dental Hospitals in Pakistan: Dentists and Dental Patients' Perspectives on Current Practices, Support Needed, and Opportunities Available

INTRODUCTION

Despite evidence on the effectiveness of tobacco cessation interventions in dental settings, the implementation remains low, especially for smokeless tobacco (ST). The purpose of this study was to develop an understanding of the influences governing the implementation of ST cessation support in dental hospitals.

AIMS AND METHODS

A multicenter qualitative study was conducted at two tertiary-care dental hospitals, in Pakistan. Semi-structured interview guide, guided by the Capability-Opportunity-Motivation-Behavior (COM-B) model, were used to capture the views of dentists (n = 12) and dental patients (n = 12), regarding ST cessation support in dental hospitals. Framework approach was used to thematically analyze the data.

RESULTS

Screening of ST users in routine dental practice was seldom practiced and the cessation support offered was brief advice. Barriers identified by dentists included: Fear of offending and stereotyping patients; lack of knowledge and skills; lack of privacy; lack of belief in the effectiveness of behavioral support; lack of time and workload pressure; ST use amongst dentists; lack of referral systems and; the absence of a mandatory requirement of offering ST cessation support. Facilitators included: Delivering support through junior dentists and the length of interaction between the dentist and the patient. Naswar was the most common ST product used by dental patients. Patients reported receiving negligible cessation support from any healthcare provider.

CONCLUSIONS

A range of influences governing the implementation of ST cessation support in dental hospitals were identified. These findings can inform the implementation of behavioral interventions for ST cessation in dental and other clinical settings, in low and middle-income countries.

IMPLICATIONS

Smokeless tobacco control considerably lags, in comparison to the control of combustible tobacco. This is the first study that qualitatively explores the implementation of ST cessation support in dental settings in Pakistan. Utilizing the "Capability-Opportunity-Motivation-Behavior" model, it provides an in-depth understanding of the inability of dentists in implementing effective behavioral interventions for ST cessation support in routine dental practice. Highlighting the striking discrepancy between the patient's need for and receptivity towards cessation support and the dentists' concerns over their patients' receptivity towards cessation support, it calls for the need for effective implementation strategies to optimize dentist-led tobacco cessation interventions in low-resource settings.

Results From a National Survey of Asthma Provider Beliefs and Practices Regarding Exercise and Asthma: A Work Group Report of the AAAAI Committee on Sports, Exercise, and Fitness

BACKGROUND

National Heart, Lung, and Blood Institute guidelines recommend regular physical activity (PA) for patients with asthma. Health care provider (HCP) counseling represents an effective approach to optimizing patient PA. However, current exercise rates among asthma patients are suboptimal, which suggests that counseling may be improved.

OBJECTIVE

To understand PA counseling behaviors among HCPs who manage asthma.

METHODS

A voluntary 36-item survey assessing self-reported awareness of PA recommendations and current clinical practices was sent to 979 randomly selected HCP members of the American Academy of Allergy, Asthma & Immunology (AAAAI).

RESULTS

The overall response rate was 9.3% (91 of 979). Respondents were physicians (100%) and allergists/immunologists (96%) who reported an average of 18.1 ± 12.3 years in independent practice. Over half (58%) reported personally engaging in 150 min/wk or more of moderate to strenuous PA. Eighty percent of participants were unaware of specific PA guidelines for patients with asthma, yet 66% acknowledged evidence for improved asthma outcomes with moderate exercise. A large majority of respondents believed that patients with asthma (97%) and severe asthma (84%) should pursue exercise. Whereas 90% of respondents support incorporating exercise counseling into asthma care, only 69% regularly counsel asthma patients about PA. Barriers cited included limited time, lack of knowledge regarding how and where to refer patients for exercise, and other medical priorities. Potential facilitators of PA included increasing practitioner education and patient-directed posters in waiting areas.

CONCLUSIONS

Health care providers recognized PA as an important component of asthma care but were often unaware of specific guidelines. Promoting PA counseling may require using a time-efficient approach to implement counseling at each asthma patient encounter.

Smoking-cessation advice from dental care professionals and its association with smoking status: Analysis of National Health and Nutrition Examination Survey 2015-2018

BACKGROUND

Smoking remains a major contributor to mortality and morbidity. Dental care professionals are positioned to help patients quit smoking. Results of clinical trials have shown the efficacy of dental care professionals' smoking-cessation advice; however, the evidence of its effectiveness in the general population in the United States is limited. The authors examined the association between smoking-cessation advice from dental care professionals and quitting behaviors of adult smokers in the general population.

METHODS

The authors used an observational study design with data from the National Health and Nutrition Examination Survey for the years 2015 through 2018. The authors included 1,024 respondents 18 years and older who were current or former smokers who quit smoking within the past 12 months and reported a dental visit within the past 12 months.

RESULTS

Among the study sample, 44.6% received smoking-cessation advice from a dental care professional. The authors found no significant association between smoking-cessation advice and any attempt to quit smoking (as a binary outcome; adjusted odds ratio, 1.11; 95% CI, 0.68 to 1.80; P = .677). Although respondents who received smoking-cessation advice reported 18% more quit attempts (on a continuous scale; adjusted rate ratio, 1.18; 95% CI, 1.00 to 1.39, P = .05), smoking-cessation advice was not associated with smoking abstinence beyond 6 months.

CONCLUSIONS

Receiving smoking-cessation advice from a dental care professional was associated with more attempts to quit smoking but not with abstinence of 6 months or longer.

PRACTICAL IMPLICATIONS

Additional efforts seem to be needed for smoking cessation in dental practices. Implementing enhanced incentive programs or promoting tobacco-use cessation certification in dental education may be an effective strategy to enhance dental professionals' knowledge and skills in providing additional support to their patients.

Delivering Opportunistic Behavior Change Interventions: a Systematic Review of Systematic Reviews

Opportunities for healthcare professionals to deliver health behavior change interventions are often missed, but understanding the barriers and enablers to this activity is limited by a focus on defined specialisms/health conditions. This systematic review of systematic reviews collates all the evidence across professional groups to provide guidance to policy makers for implementing healthcare professional delivery of behavior change interventions. Eight electronic databases were searched for systematic reviews reporting patient-facing healthcare professionals’ (e.g., general practitioners, nurses) barriers and enablers to delivering behavior change interventions (diet, physical activity, alcohol reduction, smoking cessation, and weight management). A narrative synthesis was conducted. Thirty-six systematic reviews were included. Four themes emerged as both barriers and enablers: (1) perceptions of the knowledge or skills needed to support behavior change with patients, (2) perceptions of the healthcare professional role, (3) beliefs about resources and support needed, and (4) healthcare professionals’ own health behavior. There were four cross-disciplinary barriers: (1) perceived lack of time, (2) perceived lack of prioritization of health behavior change, (3) negative attitudes towards patients and perceptions of patient risk, and (4) perceptions of patient motivation. The three enablers were as follows: (1) training, (2) context, and (3) attitudes towards delivering interventions. To enhance healthcare professionals’ delivery of behavior change interventions, policy makers should (a) address perceptions about patient need for interventions, (b) support diverse professional groups to identify opportunities to deliver interventions, and (c) encourage professionals to focus on prevention and management of health conditions.

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.

Perceived influences on smoking behaviour and perceptions of dentist-delivered smoking cessation advice: A qualitative interview study

OBJECTIVES

Many factors lead to the commencement and maintenance of smoking, and better understanding of these is relevant in the management of oral health, particularly as smoking cessation advice (SCA) from the dental team is a key component of patient care. Whereas most previous research has focused on dental professionals' perceptions of providing SCA, and identified facilitators and barriers to its provision, there has been more limited research focusing on patients' perceptions of receiving SCA in the dental context. Accordingly, this study aimed to explore the views of smokers with periodontitis receiving dentist-delivered SCA.

METHODS

One-to-one, semi-structured interviews were conducted with a purposive sample of 28 adults who smoked tobacco and had recently received SCA during dentist-delivered periodontal therapy. Participants were sampled to reflect a range of ages and smoking behaviours. The interview schedule was based on the Theoretical Domains Framework (TDF) to explore perceived influences on smoking behaviour. Interviews also elicited participants' views on dentist-delivered SCA. Interviews were audio-recorded, transcribed verbatim and analysed thematically, drawing on the TDF.

RESULTS

A broad range of perceived influences on smoking behaviour emerged from the data. Influences were allocated into seven prominent TDF domains: (i) social influences (family and friends, social pressures); (ii) social/professional role and identity (secret smoking); (iii) knowledge (experiences/perceptions of smoking cessation medications); (iv) environmental context and resources (social, home and workplace environment, cost of smoking, resentment towards authority); (v) emotions (stress management, pleasure of smoking and fear of quitting); (vi) nature of the behaviour (habitual nature, link to other behaviours, smell); and (vii) beliefs about consequences (health). With regard to views on dentist-delivered SCA, five main themes emerged: (i) opportunistic nature; (ii) personal impact and tangible prompts; (iii) positive context of cessation attempt; (iv) lack of previous support; and (v) differences between dentist-delivered SCA and other setting SCA.

CONCLUSIONS

Smokers with periodontitis consider that a wide range of factors influence their smoking behaviour. Dentist-delivered SCA was supported and positively received. Important aspects included the opportunistic nature, personal impact, use of tangible prompts and positive context (of the quit attempt). Future research should focus on optimizing dentist-led smoking cessation intervention based on the themes identified.

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.

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.

'It's difficult, I think it's complicated': Health care professionals' barriers and enablers to providing opportunistic behaviour change interventions during routine medical consultations

OBJECTIVES

Internationally, public health strategies encourage health care professionals to deliver opportunistic behaviour change interventions. The present study: (1) examines the barriers and enablers to delivering interventions during routine consultations, and (2) provides recommendations for the design of interventions to increase delivery of opportunistic behaviour change interventions.

DESIGN

Qualitative interview study.

METHODS

Twenty-eight semi-structured interviews were conducted with patient-facing health care professionals. The Behaviour Change Wheel informed a framework analysis in which findings were mapped onto the Theoretical Domains Framework (TDF). Intervention functions and behaviour change techniques (BCTs) targeting each TDF domain were identified.

RESULTS

Health care professionals understood the importance of opportunistic behaviour change interventions (beliefs about consequences), but were sceptical about their capabilities to facilitate behaviour change with patients (beliefs about capabilities). Some clinicians were unwilling to discuss behaviours perceived as unrelated to the patient's visit (social/professional role and identity). Discipline-specific tasks were prioritized, and delivering interventions was perceived as psychologically burdensome. One-to-one contact was favoured over busy hospital settings (environmental context and resources). Seven intervention functions (training, restriction, environmental restructuring, enablement, education, persuasion, and modelling) and eight BCT groupings (antecedents, associations, comparison of outcomes, covert learning, feedback and monitoring, natural consequences, reward and threat, and self-belief) were identified.

CONCLUSIONS

Across disciplines, health care professionals see the value of opportunistic behaviour change interventions. Barriers related to workload, the clinical environment, competence, and perceptions of the health care professional role must be addressed, using appropriate intervention functions and BCTs, in order to support health care professionals to increase the delivery of interventions in routine practice. Statement of contribution What is already known on this subject? Brief, opportunistic interventions can be a cost effective way of addressing population health problems. Public health policies compel health care professionals to deliver behaviour change interventions opportunistically. Health care professionals do not always deliver interventions opportunistically during routine medical consultations; however the barriers and enablers are currently unclear. What does this study add? This is the first study to examine cross-disciplinary barriers and enablers to delivering opportunistic behaviour change interventions. Across diverse professional groups, working in different medical professions, participants saw the value of delivering opportunistic behaviour change interventions. Targeting key theoretical domains that are shared across professional groups may be useful for increasing the delivery of opportunistic behaviour change interventions.

Permanence of Modifications in Oral Microcirculation in Ex-Smokers

Background

The aim of this study was to assess the long-term effects of smoking and to investigate the permanence of this damage to the oral microcirculation.

Material/Methods

We recruited 75 patients and divided them into 3 groups: group 1 was composed of 25 healthy non-smokers, group 2 was composed of 25 healthy current smokers, and group 3 was composed of 25 healthy ex-smokers. Video-capillaroscopic examination was performed on all patients.

The video-capillaroscopic investigation was performed on patients in sitting position, always with the same light source, at the same room temperature (23°C), in the morning, with the same operator (GAS), and was repeated many times for every area under investigation. An enlargement of 200× allowed us to explore point-by-point all the morpho-structural characteristics of the capillaroscopic field. For non-parametric data, we evaluated the visibility of the loops and their position in relation to the surface of the mucosa. The evaluated parametric data were length of capillary loop, diameter of the loop, capillary tortuosity, and capillary density.

Results

Our study clearly shows there was no remission of vascular damage, even 13 years after smoking cessation.

Conclusions

Our research shows that that the effects of smoking are still visible in ex-smokers, even at 13 years after cessation and also that ex-smokers are still subject to the risk of oral pathologies in the interval of time that we considered.

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.

Are healthcare professionals delivering opportunistic behaviour change interventions? A multi-professional survey of engagement with public health policy

BACKGROUND

"Making Every Contact Count" (MECC), a public health policy in the UK, compels healthcare professionals to deliver opportunistic health behaviour change interventions to patients during routine medical consultations. Professionals' awareness of, and engagement with, the policy is unclear. This study examined (1) awareness of the MECC policy, and (2) the prevalence of MECC-related practice in relation to (a) perceived patient benefit, (b) how often healthcare professionals deliver interventions during routine consultations, and (c) the time spent on this activity.

METHODS

Cross-sectional national survey was administered in 2017 of 1387 healthcare professionals working in the UK's National Health Service (NHS). Descriptive statistics were used to assess awareness and practice consistent with the MECC policy. Chi-square was used to gauge the potential representativeness of our sample compared to NHS employment data.

RESULTS

31.4% of healthcare professionals reported having heard of the policy; nevertheless, healthcare professionals perceived a need to provide patients with opportunistic behaviour change interventions in 55.9% (32,946/58,906) of consultations. However, healthcare professionals did not deliver interventions on 50.0% of occasions in which they perceived a need. Where behaviour change interventions were delivered to patients, this constituted 35.3% of the appointment time.

CONCLUSIONS

Policy makers must address the gap between the proportion of patients that healthcare professionals perceive would benefit from opportunistic behaviour change interventions and those receiving them (an estimated 50.0%; 16,473 additional patients could have benefited). Future research should consider how healthcare professionals identify patients who might benefit from opportunistic behaviour change interventions and developing training for efficient delivery of interventions.

Systematic Review of Clinician-Reported Barriers to Provision of Smoking Cessation Interventions in Hospital Inpatient Settings

Background: Although the hospital inpatient setting arguably provides an ideal opportunity to engage patients in smoking cessation interventions, this is done infrequently. We therefore aimed to systematically review the perceived barriers to the implementation of smoking cessation interventions in the hospital inpatient setting.

Methods: A systematic literature search was conducted specific to hospital-based healthcare workers’ perceived barriers to implementing smoking cessation interventions. Reported barriers were categorised using the capability, opportunity and motivation (COM-B) framework.

Results: Eighteen studies were selected for inclusion, which consisted of cross-sectional surveys and interviews. The most commonly identified barrier in capability was lack of knowledge (56% of studies); in Opportunity, it was a lack of time (78%); while in Motivation, a lack of perceived patient motivation to quit smoking (44%). Seventeen other barriers were also endorsed, but less frequently.

Conclusion: Healthcare workers report a plethora of barriers to providing smoking cessation interventions in hospital settings, which cover all aspects of the COM-B framework. These impediments need to be addressed in a multidisciplinary approach, at clinical, educational, and administrative levels, to improve intervention provision.