The COMMIT dental model: tobacco control practices and attitudes

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.

Interventions for tobacco cessation in the dental setting

BACKGROUND

Tobacco use has significant adverse effects on oral health. Oral health professionals in the dental office or community setting have a unique opportunity to increase tobacco abstinence rates among tobacco users.

OBJECTIVES

This review assesses the effectiveness of interventions for tobacco cessation delivered by oral health professionals and offered to cigarette smokers and smokeless tobacco users in the dental office or community setting.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register (CENTRAL), MEDLINE (1966-November 2011), EMBASE (1988-November 2011), CINAHL (1982-November 2011), Healthstar (1975-November 2011), ERIC (1967-November 2011), PsycINFO (1984-November 2011), National Technical Information Service database (NTIS, 1964-November 2011), Dissertation Abstracts Online (1861-November 2011), Database of Abstract of Reviews of Effectiveness (DARE, 1995-November 2011), and Web of Science (1993-November 2011).

SELECTION CRITERIA

We included randomized and pseudo-randomized clinical trials assessing tobacco cessation interventions conducted by oral health professionals in the dental office or community setting with at least six months of follow-up.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed abstracts for potential inclusion and abstracted data from included trials. Disagreements were resolved by consensus. The primary outcome was abstinence from smoking or all tobacco use (for users of smokeless tobacco) at the longest follow-up, using the strictest definition of abstinence reported. The effect was summarised as an odds ratio, with correction for clustering where appropriate. Heterogeneity was assessed using the I² statistic and where appropriate a pooled effect was estimated using an inverse variance fixed-effect model.

MAIN RESULTS

Fourteen clinical trials met the criteria for inclusion in this review. Included studies assessed the efficacy of interventions in the dental office or in a community school or college setting. Six studies evaluated the effectiveness of interventions among smokeless tobacco (ST) users, and eight studies evaluated interventions among cigarette smokers, six of which involved adult smokers in dental practice settings. All studies employed behavioral interventions and only one required pharmacotherapy as an interventional component. All studies included an oral examination component. Pooling all 14 studies suggested that interventions conducted by oral health professionals can increase tobacco abstinence rates (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.44 to 2.03) at six months or longer, but there was evidence of heterogeneity (I² = 61%). Within the subgroup of interventions for smokers, heterogeneity was smaller (I² = 51%), but was largely attributable to a large study showing no evidence of benefit. Within this subgroup there were five studies which involved adult smokers in dental practice settings. Pooling these showed clear evidence of benefit and minimal heterogeneity (OR 2.38, 95% CI 1.70 to 3.35, 5 studies, I² = 3%) but this was a posthoc subgroup analysis. Amongst the studies in smokeless tobacco users the heterogeneity was also attributable to a large study showing no sign of benefit, possibly due to intervention spillover to control colleges; the other five studies indicated that interventions for ST users were effective (OR 1.70; 95% CI 1.36 to 2.11).

AUTHORS' CONCLUSIONS

Available evidence suggests that behavioral interventions for tobacco cessation conducted by oral health professionals incorporating an oral examination component in the dental office or community setting may increase tobacco abstinence rates among both cigarette smokers and smokeless tobacco users. Differences between the studies limit the ability to make conclusive recommendations regarding the intervention components that should be incorporated into clinical practice, however, behavioral counselling (typically brief) in conjunction with an oral examination was a consistent intervention component that was also provided in some control groups.

The potential use of gingival crevicular blood for measuring glucose to screen for diabetes: an examination based on characteristics of the blood collection site

BACKGROUND

This study examined conditions under which gingival crevicular blood (GCB) could be used to obtain a useful glucose reading to screen for undiagnosed diabetes during routine dental visits.

METHODS

GCB and capillary finger-stick blood (CFB) glucose readings obtained with a glucometer were compared for 46 patients recruited from an urban university dental clinic. Study participants were divided into two groups based on probing depth or bleeding on probing (BOP) at the site of collection of the GCB sample. Group 1 participants had blood collected from sites with adequate BOP to obtain a sample without touching the tooth or gingival margin, whereas group 2 participants had blood collected from sites with little or no bleeding. For each group, Pearson correlations were calculated for glucose readings obtained using GCB and CFB samples, and the limits of agreement between the two samples were examined.

RESULTS

For group 1 participants, correlations between CFB and GCB glucose readings were high (0.89), and the limits of agreement were acceptable (-27.1 to 29.7). By contrast, for participants in group 2, correlations between the glucose readings were lower (0.78), and limits of agreement were much broader (-25.1 to 80.5).

CONCLUSION

GCB samples were suitable to screen for diabetes in persons with sufficient BOP to obtain a sample without touching the tooth or gingival margin (i.e., in patients having the basic clinical signs of gingivitis or periodontal disease).

The impact of smoking-cessation intervention by multiple health professionals

BACKGROUND

Smokers have contact with many different types of health professionals. The impact of tobacco intervention by multiple types of heath professionals is not known.

METHODS AND MATERIALS

As part of the 2003 Minnesota Adult Tobacco Survey, smokers (n=1723) reported on tobacco treatment by medical doctors, nurses, dentists, pharmacists, or other health professionals. This analysis examined: (1) smokers' report of tobacco intervention by different types of healthcare providers, (2) the proportion of smokers who report intervention by multiple provider types, and (3) the relationship between smokers' report of intervention by multiple provider types and readiness to quit, quit attempts, and recent quitting.

RESULTS

Among past-year smokers, 65% had visits with two or more types of health professionals. Among smokers who visited health professionals (n=1523), only 34% reported being asked about smoking by two or more types of professionals. Among current smokers (n=1324), advice or assistance from more than one type of professional was uncommon (26% and 7%, respectively). Being asked about smoking by two or more types of professionals substantially increased the odds of recent quitting (OR=2.37; 95% CI=1.15-4.88). Among current smokers, being advised to quit by two or more types of professionals increased the odds of having made a quit attempt in the past year (OR=2.92; 95% CI=1.56-5.45) or intending to quit in the next 6 months (OR=2.17; 95% CI=1.10-4.29).

CONCLUSIONS

Smoking-cessation interventions by more than one type of health professional have the potential to substantially increase quitting and readiness to quit in the population.

Management of smoking patients by specialist periodontists and hygienists in the United Kingdom

OBJECTIVE

To assess the management of patients who are current smokers in dental practice.

MATERIALS AND METHODS

A postal questionnaire to the 243 periodontists on the UK specialist register and 239 randomly selected hygienists on the General Dental Council register.

RESULTS

Eighty per cent of both groups responded. There were significant demographic differences between the two groups of respondents: 88% of periodontists were in specialist practice and/or hospital or university departments, while 89% of hygienists were in general dental practice. Periodontists routinely asked their patients about smoking 99% of the time, hygienists 89%. More than 5 min. was spent advising a smoker patient by 35% of periodontists and 19% of hygienists. A proportion of both groups claimed to have had some recognized training in quit smoking (44% and 39%). When asked about the oral conditions of their smoking patients, 26% of periodontists stated that these patients did not have poorer oral hygiene, while 67% of hygienists thought that they did. While the majority of both groups discussed the oral effects of smoking, less than two-thirds discussed methods of giving up.

CONCLUSION

Both periodontists and hygienists are generally aware of the problems of treating smokers, and accordingly ask and advise their patients. However, lack of time and poor patient response may inhibit active involvement in assisting patients to quit smoking.

Interventions for tobacco cessation in the dental setting

BACKGROUND

Tobacco use has significant adverse effects on oral health. Oral health professionals in the dental office or community setting have a unique opportunity to increase tobacco abstinence rates among tobacco users.

OBJECTIVES

This review assesses the effectiveness of interventions for tobacco cessation offered to cigarette smokers and smokeless tobacco users in the dental office or community setting.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction group Specialized Register (CENTRAL), MEDLINE (1966-2004), EMBASE (1988-2004), CINAHL (1982-2004), Healthstar (1975-2004), ERIC (1967-2004), PsycINFO (1984-2004), National Technical Information Service database (NTIS, 1964-2004), Dissertation Abstracts Online (1861-2004), Database of Abstract of Reviews of Effectiveness (DARE, 1995-2004), and Web of Science (1993-2004).

SELECTION CRITERIA

We included randomized and pseudo-randomized clinical trials assessing tobacco cessation interventions conducted by oral health professionals in the dental office or community setting with at least six months of follow up.

DATA COLLECTION AND ANALYSIS

Two authors independently reviewed abstracts for potential inclusion and abstracted data from included trials. Disagreements were resolved by consensus.

MAIN RESULTS

Six clinical trials met the criteria for inclusion in this review. Included studies assessed the efficacy of interventions in the dental office or a school community setting. All studies assessed the efficacy of interventions for smokeless tobacco users, one of which included cigarettes smokers. All studies employed behavioural interventions and only one offered pharmacotherapy as an interventional component. All studies included an oral examination component. Pooling of the studies suggested that interventions conducted by oral health professionals increase tobacco abstinence rates (odds ratio [OR] 1.44; 95% confidence interval [CI]: 1.16 to 1.78) at 12 months or longer. Heterogeneity was evident (I(2) = 75%) and could not be adequately explained through subgroup or sensitivity analyses.

AUTHORS' CONCLUSIONS

Available evidence suggests that behavioural interventions for tobacco use conducted by oral health professionals incorporating an oral examination component in the dental office and community setting may increase tobacco abstinence rates among smokeless tobacco users. Differences between the studies limit the ability to make conclusive recommendations regarding the intervention components that should be incorporated into clinical practice.

Tobacco attitudes, practices, and behaviors: A survey of dentists participating in managed care

Tobacco cessation knowledge, attitudes, and behaviors of dentists participating in a large national managed care dental plan were assessed using a mailed survey. The survey was administered to dentists recruited to participate in an evaluation of a CD-ROM and supportive electronic detailing to promote increased tobacco cessation activities. General dentists who met specific technological criteria, had an active E-mail account, and at least 200 adult patients were eligible to participate in this study. A total of 184 dentists, located in 29 states, agreed to participate. The survey instrument included questions that addressed (a) Ask, Advise, Assess, Assist, and Arrange behaviors, (b) self-efficacy including knowledge, confidence, and success regarding tobacco cessation, (c) success of various tobacco cessation strategies, (d) barriers to tobacco cessation, and (e) demographics including year of graduation, gender, and race/ethnicity. Self-reported baseline tobacco intervention-related behaviors were low, with 28% of dentists reporting that they asked their patients about tobacco or recorded tobacco use in their patients' charts at least 41% of the time. For Advise behavior, approximately half of the dentists advised tobacco-using patients to quit at least 41% of the time. Although self-reported lack of knowledge was high, 71% of respondents indicated that their lack of knowledge was either not a barrier or a slight barrier to incorporating tobacco cessation into their practices. The survey revealed that dentists do not routinely incorporate tobacco cessation into their practices. Newer information-transfer technologies may serve as vehicles for increased smoking cessation activities by dentists.

Tobacco prevention in Swedish dental care

OBJECTIVE

To assess tobacco prevention in Swedish dental care and to identify barriers. Also, to investigate whether dentists and dental hygienists were familiar with recently published review of smoking cessation methods.

METHODS

A questionnaire was mailed to all 353 dental hygienists and 528 dentists in Stockholm County.

RESULTS

The overall response rate was 61% for the dentists and 67% for the dental hygienists. Nearly all considered smoking to be a major health issue, but one out of two was not convinced that smokeless tobacco use was a major health problem. A small minority was routinely engaged in cessation support. However, on the aggregate level, the active dentists and hygienists advised annually approximately 70 000 and 40 000 smokers, respectively. The main barrier to cessation counseling was lack of smoking cessation experts to refer to and was followed by a lack of reimbursement, a lack of knowledge, time constraints, and a feeling of inadequacy. Also, one out of two dentists and 3 out of 10 hygienists did not see it as a part of their job to help patients stop smoking. Approximately 10% in both groups made use of the review of smoking cessation methods. Fifty per cent of these had increased their cessation consultations by an average of 30% because of the guidelines. On the average, dentists and hygienists had spent approximately 1.4 and 2.9 h, respectively, during the previous month on all smoking cessation activities.

CONCLUSIONS

Despite several barriers, there is an excellent potential for a more active role in tobacco cessation counseling in Swedish dental care.

Addressing tobacco in managed care: a survey of dentists' knowledge, attitudes, and behaviors

OBJECTIVES

This study assessed the tobacco cessation knowledge, attitudes, and behaviors of dentists participating in a large managed care dental plan.

METHODS

Participating dentists in 4 states were surveyed via mail.

RESULTS

Dentists' perceived success in helping patients quit using tobacco was highly correlated with discussion of specific strategies for quitting, advice about the use of nicotine gum, and time spent counseling patients. Dentists who were confident about their smoking cessation knowledge frequently advised patients to quit and spent more time counseling patients about tobacco cessation.

CONCLUSIONS

Tobacco cessation is not a routine part of dental practice. Knowledge, time spent counseling patients, and specific strategies for quitting were associated with dentists' perceptions of success.

Training chemical dependency counselors to treat nicotine dependence

To test the effectiveness of providing chemical dependency (CD) staff with a knowledge-and-skills-building workshop on treatment of nicotine dependence, we employed a nested cross-sectional design with six outpatient CD programs in Nebraska (3 intervention, 3 control sites). Data on tobacco counseling provided by CD staff were obtained by telephone from sequential samples of smokers currently receiving alcohol treatment at each participating site. Intervention site clients with clinic visits after the staff training workshop were no more likely than intervention-site clients with clinic visits before the workshop to report having been counseled about their smoking (OR = 0.95, 95% confidence interval (CI): 0.74-1.21). However, control-site clients were significantly more likely to report having been counseled about smoking during the second half of the study (OR = 2.15, 95% CI: 1.49-3.08), even though staff training was not provided at control sites until data collection had been completed. These findings suggest that in some alcohol treatment programs simple monitoring of staff counseling practices may be sufficient to increase the frequency of attention to tobacco. In others, more intensive efforts might be needed to shift CD staff toward more consistent treatment of nicotine dependence.