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

The Effectiveness and Cost of an Intervention to Increase the Provision of Preventive Care in Community Mental Health Services: Protocol for a Cluster-Randomized Controlled Trial

Preventive care to address chronic disease risk behaviours is infrequently provided by community mental health services. In this cluster-randomised controlled trial, 12 community mental health services in 3 Local Health Districts in New South Wales, Australia, will be randomised to either an intervention group (implementing a new model of providing preventive care) or a control group (usual care). The model of care comprises three components: (1) a dedicated ‘healthy choices’ consultation offered by a ‘healthy choices’ clinician; (2) embedding information regarding risk factors into clients’ care plans; and (3) the continuation of preventive care by mental health clinicians in ongoing consultations. Evidence-based implementation strategies will support the model implementation, which will be tailored by being co-developed with service managers and clinicians. The primary outcomes are client-reported receipt of: (1) an assessment of chronic disease risks (tobacco smoking, inadequate fruit and vegetable consumption, harmful alcohol use and physical inactivity); (2) brief advice regarding relevant risk behaviours; and (3) referral to at least one behaviour change support. Resources to develop and implement the intervention will be captured to enable an assessment of cost effectiveness and affordability. The findings will inform the development of future service delivery initiatives to achieve guideline- and policy-concordant preventive care delivery.

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

BACKGROUND

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

AIM

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

OBJECTIVES

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

METHODS

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

RESULT

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

CONCLUSION

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

Utilisation of a brief tobacco smoking cessation intervention tool in public dental services

ISSUE ADDRESSED

Dental practitioners have an important opportunity to promote smoking cessation. This study aimed to determine how many smokers attended West Moreton Oral Health Service (WMOHS), completion rates for the standardised Smoking Cessation Pathway, and smoking cessation practices, confidence levels and attitudes of dental practitioners in WMOHS.

METHODS

A mixed-methods approach collected clinical and demographic data from a retrospective audit of WMOHS reports from 1 August 2017 to 31 July 2019 and a cross-sectional survey of WMOHS dental practitioners. Logistic regression models determined factors associated with smoking status and delivery of the Pathway.

RESULTS

Over 24 months, 14,919 courses of care (COC) were completed. Twenty-five percent of patients identified as current smokers. The Pathway was delivered in 54% (n = 1999) of smokers' COC, which was significantly associated with patient age (aOR 0.99 [CI 0.99, 0.99; P < .001]), Indigenous status (aOR 1.47 [CI 1.05, 2.08; P =.02]) and high socio-economic status (aOR 1.41 [CI 1.06, 1.88; P =.02]). Practitioners identified lack of time and training as the main barriers to Pathway completion.

CONCLUSIONS

High-risk populations for tobacco use are frequently utilising WMOHS, however not all patients who smoke received smoking cessation support. Understanding and addressing barriers to smoking cessation promotion in oral health care settings may improve general and oral health outcomes for patients. SO WHAT?: Targeted training and utilisation of team-based models of care may better enhance delivery and uptake of the Pathway within the public dental setting, thus improving services to a high-need population and reducing smoking rates in priority populations.

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.

The effectiveness of interventions to increase preventive care provision for chronic disease risk behaviours in mental health settings: A systematic review and meta-analysis

Clinical practice guidelines direct mental health services to provide preventive care to address client chronic disease risk behaviours, however, this care is not routinely provided. The aim of this systematic review was to synthesise evidence regarding the effectiveness of interventions to increase provision of preventive care by mental health services; by care element (ask, assess, advice, assist, arrange) and risk behaviour (tobacco smoking, poor nutrition, harmful alcohol consumption, physical inactivity). Electronic bibliographic databases, Google Scholar, relevant journals, and included study reference lists were searched. Eligible studies were of any design with a comparison group that reported the effectiveness of an intervention to increase the provision of at least one element of preventive care for at least one risk behaviour in a mental health setting. Twenty studies were included, most commonly examining smoking (n = 20) and 'ask' (n = 12). Meta-analysis found interventions involving task shifting were effective in increasing smoking 'advice' (n = 2 RCTs; p = 0.009) and physical activity 'advice' (n = 2 RCTs; p = 0.002). Overall, meta-analysis and narrative synthesis indicated that effective intervention strategies (categorised according to the Effective Practice and Organisation of Care taxonomy) were: task shifting, educational meetings, health information systems, local consensus processes, authority and accountability, and reminders. The most consistent findings across studies were with regard to preventive care for smoking, while conflicting or limited evidence was found regarding other risk behaviours. While further rigorous research examining key risk behaviours is recommended, the findings may inform the selection of strategies for future interventions and service delivery initiatives.

Tobacco Cessation and Referral to the National Quitline

Background: Smoking is the leading cause of preventable deaths in the United States. The rates of smoking remain elevated in rural, low income populations in comparison with the rest of the United States. Thus, prompting the process improvement project of implementing the Ask–Advise–Connect (AAC) method to the national quitline in a nurse practitioner–managed clinic for an automotive manufacturing plant in rural Tennessee. Methods: Ask–Advise–Connect method was added to the current smoking cessation program. The employees who utilized the clinic were assessed for smoking status at each visit and subsequently counseled on cessation. Individuals interested in cessation were connected to the national quitline with the AAC method. Pharmaceutical options and nicotine replacement therapy was also offered at no cost to the employee. Findings: In the 4-month period, the clinic provided 102 tobacco cessation counseling visits to workers who smoke. Twenty-four employees enrolled in the cessation program. The participants reported a cessation rate of 12.5% and 21% had a significant decrease in the number of cigarettes smoked. Of the participants, 12.5% ( n = 3) engaged in behavioral counseling with the quitline. Conclusion/application to practice: The addition of the AAC method as part of the smoking cessation program had limited success. As smoking cessation is difficult to achieve, any success greater than 7% can be considered an achievement. The 12.5% cessation rate of the participants was above the national average. Thus, demonstrating the benefit of having a workplace cessation program and incorporating the AAC method to the current smoking cessation program.

Current advances in research in treatment and recovery: Nicotine addiction

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

The association between the receipt of primary care clinician provision of preventive care and short term health behaviour change

Primary healthcare services are recommended to provide preventive care to address chronic disease risk behaviours. However, all care elements are infrequently provided, and there is a need to understand the impact of partial care provision on behaviour change. This study examined the association between variable levels of preventive care receipt from primary care clinicians on short-term behaviour change for four risk behaviours. A survey was undertaken with 5639 Australian community health service clients (2009-2014). Clients self-reported: engagement in risk behaviours (tobacco smoking, harmful alcohol consumption, inadequate fruit and/or vegetable consumption, physical inactivity) in the month prior to and four week post their community health service appointment; receipt of preventive care during appointments (assessment, advice, referral/follow-up) for each behaviour. Univariate regression models explored the association between change in risk status and preventive care received. The odds of behaviour change for those receiving all three care elements was significant for all behaviours, compared to no care, ranging from 2.02 (alcohol consumption, 95% CI 1.16-3.49) to 4.17 (inadequate fruit and/or vegetable consumption, 95% CI 2.91-5.96). Receipt of both assessment and advice increased the odds of behaviour change, compared to no care, for all behaviours except smoking, ranging from 2.32 (physical inactivity, 95% CI 1.60-3.35) to 2.83 (alcohol consumption, 95% CI 1.84-4.33). Receipt of 'assessment only' increased the odds of behaviour change, compared to no care, for inadequate fruit and/or vegetable consumption (OR = 2.40, 95% CI 1.60-3.59) and physical inactivity (OR = 2.81, 95% CI 1.89-4.17). Results highlight the importance of primary care clinicians providing best practice preventive care to maximise client behaviour change.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of telephone support to help smokers quit, including proactive or reactive counselling, or the provision of other information to smokers calling a helpline.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2018.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which offered proactive or reactive telephone counselling to smokers to assist smoking cessation.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We pooled studies using a random-effects model and assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I² statistic. In trials including smokers who did not call a quitline, we used meta-regression to investigate moderation of the effect of telephone counselling by the planned number of calls in the intervention, trial selection of participants that were motivated to quit, and the baseline support provided together with telephone counselling (either self-help only, brief face-to-face intervention, pharmacotherapy, or financial incentives).

MAIN RESULTS

We identified 104 trials including 111,653 participants that met the inclusion criteria. Participants were mostly adult smokers from the general population, but some studies included teenagers, pregnant women, and people with long-term or mental health conditions. Most trials (58.7%) were at high risk of bias, while 30.8% were at unclear risk, and only 11.5% were at low risk of bias for all domains assessed. Most studies (100/104) assessed proactive telephone counselling, as opposed to reactive forms.Among trials including smokers who contacted helplines (32,484 participants), quit rates were higher for smokers receiving multiple sessions of proactive counselling (risk ratio (RR) 1.38, 95% confidence interval (CI) 1.19 to 1.61; 14 trials, 32,484 participants; I² = 72%) compared with a control condition providing self-help materials or brief counselling in a single call. Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate.In studies that recruited smokers who did not call a helpline, the provision of telephone counselling increased quit rates (RR 1.25, 95% CI 1.15 to 1.35; 65 trials, 41,233 participants; I² = 52%). Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate. In subgroup analysis, we found no evidence that the effect of telephone counselling depended upon whether or not other interventions were provided (P = 0.21), no evidence that more intensive support was more effective than less intensive (P = 0.43), or that the effect of telephone support depended upon whether or not people were actively trying to quit smoking (P = 0.32). However, in meta-regression, telephone counselling was associated with greater effectiveness when provided as an adjunct to self-help written support (P < 0.01), or to a brief intervention from a health professional (P = 0.02); telephone counselling was less effective when provided as an adjunct to more intensive counselling. Further, telephone support was more effective for people who were motivated to try to quit smoking (P = 0.02). The findings from three additional trials of smokers who had not proactively called a helpline but were offered telephone counselling, found quit rates were higher in those offered three to five telephone calls compared to those offered just one call (RR 1.27, 95% CI 1.12 to 1.44; 2602 participants; I² = 0%).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that proactive telephone counselling aids smokers who seek help from quitlines, and moderate-certainty evidence that proactive telephone counselling increases quit rates in smokers in other settings. There is currently insufficient evidence to assess potential variations in effect from differences in the number of contacts, type or timing of telephone counselling, or when telephone counselling is provided as an adjunct to other smoking cessation therapies. Evidence was inconclusive on the effect of reactive telephone counselling, due to a limited number studies, which reflects the difficulty of studying this intervention.

Development and evaluation of the See Me Smoke-Free multi-behavioral mHealth app for women smokers

Women face particular challenges when quitting smoking, especially those with weight concerns. A multi-behavioral smoking cessation intervention addressing these concerns and incorporating guided imagery may assist women to engage in healthy lifestyle behaviors. An mHealth app can easily disseminate such an intervention. The goals of this pilot study were to develop and test the feasibility and potential of the See Me Smoke-Free™ mHealth app to address smoking, diet, and physical activity among women smokers. We used pragmatic, direct-to-consumer methods to develop and test program content, functionality, and the user interface and conduct a pre-/post-test, 90-day pilot study. We enrolled 151 participants. Attrition was 52%, leaving 73 participants. At 90 days, 47% of participants reported 7-day abstinence and significant increases in physical activity and fruit consumption. Recruitment methods worked well, but similar to other mHealth studies, we experienced high attrition. This study suggests that a guided imagery mHealth app has the potential to address multiple behaviors. Future research should consider different methods to improve retention and assess efficacy.

Behaviour change counselling for tobacco use cessation and promotion of healthy lifestyles: a systematic review

AIM

To systematically assess the efficacy of oral health behaviour change counselling for tobacco use cessation (TUC) and the promotion of healthy lifestyles.

MATERIALS AND METHODS

Systematic Reviews, Randomized (RCTs), and Controlled Clinical Trials (CCTs) were identified through an electronic search of four databases complemented by manual search. Identification, screening, eligibility and inclusion of studies were performed independently by two reviewers. Quality assessment of the included publications was performed according to the AMSTAR tool for the assessment of the methodological quality of systematic reviews.

RESULTS

A total of seven systematic reviews were included. With the exception of inadequate oral hygiene, the following unhealthy lifestyles related with periodontal diseases were investigated: tobacco use, unhealthy diets, harmful use of alcohol, physical inactivity, and stress. Brief interventions for TUC were shown to be effective when applied in the dental practice setting while evidence for dietary counselling and the promotion of other healthy lifestyles was limited or non-existent.

CONCLUSIONS

While aiming to improve periodontal treatment outcomes and the maintenance of periodontal health current evidence suggests that tobacco use brief interventions conducted in the dental practice setting were effective thus underlining the rational for behavioural support.

Proactive enrollment of parents to tobacco quitlines in pediatric practices is associated with greater quitline use: a cross-sectional study

BACKGROUND

Every U.S. state has a free telephone quitline that tobacco users can access to receive cessation assistance, yet referral rates for parents in the pediatric setting remain low. This study evaluates, within pediatric offices, the impact of proactive enrollment of parents to quitlines compared to provider suggestion to use the quitline and identifies other factors associated with parental quitline use.

METHODS

As part of a cluster randomized controlled trial (Clinical Effort Against Secondhand Smoke Exposure), research assistants completed post-visit exit interviews with parents in 20 practices in 16 states. Parents' quitline use was assessed at a 12-month follow-up interview. A multivariable analysis was conducted for quitline use at 12 months using a logistic regression model with generalized estimating equations to account for provider clustering. Self-reported cessation rates were also compared among quitline users based on the type of referral they received at their child's doctor's office.

RESULTS

Of the 1980 parents enrolled in the study, 1355 (68 %) completed a 12-month telephone interview and of those 139 (10 %) reported talking with a quitline (15 % intervention versus 6 % control; p < .0001). Parents who were Hispanic (aOR 2.12 (1.22, 3.70)), black (aOR 1.57 (1.14, 2.16)), planned to quit smoking in the next 30 days (aOR 2.32 (1.47, 3.64)), and had attended an intervention practice (aOR 2.37 (1.31, 4.29)) were more likely to have talked with a quitline. Parents who only received a suggestion from a healthcare provider to use the quitline (aOR 0.45 (0.23, 0.90)) and those who were not enrolled and did not receive a suggestion (aOR 0.33 (0.17, 0.64)) were less likely to talk with a quitline than those who were enrolled in the quitline during the baseline visit. Self-reported cessation rates among quitline users were similar regardless of being proactively enrolled (19 %), receiving only a suggestion (25 %), or receiving neither a suggestion nor an enrollment (17 %) during a visit (p = 0.47).

CONCLUSIONS

These results highlight the enhanced clinical effectiveness of not just recommending the quitline to parents but also offering them enrollment in the quitline at the time of their child's visit to the pediatric office.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT00664261.

Development and Testing of a Computerized Decision Support System to Facilitate Brief Tobacco Cessation Treatment in the Pediatric Emergency Department: Proposal and Protocol

Background

Tobacco smoke exposure (TSE) is unequivocally harmful to children's health, yet up to 48% of children who visit the pediatric emergency department (PED) and urgent care setting are exposed to tobacco smoke. The incorporation of clinical decision support systems (CDSS) into the electronic health records (EHR) of PED patients may improve the rates of screening and brief TSE intervention of caregivers and result in decreased TSE in children.

Objective

We propose a study that will be the first to develop and evaluate the integration of a CDSS for Registered Nurses (RNs) into the EHR of pediatric patients to facilitate the identification of caregivers who smoke and the delivery of TSE interventions to caregivers in the urgent care setting.

Methods

We will conduct a two-phase project to develop, refine, and integrate an evidence-based CDSS into the pediatric urgent care setting. RNs will provide input on program content, function, and design. In Phase I, we will develop a CDSS with prompts to: (1) ASK about child TSE and caregiver smoking, (2) use a software program, Research Electronic Data Capture (REDCap), to ADVISE caregivers to reduce their child's TSE via total smoking home and car bans and quitting smoking, and (3) ASSESS their interest in quitting and ASSIST caregivers to quit by directly connecting them to their choice of free cessation resources (eg, Quitline, SmokefreeTXT, or SmokefreeGOV) during the urgent care visit. We will create reports to provide feedback to RNs on their TSE counseling behaviors. In Phase II, we will conduct a 3-month feasibility trial to test the results of implementing our CDSS on changes in RNs’ TSE-related behaviors, and child and caregiver outcomes.

Results

This trial is currently underway with funding support from the National Institutes of Health/National Cancer Institute. We have completed Phase I. The CDSS has been developed with input from our advisory panel and RNs, and pilot tested. We are nearing completion of Phase II, in which we are conducting the feasibility trial, analyzing data, and disseminating results.

Conclusions

This project will develop, iteratively refine, integrate, and pilot test the use of an innovative CDSS to prompt RNs to provide TSE reduction and smoking cessation counseling to caregivers who smoke. If successful, this approach will create a sustainable and disseminable model for prompting pediatric practitioners to apply tobacco-related guideline recommendations. This systems-based approach has the potential to reach at least 12 million smokers a year and significantly reduce TSE-related pediatric illnesses and related costs.

Interventions for smokeless tobacco use cessation

BACKGROUND

Use of smokeless tobacco (ST) can lead to tobacco dependence and long-term use can lead to health problems including periodontal disease, cancer, and cerebrovascular and cardiovascular disease.

OBJECTIVES

To assess the effects of behavioural and pharmacologic interventions for the treatment of ST use.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group specialised register in June 2015.

SELECTION CRITERIA

Randomized trials of behavioural or pharmacological interventions to help users of ST to quit with follow-up of at least six months.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by the Cochrane Collaboration. We summarised outcomes as risk ratios (RRs). For subgroups of trials with similar types of intervention and without substantial statistical heterogeneity, we estimated pooled effects using a Mantel-Haenszel fixed-effect method.

MAIN RESULTS

We identified 34 trials that met the inclusion criteria, of which nine were new for this update, representing over 16,000 participants. There was moderate quality evidence from two studies suggesting that varenicline increases ST abstinence rates (risk ratio [RR] 1.34, 95% confidence interval (CI) 1.08 to 1.68, 507 participants). Pooled results from two trials of bupropion did not detect a benefit of treatment at six months or longer (RR 0.89, 95% CI 0.54 to 1.44, 293 participants) but the confidence interval was wide. Neither nicotine patch (five trials, RR 1.13, 95% CI 0.93 to 1.37, 1083 participants) nor nicotine gum (two trials, RR 0.99, 95% CI 0.68 to 1.43, 310 participants) increased abstinence. Pooling five studies of nicotine lozenges did increase tobacco abstinence (RR 1.36, 95% CI 1.17 to 1.59, 1529 participants) but confidence in this estimate is low as the result is sensitive to the exclusion of three trials which did not use a placebo control.Statistical heterogeneity was evident among the 17 trials of behavioural interventions: eight of them reported statistically and clinically significant benefits; six suggested benefit but with wide CIs and no statistical significance; and three had similar intervention and control quit rates and relatively narrow CIs. Heterogeneity was not explained by study design (individual or cluster randomization), whether participants were selected for interest in quitting, or specific intervention components. In a post hoc subgroup analysis, trials of behavioural interventions incorporating telephone support, with or without oral examination and feedback, were associated with larger effect sizes, but oral examination and feedback alone were not associated with benefit.In one trial an interactive website increased abstinence more than a static website. One trial comparing immediate cessation using nicotine patch versus a reduction approach using either nicotine lozenge or brand switching showed greater success for the abrupt cessation group.

AUTHORS' CONCLUSIONS

Varenicline, nicotine lozenges and behavioural interventions may help ST users to quit. Confidence in results for nicotine lozenges is limited. Confidence in the size of effect from behavioural interventions is limited because the components of behavioural interventions that contribute to their impact are not clear.

Models of smoking cessation brief interventions in oral health

The links between tobacco smoking, and periodontal disease and oral cancer make the inclusion of smoking cessation interventions at dental visits an important prevention strategy in oral health services. The 5As (Ask, Advise, Assess, Assist, Arrange), which utilises a stages of change model, is the most commonly recognised framework for the provision of smoking cessation brief interventions and is advocated widely. While the popularity of the 5As continues, increasingly evidence suggests that staged-based interventions in smoking cessation may not be the best approach. Lack of time and expertise are also cited by health professionals as barriers to undertaking brief interventions and thus abbreviated forms of the 5As have been advocated. In 2009, NSW Health introduced a mandatory policy for public dental services in NSW to conduct smoking cessation brief interventions at the chairside based on a three-step approach, which is currently being evaluated. Given the debate and the pending evaluation results, this paper reviews models of smoking cessation brief interventions, to contribute to achieving a best practice model for public oral health in NSW.

Impact of a brief telephone referral on quitline use, quit attempts and abstinence

Quitline use can prompt quit attempts and promote abstinence among smokers, but rates of use are low and outcomes of brief quitline referrals unclear. In this study, a brief intervention was delivered to smokers who expressed motivation to quit in the next 30 days (N = 221) to encourage use of their state quitline. Correlates of quitline use were examined, and quitline callers versus non-callers were compared on the following outcomes at 2-month follow-up: cessation medication use, quit attempts and abstinence. Of the 221 smokers given a quitline referral, 34% called the quitline. Baseline motivation alone distinguished quitline callers from non-callers. Quitline use was positively associated with use of cessation medication, an association that remained robust even after adjusting for baseline motivation to quit. A trend was observed in which callers were marginally more likely than non-callers to report both a 24-h quit attempt and 7-day point prevalence abstinence. Relative to non-callers, callers also endorsed greater confidence to quit and increased self-efficacy to resist smoking temptations at follow-up. This study demonstrates a minimal intervention can promote acceptance of quitlines and favorable cessation outcomes among smokers motivated to quit.

Evaluation of a brief counseling for tobacco cessation in dental clinics among Swedish smokers and snus users. A cluster randomized controlled trial (the FRITT study)

OBJECTIVE

The aim of this study is to assess the effectiveness of a very brief structured counseling for tobacco cessation in dentistry clinics.

METHOD

A cluster randomized trial was conducted in Sweden in 2012-2013. Twenty-seven dentistry clinics in two Swedish counties were randomized to provide either a structured brief advice based on the 5 A's model or usual care. Participants were 467 patients currently using tobacco daily (225 in the intervention group and 242 in usual care), of which 97% were retained at follow-up, six months after enrolment. Study outcomes were: 7-day abstinence (primary outcome); 3-month sustained abstinence; 50% reduction of the amount tobacco used; quit attempts lasting at least 24h.

RESULTS

Compared to usual care, brief counseling was not associated to statistically significant increase in the proportion abstinent from tobacco use after 6months. However, there was a statistically significant association with reduction of tobacco consumption (OR=2.07 95% CI 1.28-3.35). Changes in the expected direction for all outcomes were more frequent in the intervention than in the usual care group, and larger among exclusive snus users than among smokers.

CONCLUSIONS

Very brief and structured counseling in dentistry may achieve positive behavioral modifications among tobacco users, with significant reduction of tobacco consumption, particularly among smokeless tobacco users.

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.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of proactive and reactive telephone support via helplines and in other settings to help smokers quit.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2013.

SELECTION CRITERIA

randomized or quasi-randomised controlled trials in which proactive or reactive telephone counselling to assist smoking cessation was offered to smokers or recent quitters.

DATA COLLECTION AND ANALYSIS

One author identified and data extracted trials, and a second author checked them. The main outcome measure was the risk ratio for abstinence from smoking after at least six months follow-up. We selected the strictest measure of abstinence, using biochemically validated rates where available. We considered participants lost to follow-up to be continuing smokers. Where trials had more than one arm with a less intensive intervention we used only the most similar intervention without the telephone component as the control group in the primary analysis. We assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I² statistic. We considered trials recruiting callers to quitlines separately from studies recruiting in other settings. Where appropriate, we pooled studies using a fixed-effect model. We used a meta-regression to investigate the effect of differences in planned number of calls, selection for motivation, and the nature of the control condition (self help only, minimal intervention, pharmacotherapy) in the group of studies recruiting in non-quitline settings.

MAIN RESULTS

Seventy-seven trials met the inclusion criteria. Some trials were judged to be at risk of bias in some domains but overall we did not judge the results to be at high risk of bias. Among smokers who contacted helplines, quit rates were higher for groups randomized to receive multiple sessions of proactive counselling (nine studies, > 24,000 participants, risk ratio (RR) for cessation at longest follow-up 1.37, 95% confidence interval (CI) 1.26 to 1.50). There was mixed evidence about whether increasing the number of calls altered quit rates but most trials used more than two calls. Three studies comparing different counselling approaches during a single quitline contact did not detect significant differences. Of three studies that tested the provision of access to a hotline two detected a significant benefit and one did not.Telephone counselling not initiated by calls to helplines also increased quitting (51 studies, > 30,000 participants, RR 1.27; 95% CI 1.20 to 1.36). In a meta-regression controlling for other factors the effect was estimated to be slightly larger if more calls were offered, and in trials that specifically recruited smokers motivated to try to quit. The relative extra benefit of counselling was smaller when it was provided in addition to pharmacotherapy (usually nicotine replacement therapy) than when the control group only received self-help material or a brief intervention.A further eight studies were too diverse to contribute to meta-analyses and are discussed separately. Two compared different intensities of counselling, both of which detected a dose response; one of these detected a benefit of multiple counselling sessions over a single call for people prescribed bupropion. The others tested a variety of interventions largely involving offering telephone counselling as part of a referral or systems change and none detected evidence of effect.

AUTHORS' CONCLUSIONS

Proactive telephone counselling aids smokers who seek help from quitlines. Telephone quitlines provide an important route of access to support for smokers, and call-back counselling enhances their usefulness. There is limited evidence about the optimal number of calls. Proactive telephone counselling also helps people who receive it in other settings. There is some evidence of a dose response; one or two brief calls are less likely to provide a measurable benefit. Three or more calls increase the chances of quitting compared to a minimal intervention such as providing standard self-help materials, or brief advice, or compared to pharmacotherapy alone.

Cluster-randomized trial of a web-assisted tobacco quality improvement intervention of subsequent patient tobacco product use: a National Dental PBRN study

Background

Brief clinician delivered advice helps in tobacco cessation efforts. This study assessed the impact of our intervention on instances of advice given to dental patients during visits on tobacco use quit rates 6 months after the intervention.

Methods

The intervention was cluster randomized trial at the dental practice level. Intervention dental practices were provided a longitudinal technology-assisted intervention, oralcancerprevention.org that included a series of interactive educational cases and motivational email cues to remind dental provides to complete guideline-concordant brief behavioral counseling at the point of care. In all dental practices, exit cards were given to the first 100 consecutive patients, in which tobacco users provided contact information for a six month follow-up telephone survey.

Results

A total of 564 tobacco using dental patients completed a six month follow-up survey. Among intervention patients, 55% reported receiving advice to quit tobacco, and 39% of control practice patients reported receiving advice to quit tobacco (p < 0.01). Six-month tobacco use quit rates were not significantly between the Intervention (9%) and Control (13%) groups, (p = 0.088).

Conclusion

Although we increased rates of cessation advice delivered in dental practices, this study shows no evidence that brief advice by dentist’s increases long-term abstinence in smokers.

Trial registration

ClinicalTrials.gov NCT00627185

Effectiveness of intervention to implement tobacco cessation counseling in community chain pharmacies

OBJECTIVES

To test the feasibility of implementing ask-advise-refer (AAR) tobacco cessation counseling approach in community chain pharmacies serving low socioeconomic areas and to assess the effectiveness of a multimodal intervention on short-term implementation of AAR.

DESIGN

Randomized controlled trial.

SETTING

South-central Wisconsin from July 2008 through March 2009.

PARTICIPANTS

Pharmacists and technicians from 16 community chain pharmacies.

INTERVENTION

Training to implement AAR, workflow integration recommendations, tobacco cessation poster to create awareness, and a support visit.

MAIN OUTCOME MEASURES

Number of pharmacy patrons asked about tobacco use, number of tobacco users advised to quit, number of tobacco users enrolled in the quit line, and number of quit line cards given.

RESULTS

As hypothesized, the multimodal intervention significantly predicted the number of patrons asked to quit (estimate 4.84, incidence rate ratio 127.2, P < 0.001), number of tobacco users advised to quit (2.12, 8.33, P < 0.01), number of tobacco users enrolled in the quit line (2.31, 10.13, P < 0.001), and number of quit line cards given (1.04, 2.82, P < 0.05).

CONCLUSION

This trial demonstrates the feasibility of implementing AAR in routine community pharmacy practice. This trial also supports the short-term effectiveness of the multimodal intervention in facilitating AAR in partnership with other public health systems. More research is needed to evaluate the generalizability, effectiveness, and sustainability of AAR, including factors influencing adoption and the impact on cessation.

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.

Evidence summary: is smoking cessation an effective and cost-effective service to be introduced in NHS dentistry?

Since August 2009, members of the Primary Care Dentistry Research Forum (www.dentistryresearch.org) have taken part in an online vote to identify questions in day-to-day practice that they felt most needed to be answered with conclusive research. The question that receives the most votes each month forms the subject of a critical appraisal of the relevant literature. Each month a new round of voting takes place to decide which further questions will be reviewed. Dental practitioners and dental care professionals are encouraged to take part in the voting and submit their own questions to be included in the vote by joining the website. The paper below details a summary of the findings of the eighth critical appraisal. In order to address the question raised by the primary care dentistry research forum, first any international study was included that evaluated the effectiveness smoking cessation in dental practice. The aim was to understand whether smoking cessation in dental practice is an effective treatment strategy to increase tobacco cessation and abstinence. Moreover, this rapid assessment intended to identify whether there are certain types of smoking cessation intervention (or components of an intervention) in dental settings that are more effective than the others. In order to determine the applicability of the results to the NHS, we also looked for studies evaluating the cost-effectiveness of these interventions in NHS dentistry, studies reporting the current practice in NHS dentistry and finally qualitative and quantitative studies describing and evaluating the experience and views of dentists in the UK regarding implementing smoking cessation interventions in dental settings. The latter studies would help us to identify the possible barriers and facilitators in implementing these interventions in a dental setting. In conclusion, the critical appraisal of the international literature suggests that behavioural intervention for smoking cessation involving oral health professionals is an effective method of reducing tobacco use in smokers and users of smokeless tobacco and preventing uptake in non-smokers. There is not enough evidence available to assess whether these interventions are cost-effective and the effectiveness of one intervention (or component of the intervention) over another is not clear. The evaluation of the UK-related literature shows that private dental practices deliver more smoking cessation activities than their NHS counterparts. NHS practitioners report lack of reimbursement from the NHS, lack of time and training and fears over patient response as barriers to delivering smoking cessation interventions. We did not find studies evaluating the cost-effectiveness of the intervention in the UK.

Development of a Web-based tobacco cessation educational program for pediatric nurses and respiratory therapists

BACKGROUND

Nurses can be effective in providing advice and counseling to tobacco-using parents of hospitalized pediatric patients. However, lack of training in effective interventions is a barrier to the incorporation of tobacco cessation interventions into routine practice. This article describes the development and evaluation of a web-based tobacco cessation educational program aimed at pediatric nurses and respiratory therapists.

METHOD

The program was developed with input from four focus groups of nurses, respiratory therapists, and educators. The interactive training program was evaluated by 33 nurses and 17 respiratory therapists employed at a children's hospital.

RESULTS

After completing the program, participants reported a significant change in their knowledge, attitudes, perceived barriers, and self-efficacy toward providing tobacco cessation interventions to their patients' parents.

CONCLUSION

The results of the evaluation of the program were extremely promising, and further investigation is warranted.