Making the most of a teachable moment: a smokeless-tobacco cessation intervention in the dental office

Behavior Change Intervention for Smokeless Tobacco Cessation Delivered Through Dentists in Dental Settings: A Pragmatic Pilot Trial

INTRODUCTION

Evidence on smokeless tobacco (ST) cessation interventions is scarce. The South Asian (SA) region that shares more than 90% of the burden of ST use is grossly underrepresented in research on ST cessation. This study aimed to assess the feasibility of delivering and investigating a behavioral support intervention for ST cessation in dental settings in Pakistan.

METHODS

A multicenter, pilot, two-armed parallel-group, individually randomized control trial, with a 1:1 allocation ratio, was conducted at two dental hospitals. Eligibility criteria included being an ST user seeking dental treatment and not currently accessing cessation support. All participants were provided written self-help ST cessation material. The intervention group also received a dentist-delivered, bespoke behavioral support intervention for ST cessation developed for users of SA origin. Participants were followed up telephonically at 3 and 6 months. Self-reported 6-month abstinence was verified by salivary cotinine. Analysis was descriptive, with 95% confidence intervals presented where appropriate.

RESULTS

One hundred participants were successfully recruited from the selected hospitals. Of these, 78% continued to engage throughout the study duration and provided primary outcome data, whereas 63% completed all hospital visits. The outcome measures were successfully collected. Biochemically verified 6-month abstinence in the intervention and control groups was 10% and 4%.

CONCLUSIONS

It was feasible to deliver and evaluate a dentist-delivered behavioral support intervention for ST cessation in Pakistan. The data suggested that the intervention may improve ST quit rates. The findings of this study will be useful in informing the design of future definitive studies.

IMPLICATIONS

To our knowledge, this is the first pragmatic pilot trial on ST cessation in dental settings in Pakistan and the first trial on dentist-delivered structured behavioral support intervention for ST cessation. It adds to the scarce, trial evidence based on ST cessation interventions. The findings suggest behavioral support intervention for ST cessation may improve quit rates. The trial was conducted in a country with poor ST control measures, where ST products are not taxed, the products are sold openly to and by minors, and the users are offered negligible cessation support. The findings may, therefore, be generalizable to low-middle-income countries, particularly SA countries, with similar policy backgrounds.

Co-substance use of nicotine vaping and non-cigarette tobacco products among U.S. grade 12 students from 2017-2019

Background

Nicotine vaping among U.S. adolescents has risen rapidly over the past decade, particularly for youth in grade 12. While previous studies examined the relationship between nicotine vaping and combustible cigarette use, less is known about the co-occurrence between vaping and other tobacco products.

Methods

Using Monitoring the Future grade 12 data (2017-2019), we investigated associations between past 30-day nicotine vaping and non-vaping, non-cigarette tobacco use (smokeless tobacco, large cigars, cigarillos, hookah). Population prevalences of four categories were assessed: neither, vaping only, non-vaping of non-cigarette tobacco only, or both. We further investigated these relationships with logistic regressions accounting for the complex survey design (unadjusted, demographic-adjusted, and further adjusted for other substance use). Finally, analyses were stratified by combustible cigarette use.

Results

Depending on the non-cigarette tobacco product, 2.5% to 5.4% of grade 12 students vaped nicotine and used a non-cigarette tobacco product. Controlling for demographics, cigarillo use was associated with nicotine vaping (adjusted RR = 3.44, 95% CI: 3.08, 3.84), as was hookah use (aRR = 3.51, 95% CI: 2.92, 4.23), smokeless tobacco (aRR = 2.97, 95% CI: 2.51, 3.52), and cigar use (aRR = 2.90, 95% CI: 2.49, 3.37). Controlling for cannabis and all non-cigarette tobacco products simultaneously attenuated associations. Associations were stronger among students who did not use cigarettes.

Discussion

Nicotine vaping is associated with use of many non-cigarette tobacco products, including smokeless tobacco, cigarillos, cigars, and hookah. As prevalence of nicotine vaping remains high among adolescents, we should monitor co-use of vaping and other tobacco products.

Providers' Non-Cigarette Tobacco Use Intervention Practices in Relation to Beliefs about Patients, Prioritization of and Skills for Intervention, and Referral Knowledge in Texas Healthcare Centers Providing Care to Persons with Behavioral Health Needs

Rates of non-cigarette (colloquially, other) tobacco use is elevated among adults with behavioral health conditions. Little is known about whether behavioral health providers are using brief interventions, including the evidence-based 5As (Ask, Advise, Assess, Assist, and Arrange) for other tobacco use, or what provider factors may be associated with use of these interventions. The current study redressed this gap. Overall, 86 providers in Texas (9 Federally Qualified Health Centers, 16 Local Mental Health Authorities (LMHAs) that provide a broad range of mental and behavioral health services, 6 substance use treatment programs in LMHAs, and 55 stand-alone substance use treatment programs) took a survey assessing their beliefs regarding (1) patients' concerns about other tobacco use; (2) their desire to quit; (3) importance of intervening on other tobacco use with cessation counseling; (4) perceived skills to intervene; (5) knowledge of referral options for treatment. Logistic regression analyses were conducted to determine the association between each factor and use of the 5As. Results showed that 70.9% of providers asked patients about other tobacco use status, 65.1% advised them to quit, 59.3% assessed quit interest, 54.7% assisted with a quit attempt, and 31.4% arranged a follow-up. Providers who believed patients were concerned about other tobacco use, recognized the importance of offering other tobacco use cessation counseling, believed they had the necessary skills to treat other tobacco use, and possessed knowledge of referral options, respectively, were more likely to deliver the 5As (ps < 0.05). Results add to a limited literature on provider intervention practices for other tobacco use in settings where behavioral health care is provided, highlighting the significance of provider beliefs, perceived skills, and referral knowledge to care delivery. Findings reveal opportunities to increase delivery of the 5As for other tobacco use to behavioral health patients and suggest provider factors that could be targeted to build this capacity.

The Longitudinal Impact of Arrest, Criminal Conviction, and Incarceration on Smoking Classes

Background

Previous research identifies three to six smoking classes over the life course. This study expands on earlier work about the impact of getting arrested in early adulthood on individuals' smoking classes, by including additional, more serious measures of justice system involvement (JSI), specifically criminal conviction and incarceration. Family processes were examined as secondary outcomes.

Method

Data from seventeen waves (1997-2015) of the National Longitudinal Survey of Youth were analyzed via group-based trajectory modeling (GBTM), multinomial logistic regression, and latent transition analyses (LTA). Smoking behavior through age 36 is examined. Marital status, parenthood, juvenile smoking, juvenile arrest, and prior crime victimization experiences were also included in the models.

Results

Seven smoking classes were revealed: two low- or non-smoking classes; two decreasing classes; and three "problem" smoking (e.g., increasing, or chronic) classes. All JSI types increased the likelihood of being in a smoking class rather than a non-smoking class. Arrest and conviction had larger odds ratios than the most severe form of JSI-incarceration-with respect to respondents' likelihood of being in an increasing or chronic smoking class. Juvenile smoking was the most robust predictor of smoking in adulthood.

Conclusion

Involvement with the justice system in all forms remains a negative health factor that increases smoking. While not typically a goal of criminal justice officials, attention should be paid to this unintended consequence of involvement with the justice system-increased smoking-given smoking's connection to serious illnesses such as cancer. As juvenile smoking is a strong risk factor for adult smoking, smoking prevention and cessation programs should start with youth; and be part of the offerings to individuals ensnared in the justice system at all levels.

Effectiveness of Behavioral Counseling in Smokeless Tobacco Cessation Among Adult Users Reporting to a Dental Hospital in Pune: A Randomized Controlled Trial

Aim To assess the effectiveness of behavioral counseling for smokeless tobacco cessation among adult users in a dental hospital setting. Methods A total of 200 patients visiting a dental hospital who were exclusively using smokeless tobacco (SLT) were enrolled in the study. A randomized controlled trial with a concurrent parallel study design, which consisted of two arms, was conducted. Fagerstrom test for nicotine dependence level and the transtheoretical stage of change was assessed at the baseline. Behavioral cessation counseling and motivational interviewing were provided in the study arm and brief advice was given to those in the control arm. The counseling was provided at baseline and followed up till six months through telephone to assess the change in the frequency of use of SLT products and abstinence from SLT use. A biochemical validation with a urine cotinine test was done to confirm abstinence. Results At six months, there was a significant difference within and between the study and control groups, indicating the role played by behavioral tobacco cessation in reducing the frequency of consumption. About 24.4% of participants in the study group and 10% in the control group abstained from the habit at the sixth month, with an odd's ratio (OR)=2.91 and with a loss to follow-up of 10% in each of the groups. The cotinine test, which was used for validation, revealed a significant difference between the study and the control group. The number needed to treat (NNT) shows that to motivate one additional person to give up the SLT habit, we need to intervene with about seven people. Conclusion Behavior intervention with motivational interviewing was considered an effective method in promoting smokeless tobacco cessation among adults. Transtheoretical stages of change have proven to be an effective model to assess the stage of behavior change of the population toward SLT use and was also helpful for changing the behavior.

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.

Leveraging Clinical Decision Support and Integrated Medical-Dental Electronic Health Records to Implementing Precision in Oral Cancer Risk Assessment and Preventive Intervention

INTRODUCTION

Precision medicine is focused on serving the unique needs of individuals. Oral and oropharyngeal cancer risk assessment identifies individual risk factors while providing support to reduce risk. The objective is to examine potential current and future strategies to broadly implement evidence-based oral and oropharyngeal cancer risk assessment and screening in dental practices throughout the United States.

METHODS

Feasible and effective oral cancer risk assessment and risk reduction strategies, ripe for implementation in dental practice, were identified in the published literature.

RESULTS

The Screening, Brief Intervention, Referral for Treatment (SBIRT) model is a feasible approach to assessing individual oral cancer risk and providing risk reducing interventions in the dental setting. HPV is a more recently identified risk factor that dentistry is well positioned to address. Evidence supporting the utilization of specific risk assessment tools and risk reduction strategies is summarized and future opportunities discussed.

DISCUSSION

Current knowledge of risk factors for oral and oropharyngeal cancers support the recommendation for dental providers to routinely assess all patients for risk factors, educate them about their personal level of cancer risk, and recommend actions to reduce relevant risk factors. Individuals ages 9-26 should be asked about their HPV vaccination status, educated about HPV and oropharyngeal cancer and receive a recommendation to get the HPV vaccination.

Identifying Behavior Change Techniques Used in Tobacco Cessation Interventions by Oral Health Professionals and Their Relation to Intervention Effects-A Review of the Scientific Literature

This review aimed to identify the behavioral change techniques (BCTs) used in behavioral interventions for tobacco cessation at dental practices in relation to their effect on tobacco use. Six scientific databases were searched for behavior change interventions for tobacco cessation and were coded using the BCT taxonomy of behavioral support for smoking cessation (BCTTsm). Fifteen interventions were identified, and data related to intervention characteristics were abstracted. Sixteen BCTs were identified, mainly related to increased motivation and teaching regulatory skills. Goal setting was the most commonly used BCT. Ten out of fifteen interventions effectively impacted tobacco cessation outcomes (OR = 2 to 5.25). Effective interventions more frequently included goal setting, written materials, readiness to quit and ability assessment, tobacco-use assessment, self-efficacy boost, listing reasons for quitting, action planning and environment restructuring. Other BCTs were not clearly associated with an increased effect. Among the behavioral interventions, certain techniques were associated with successful tobacco quitting. Tobacco cessation interventions in a dental setting appear to benefit from using BCTs that increase motivation and teach regulatory skills. The identified BCTs in this review could provide a source to better inform researchers and dentists about the active ingredients in behavior change interventions for tobacco cessation in a dental setting.

Evaluation of Successfulness of Capacity Building Programmes on Smokeless Tobacco and Areca Nut Cessation

Background:

Prevalence of smoking in Sri Lanka has shown a gradual reduction whilst the use of smokeless tobacco and areca nut exhibits an increasing trend. At present, only a few well-structured smokeless tobacco (SLT)/areca nut (AN) cessation programs have been conducted in Sri Lanka, which is a gross underachievement as betel chewing-related oral squamous cell carcinoma is the most common cancer in Sri Lankan males. As General Dental Practitioners (GDP) do not contribute significantly to SLT/AN cessation activities at present, capacity building programs on SLT/AN control were carried out. The study evaluated the knowledge, attitude and practices imparted on SLT/AN control among dental surgeons.

Methods:

Following a single day capacity building program on smokeless tobacco / areca nut control, two self-administered questionnaires were used to assess the improvement of knowledge and change of attitudes among 663 GDPs.

Results:

Majority had a good knowledge on harmful effects of SLT but not on areca nut. Knowledge of the current legislation on SLT control in Sri Lanka and carcinogenicity of areca nut was not satisfactory. Almost all agreed that proper counseling leads to patient quitting the habit, a formal training is necessary to conduct tobacco control activities and it should be a part of the regular treatment modalities. More than 80% of the participants support strict legislation. Most important factors leading to poor involvement in tobacco cessation activities were lack of expertise and inadequate educational material and not breach of patient privacy and lack of financial incentives. 20.1% dental surgeons had consumed smokeless tobacco / areca nut products in the past and only a few were current users of tobacco and/or areca nut.

Conclusions:

Well planned workshops are efficient in improving knowledge, practices and attitudes of dental surgeons towards SLT/AN cessation.

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.

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.

Smokeless tobacco use: its prevalence and relationships with dental symptoms, nutritional status and blood pressure among rural women in Burkina Faso

BACKGROUND

Sub-Saharan women use smokeless tobacco (SLT) more than smoked tobacco. Among Western African countries, the estimated weighted prevalence of SLT use in rural women was found to be the highest in Burkina Faso (after Sierra Leone). This study aimed to assess the prevalence of SLT use and its associated factors among rural women in Burkina Faso by using nationally representative data.

METHODS

We used data from the 2013 STEPwise approach to Surveillance (STEPS) study, which provided sociodemographic, clinical (anthropometric, systolic blood pressure [SBP], diastolic blood pressure [DBP] and dental symptoms), biological (total and high-density lipoprotein cholesterol and fasting blood sugar), and tobacco and alcohol consumption data. Data for 1730 rural women were used, and we performed Student's chi-squared and logistic regression analyses.

RESULTS

The prevalence of current SLT use was 13.8% (95% CI: 12.2-15.5). Significant risks for SLT use were the presence of dental symptoms (adjusted odds ratio [aOR] = 2.59; p < 0.001), undernourishment (aOR = 1.78; p < 0.01), decreased waist circumference (aOR = 0.98; p < 0.05), decreased DBP (aOR = 0.97; p < 0.01), increased SBP (aOR = 1.01; p < 0.05), and increased differential blood pressure (aOR = 1.01; p < 0.05). The co-use of alcohol was also a significant risk factor (aOR = 2.80; p < 0.001).

CONCLUSION

The prevalence of current SLT use was high among rural women in Burkina Faso, and significant concerns for users included alcohol co-use, the occurrence of dental symptoms, undernourishment, and an increase in differential blood pressure. National Public Health interventions are needed to reduce SLT use and its health-related concerns.

Behavioral Interventions for Smokeless Tobacco Cessation

INTRODUCTION

Consumption of smokeless tobacco (SLT) is on the rise (especially in the World Health Organization South-East Asian region) and has numerous repercussions over the consumer's health. This article reviews studies performed for SLT cessation using behavioral interventions, worldwide till 2017.

METHODS

A systematic review by PICO (Problem, intervention, comparison, outcome) of behavioral intervention-based SLT cessation studies with minimum 6 months' follow-up, reporting outcomes in terms of risk ratios (RRs) and 95% confidence interval (CI), published between 1992 and 2017 was performed. This was followed by a meta-analysis of the outcomes of these studies by deriving the pooled estimates by the random effects model, for those on adults and youth, categorized according to the type of country where the study was performed, that is, in terms of developed or developing. Publication bias among the included studies was assessed by the Begg's test.

RESULTS

Nineteen eligible studies comprising 24 498 participants, from all over the world were included. Behavioral interventions showed overall efficacy in SLT cessation in adults (RR = 1.63, 95% CI = 1.32 to 1.94) both in the developed (RR = 1.39, 95% CI = 1.16 to 1.63) and developing (RR = 2.79, 95% CI = 2.32 to 3.25) countries. However, these interventions did not prove effective for SLT cessation among youth overall (RR = 1.07, 95% CI = 0.73 to 1.41), either in the developed (RR = 1.39, 95% CI = 0.58 to 2.21) or in the developing (RR = 0.87, 95% CI = 0.68 to 1.07) countries. Publication bias was noted in all the studies among adults (p = .22) and youth (p = .05).

CONCLUSION

Behavioral interventions as a single modality are effective in SLT cessation, both in the developed and developing countries. Health care providers should be sensitized to provide the same.

IMPLICATIONS

A recent literature survey by Cochrane reviewed studies on interventions for SLT, including behavioral interventions, which included only those from the developed countries. The current analysis provides a broader, global update on the same by including studies performed both in the developed and developing countries (specifically the South-East Asian region-the high burden countries of SLT products).

Stroke Prophylaxis for Atrial Fibrillation? To Prescribe or Not to Prescribe-A Qualitative Study on the Decisionmaking Process of Emergency Department Providers

STUDY OBJECTIVE

Although clinical guidelines recommend oral anticoagulation for atrial fibrillation patients at high risk of stroke, emergency physicians inconsistently prescribe it to patients with newly diagnosed atrial fibrillation. We interview emergency physicians to gain insight into themes influencing prescribing of oral anticoagulation for patients discharged from the ED with new-onset atrial fibrillation.

METHODS

From September 2015 to January 2017, we conducted semistructured qualitative interviews with a purposeful sampling of 18 ED attending physicians who had evaluated a patient with new-onset atrial fibrillation within the past 30 days. Interview prompts examined physicians' attitudes toward prescription of oral anticoagulation therapy and current clinical guidelines. We used a constructivist grounded theory approach to analyze data and develop a theory on prescribing practices among emergency physicians.

RESULTS

Three broad domains emerged from our analyses. (1) Oral anticoagulation prescribing practice: underlying themes affecting oral anticoagulation prescribing from the ED included physician practice patterns, beliefs, and barriers (including experience, comfort, and insurance coverage), and patient factors (including comorbidities, bleeding risk, and social concerns). Ultimately, these themes indicated physician discomfort and a sense of futility in prescribing oral anticoagulation for atrial fibrillation. (2) Guideline usage for oral anticoagulation prescribing: regardless of experience, most emergency physicians did not report using clinical guidelines when treating patients. (3) Recommendations for improved prescribing: physicians recommended the development of a validated, reliable, simple, accessible, and population-specific guideline that considers patient social factors.

CONCLUSION

The decision to prescribe oral anticoagulation in the ED is complex. Improving guideline adherence will require a multifaceted approach inclusive of system-level improvements, physician education, and the development of ED-specific tools and guidelines.

Smokeless tobacco cessation interventions: A systematic review

Background & objectives:

Smokeless tobacco (SLT) consumption is a global health issue with about 350 million users and numerous adverse health consequences like oral cancer and myocardial disorders. Hence, cessation of SLT use is as essential as smoking cessation. An update on the available literature on SLT cessation intervention studies is provided here.

Methods:

Through an extensive literature search on SLT cessation intervention studies, using keywords such as smokeless tobacco, cessation, interventions, quitlines, brief advice, nicotine replacement therapy, nicotine gum, nicotine lozenge, nicotine patch, bupropion, varenicline, mHealth, etc., 59 eligible studies were selected. Furthermore, efficacy of the interventions was assessed from the reported risk ratios (RRs) [confidence intervals (CIs)] and quit rates.

Results:

Studies were conducted in Scandinavia, India, United Kingdom, Pakistan and the United States of America, with variable follow up periods of one month to 10 years. Behavioural interventions alone showed high efficacy in SLT cessation; most studies were conducted among adults and showed positive effects, i.e. RR [CI] 0.87 [0.7, 1.09] to 3.84 [2.33, 6.33], quit rate between 9-51.5 per cent, at six months. Regular telephone support/quitlines also proved beneficial. Among pharmacological modalities, nicotine lozenges and varenicline proved efficacious in SLT cessation.

Interpretation & conclusions:

Globally, there is limited information available on SLT cessation intervention trials, research on which must be encouraged, especially in the low-resource, high SLT burden countries; behavioural interventions are most suitable for such settings. Appropriate training/sensitization of healthcare professionals, and school-based SLT use prevention and cessation programmes need to be encouraged.

Freedom From Chew: Using Social Branding to Reduce Chewing Tobacco Use Among Country Peer Crowd Teens

Background. Peer crowds are macro-level, reputation-based subcultures with shared preferences, values, and behavior. The Country peer crowd has been the focus of tobacco industry research and marketing but has yet to be the primary focus of public health research. The current study explores the utility of Down and Dirty, a Social Branding tobacco education campaign, in changing Virginia Country teens’ chewing tobacco-related attitudes and behavior. The relationship between chew use and Country peer crowd identification was also explored. Method. To evaluate the campaign, a cross-sectional survey was administered online for 3 years from 2014 to 2016. Responses were collected via social media advertisements targeting 13- to 18-year-old Country youth from Virginia (total n = 1,264). Participants reported peer crowd identification, chew-related attitudes and behavior, and campaign engagement and appeal. Results. Compared with Wave 1, Waves 2 and 3 Country teens who engaged with Down and Dirty had greater odds of holding strong attitudes against chew. Among campaign-engaged Country teens, odds of chew use were lower at Waves 2 and 3, and lower odds were associated with liking the campaign. Related to chew prevalence, Country teens demonstrated greater odds of past 30-day chew use compared to non-Country teens, and higher Country identification was associated with greater odds of chew use. Discussion. Down and Dirty is a promising intervention associated with positive attitudinal and behavioral outcomes for high-risk Country teens. Additionally, this study helps document tobacco-related behavioral patterns of the Country peer crowd, a priority for ongoing tobacco education, especially around chew.

Effective early detection of oral cancer using a simple and inexpensive point of care device in oral rinses

INTRODUCTION

Head and neck cancer remains a challenging disease that is increasing in incidence with the majority of patients diagnosed at an advanced stage where 5-year survival is approximately 50%. Current approaches including oral-brush biopsies, fluorescence-based technologies,  and salivary molecular profiling have demonstrated some success; however, cost, ease of use, and accuracy remain limiting factors. Areas covered: This is a profile of a novel, easy to use oral rinse point-of-care (POC) test to aid in the diagnosis of oral and oropharyngeal cancer. Background science related to the challenge of oral and oropharyngeal cancer and natural history of diagnostic aids for this disease are provided. Results of studies performed for validation of a POC and laboratory test are also discussed. Expert commentary: The POC test has been validated through a case : control clinical study and a prospective European trial, using version 1.0 (v1.0), which have demonstrated consistent performance including a > 90% negative predictive value, with a sensitivity of 80%. The assay was designed to identify malignant lesions in the oral cavity and oropharynx by improving upon standard clinical assessment.

Description of tobacco use and cessation among Bhutanese refugees participating in a tobacco cessation program

OBJECTIVES

To compare the tobacco use, exposure, and cessation differences between Bhutanese refugee and non-Hispanic Caucasian tobacco users in a US federally qualified health center tobacco cessation program.

DESIGN

A retrospective cohort study reviewing data from 374 patients counseled on tobacco cessation was performed. Demographic information, tobacco use history, exposure to tobacco, and type of tobacco used characterized baseline assessments. The patient record was followed forward in time to evaluate tobacco cessation outcomes as the dependent variable. Data were analyzed using odds ratios and the Mann-Whitney U-test.

RESULTS

Data analysis included 318 patients (211 non-Hispanic Caucasian patients and 107 Bhutanese refugee patients). Bhutanese refugees demonstrated a higher likelihood of smokeless tobacco product use than the non-Hispanic Caucasian population (67.3% vs 1%, OR = 214.971, 95% CI 50.429, 916.383), and a greater odds of having household tobacco users (OR = 2.533, 95% CI 1.532, 4.186). Likewise, the non-Hispanic Caucasian population exhibited larger odds of smoking cigarettes vs the Bhutanese population (97.2% vs 26.2%, OR = 96.399, 95% CI 38.449, 241.687), had a higher odds of passive smoke exposure (OR = 12.765, 95% CI 5.36, 30.393), and higher likelihood of a past quit attempt (OR = 9.037, 95% CI 5.180, 15.765). Significant gender differences with regard to type of tobacco used were noted among Bhutanese refugees. Bhutanese refugees demonstrated significantly higher likelihood of tobacco cessation, compared with the non-Hispanic Caucasian population, at all length cutpoints, while showing no difference in number of follow-up visits or median time followed.

CONCLUSION

These culture-specific findings, showing unique tobacco use characteristics and increased cessation among the Bhutanese refugee population, provide novel information helpful to professionals identifying and treating these individuals for tobacco cessation. More research is needed to confirm our results and findings.

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.

Burden of waterpipe smoking and chewing tobacco use among women of reproductive age group using data from the 2012-13 Pakistan Demographic and Health Survey

BACKGROUND

Despite the general decline in cigarette smoking, use of alternative forms of tobacco has increased particularly in developing countries. Waterpipe (WP) and Chewing Tobacco (CT) are two such alternative forms, finding their way into many populations. However, the burden of these alternative forms of tobacco and their socio demographic determinants are still unclear. We assessed the prevalence of WP and CT use among women of reproductive age group in Pakistan.

METHODS

Data from the most recent Pakistan Demographic and Health Survey 2012-13 (n = 13,558) was used for this analysis. Information obtained from ever married women, aged between 15 and 49 years were analyzed using two separate data subgroups; exclusive WP smokers (total n = 12,995) and exclusive CT users (total n = 12,771). Univariate and Multivariate logistic regression analyses were conducted and results were reported as crude and adjusted Odds Ratio with 95% confidence intervals.

RESULTS

Prevalence of WP smoking and CT were 4% and 2%, respectively. After multivariate adjustments, ever married women who were: older than 35 years (OR; 4.68 95% CI, 2.62-8.37), were poorest (OR = 4.03, 95% CI 2.08-7.81), and had no education (OR = 9.19, 95% CI 5.10-16.54), were more likely to be WP smokers. Similarly, ever married women who were: older than 35 years (OR = 3.19, 95% CI 1.69-6.00), had no education (OR = 4.94, 95% CI 2.62-9.33), were poor (OR = 1.64, 95% CI 1.07-2.48) and had visited health facility in last 12 months (OR = 1.81, 95% CI 1.22-2.70) were more likely to be CT users as well.

CONCLUSION

Older women with lower socio-economic profile were more likely to use WP and CT. Focused policies aiming towards reducing the burden of alternate forms of tobacco use among women is urgently needed to control the tobacco epidemic in the country.

Patient's lung cancer diagnosis as a cue for relatives' smoking cessation: evaluating the constructs of the teachable moment

BACKGROUND

To understand whether patient-reported experiences with lung cancer may create teachable moments (TM) for their relatives as evidenced by shifts in their risk perceptions, affective response, and self-image and in turn, motivation to quit smoking.

METHODS

Patients at a comprehensive cancer center (n = 152) completed a survey within 6 months of lung cancer diagnosis to assess their cancer-related symptoms and openness and enumerated relatives who were smokers. Relative smokers (n = 218) then completed a survey assessing their risk perceptions, affective response, and self-image as a smoker related to the patient's diagnosis (TM mechanisms), and their motivation to quit smoking. Cross-sectional mediation and moderation analyses were conducted to explore the links between patient-reported experiences, and relatives' TM mechanisms, and motivation to quit smoking.

RESULTS

Relative-reported affect was a significant mediator of the association between patient-reported symptoms and relative smoker's desire to quit. Relatives' self-image was a significant moderator of the association between patient-reported symptoms and relative smoker's desire to quit, such that patients' reported symptoms were associated with relatives' desire to quit only when the relative smoker reported a generally positive self-image as a smoker. No evidence was found for moderated mediation. However, the link between symptoms and negative affect was moderated by perceptions of risk.

CONCLUSION

Whether smokers experience a family member's lung cancer as a TM is influenced by multiple interrelated cognitive and affective factors that warrant further exploration. Clearer understanding of these factors could inform how to re-invigorate and sustain this motivation to promote concrete actions toward smoking cessation. Copyright © 2015 John Wiley & Sons, Ltd.

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.

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.

Counseling nondaily smokers about secondhand smoke as a cessation message: a pilot randomized trial

INTRODUCTION

Nondaily smoking represents a substantial and growing fraction of smokers, many of whom do not consider themselves smokers or at risk of tobacco-related diseases and, so, may be less responsive to counseling content contained in traditional cessation interventions. This study compares the effects brief counseling interventions (<20 min) focused on the harm smoking does to themselves (harm to self, HTS) versus the harm their secondhand smoke (SHS) does to others (harm to others, HTO) among nondaily smokers.

METHODS

Randomized trial of 52 nondaily smokers (smoked in the past week, but not daily) recruited between September 2009 and June 2010; 40 completed the study. We measured changes in motivation and smoking status at 3 months postintervention.

RESULTS

There was a difference in quitting between the two groups, with 9.5% (2 out of 21) for HTS and 36.8% (7 out of 19) for HTO subjects reporting not smoking any cigarettes in the prior week (p = .06 by Fisher exact test and .035 by likelihood-ratio chi-square). Motivation and self-efficacy increased from baseline to 3-month follow-up, but not differentially by intervention group.

CONCLUSIONS

Consistent with findings from research conducted by the tobacco industry as early as the 1970s that concluded that social smokers feel immune from the personal health effects of tobacco but are concerned about the consequences of their SHS on others, educating nondaily smokers about the dangers of SHS to others appears to be a more powerful cessation message than traditional smoking cessation counseling that emphasizes the harmful consequences to the smoker.

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.

Promoting Tobacco Abstinence Among Older Adolescents in Dental Clinics

The health care setting, and most notably dental clinics, may hold promise in delivering effective tobacco intervention to adolescents. Adolescents between the ages of 14 and 17 were randomly assigned to brief advice from dental hygienists and dentists only or to brief advice plus a motivational interview and follow-up telephone contact from a study hygienist. Due to difficulties in identifying and recruiting subjects, study goals were expanded from cessation only to cessation and prevention. No differences in smoking prevalence were found between treatment conditions at either 3- or 12-month follow-up. Firm conclusions cannot be drawn about the effectiveness of treatment due both to problems in enrolling subjects and limited implementation of the motivational intervention.

Necessity and readiness for smoking cessation intervention in dental clinics in Japan

BACKGROUND

The necessity and readiness for smoking cessation intervention in dental clinics was assessed by investigating smoking status and stage of behavior change in patients and the attitudes of dentists toward the effects of smoking on their patients, respectively.

METHODS

A self-administered questionnaire was mailed to 1022 dentists randomly selected from the Japanese Dental Association database. The questionnaire survey consisted of 1 section for dentists and 1 for patients aged 20 years or older and was scheduled to be completed at the dentists' clinics on a designated day in February 2008.

RESULTS

The response rate to the questionnaire was 78.2% from among target dental clinics and 73.7% and 74.7% for patient and dentist questionnaires, respectively. Data from 11,370 patients and 739 dentists were analyzed. The overall smoking prevalence among the patients (25.1%) was similar to that reported by the National Health and Nutrition Examination Survey, and young female patients had a markedly higher smoking prevalence. More than 70% of patients who smoked were interested in quitting. Although the prevalence of current smoking among dentists (27.1%) was significantly higher than that reported among Japanese physicians (15.0%), approximately 70% of dentists were concerned about the effects of smoking on patient health and prohibited smoking inside their clinic.

CONCLUSIONS

Many smokers who were interested in quitting, particularly young women, visited dental clinics, and most dentists believed that smoking was harmful for their patients. These results indicate that smoking cessation intervention in dental settings is necessary and that dentists are ready to provide such interventions.

Primary care practice and health professional determinants of immunisation coverage

AIM

To identify primary care factors associated with immunisation coverage.

METHODS

A survey during 2005-2006 of a random sample of New Zealand primary care practices, with over-sampling of practices serving indigenous children. An immunisation audit was conducted for children registered at each practice. Practice characteristics and the knowledge and attitudes of doctors, nurses and caregivers were measured. Practice immunisation coverage was defined as the percentage of registered children from 6 weeks to 23 months old at each practice who were fully immunised for age. Associations of practice, doctor, nurse and caregiver factors with practice immunisation coverage were determined using multiple regression analyses.

RESULTS

One hundred and twenty-four (61%) of 205 eligible practices were recruited. A median (25th-75th centile) of 71% (57-77%) of registered children at each practice was fully immunised. In multivariate analyses, immunisation coverage was higher at practices with no staff shortages (median practice coverage 76% vs 67%, P = 0.004) and where doctors were confident in their immunisation knowledge (72% vs 67%, P= 0.005). Coverage was lower if the children's parents had received information antenatally, which discouraged immunisation (67% vs 73%, P = 0.008). Coverage decreased as socio-economic deprivation of the registered population increased (P < 0.001) and as the children's age (P = 0.001) and registration age (P = 0.02) increased. CONCLUSIONS Higher immunisation coverage is achieved by practices that establish an early relationship with the family and that are adequately resourced with stable and confident staff. Immunisation promotion should begin antenatally.

Impact of differing definitions of dual tobacco use: implications for studying dual use and a call for operational definitions

INTRODUCTION

Concomitant use of two forms of tobacco is an increasing public health concern, yet there is little consensus regarding a consistent definition of so-called "dual use." We defined dual use as cigarette and smokeless tobacco (ST) consumption with either product used daily or nondaily.

METHODS

We analyzed a cohort of 36,013 Air Force recruits. We categorized dual tobacco use across 2 dimensions, type of tobacco products (cigarettes, ST, or others), and the frequency of use (daily vs. nondaily). We determined how varying the definition impacted the prevalence estimates and evaluated the prevalence estimate based on our recommended definition of dual use. Multivariate logistic regression analysis was used to evaluate the risk profile of dual users of ST and cigarettes versus mono users of ST and mono users of cigarettes.

RESULTS

Varying definitions of dual use vary prevalence estimates 50-fold (0.5%-25.3%). Including only ST and cigarettes narrows the prevalence estimate to less than 4-fold (2.0%-9.7%). Dual users are more likely to be young Caucasian males, with lower education, and from families with relatively higher incomes. Compared with mono users, dual users of cigarettes and ST have a distinct pattern of risk profiles.

CONCLUSIONS

Depending on the definition of dual use, markedly different prevalence and risk profiles are observed. Dual users of ST and cigarettes are a unique group of tobacco users. We propose a common definition of dual use to advance our understanding of this unique group.

Are oral health complaints related to smoking cessation intentions?

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Interventions for smokeless tobacco use cessation

BACKGROUND

Use of smokeless tobacco (ST) can lead to nicotine addiction 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 STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, Web of Science, PsycINFO, Dissertation Abstracts Online, and Scopus. Date of last search: October 2010.

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

Two authors independently extracted data. We summarised as odds ratios. 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

Data from one study suggest that varenicline increases ST abstinence rates (Odds Ratio [OR] 1.6, 95% Confidence Interval (CI) 1.08 to 2.36) among Swedish snus users.Two trials of bupropion SR did not detect a benefit of treatment at six months or longer (OR 0.86, 95% CI 0.47 to 1.57). Nicotine replacement therapy (patch, gum, and lozenge) was not observed to increase tobacco abstinence rates (OR 1.14, 95% CI: 0.91 to 1.42). There was statistical heterogeneity among the 14 trials of behavioural interventions; seven of them reported statistically and clinically significant benefits, four suggested benefit but with wide CIs, whilst two had similar intervention and control quit rates and relatively narrow CIs. Heterogeneity was not explained by the design (individual or cluster randomization), whether participants were selected for interest in quitting, or specific intervention components. Most trials included either telephone counselling, an oral examination and feedback about any ST induced mucosal changes, or both. In a post-hoc subgroup analysis there was some evidence that behavioural interventions which include telephone counselling might increase abstinence rates more than interventions with less contact. In one trial an interactive website increased abstinence more than a static website.

AUTHORS' CONCLUSIONS

Varenicline and behavioural interventions may help ST users to quit. Behavioural interventions incorporating telephone counselling or an oral examination are likely to increase abstinence rates.

"Risk homeostasis"or "teachable moment"? the interaction between smoking behavior and lung cancer screening in the Mayo Lung Project

The chest X-ray lung cancer screening program of Mayo Lung Project (MLP) yielded mixed results of improved lung case survival but no improvement in lung cancer mortality. This paper analyzes the smoking patterns of study participants in order to examine possible behavioral ramifications of periodic lung cancer screening. Using a longitudinal difference-of-difference model, we compared the smoking behavior, in terms of current smoker status among all subjects and the intensity of smoking among those continuing smokers, between those who received periodic lung cancer screening and those who received usual-care. In both arms of this lung cancer screening trial, there was a sizable decline in cigarette smoking one year after participants received baseline prevalence screening. There was no significant difference in current smoker status between the intervention group receiving periodic X-ray screening and the control group receiving usual care. While we detect that the continuing smokers in the intervention group smoked more than their counterparts in the control group, the magnitude of the difference is not sufficient to explain a substantial difference in lung cancer incidence between the two groups. Our study shows that periodic lung screening in MLP did not decrease smoking behavior beyond the observed decline following the initial prevalence screening conducted at baseline for both the intervention and control groups. Our results also indicate, paradoxically, that participants assigned to the intervention group smoked more cigarettes per day on average than those in the control group. Lung cancer screening programs need additional cessation components to sustain the abstinence effect typically observed following initial lung screening.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

The challenge to delivering oral health services in rural America

OBJECTIVES

This review identifies the challenges to oral health in rural America and describes areas of innovation in prevention, delivery of dental services, and workforce development that may improve oral health for rural populations.

METHODS

This descriptive article is based on literature reviews and personal communications.

RESULTS

Rural populations have lower dental care utilization, higher rates of dental caries, lower rates of insurance, higher rates of poverty, less water fluoridation, fewer dentists per population, and greater distances to travel to access care than urban populations. Improving the oral health of rural populations requires practical and flexible approaches to expand and better distribute the rural oral health workforce, including approaches tailored to remote areas. Solutions that involve mass prevention/public health interventions include increasing water fluoridation, providing timely oral health education, caries risk assessment and referral, preventive services, and offering behavioral interventions such as smoking and tobacco cessation programs. Solutions that train more providers prepared to work in rural areas include recruiting students from rural areas, training students in rural locations, and providing loan repayment and scholarships. Increasing the flexibility and capacity of the oral health workforce for rural areas could be achieved by creating new roles for and new types of providers. Solutions that overcome distance barriers include mobile clinics and telehealth technology.

CONCLUSIONS

Rural areas need flexibility and resources to develop innovative solutions that meet their specific needs. Prevention needs to be at the front line of rural oral health care, with systematic approaches that cross health professions and health sectors.

Smokeless tobacco use and periodontal health in a rural male population

BACKGROUND

Despite the reported effects of smokeless tobacco (ST) on the periodontium and high prevalence of ST use in rural populations and in men, studies on this specific topic are limited. The purpose of this cross-sectional investigation is to evaluate the periodontal health status of male ST users from a rural population.

METHODS

Adult male residents of two rural Appalachian Ohio counties and daily ST users, with a unilateral mandibular oral ST keratosis lesion, were recruited. Subjects completed a questionnaire and received oral examination. Teeth present, ST keratosis lesion, plaque and gingival index, probing depth (PD), recession depth (RD), and attachment level were recorded. Statistical analysis compared ST-site mandibular teeth (teeth adjacent to the subject's unilateral ST keratosis lesion) to NST-site teeth (contralateral corresponding teeth).

RESULTS

This study includes 73 ST users. Recession prevalence is much greater in ST-site quadrants (36%) compared to NST-site quadrants (18%; P <0.001). Twice as many teeth had recession on ST-site (approximately 20%) than NST-site (approximately 10%; P = 0.0001). Average buccal RD on ST-site teeth did not differ from that on the NST-site teeth (P = 0.0875). Although average buccal attachment loss is greater on ST-site teeth (P = 0.016), the mean difference is <0.5 mm. When stratified by years of ST use, subjects using ST for 10 to 18 years exhibit the most differences between ST and NST sites, whereas subjects using ST for <10 years show no differences.

CONCLUSION

The results indicate that greater gingival recession prevalence and extent are associated with ST placement site in rural male ST users.

Efficacy of brief interventions in clinical care settings for persons living with HIV

Prevention of HIV transmission from patients living with HIV (PLH) is a high national priority and strategies that are easy to implement and sustain to eliminate sexual transmission acts among PLH are needed. We evaluated a brief intervention that focused primarily on the enhancing motivations and encouraging PLH to act in accordance with their values without providing the intensity of the existing evidence-based programs for PLH. Using a quasiexperimental design, six medical clinics in Los Angeles County, CA, were evaluated across three intervention conditions: 1) computerized delivery; 2) provider delivery; or 3) standard care. We examined longitudinal changes in patients' reports of the number of HIV-negative (HIV-) or serostatus-unknown sexual partners and the number of unprotected vaginal and anal sex acts. Among 566 PLH, PLH in the computerized delivery condition reported a significant decrease in the number of HIV-/unknown sexual partners compared with the provider delivery and standard care conditions and a significant decrease in the number of unprotected sex acts in comparison to the standard care condition. Computerized motivational interventions delivered in waiting rooms at medical clinics may be an efficient strategy to reduce unprotected sex acts among PLH.

Teachable moments for health behavior change: a concept analysis

OBJECTIVE

"Teachable moments" have been proposed as events or circumstances which can lead individuals to positive behavior change. However, the essential elements of teachable moments have not been elucidated. Therefore, we undertook a comprehensive review of the literature to uncover common definitions and key elements of this phenomenon.

METHODS

Using databases spanning social science and medical disciplines, all records containing the search term "teachable moment*" were collected. Identified literature was then systematically reviewed and patterns were derived.

RESULTS

Across disciplines, 'teachable moment' has been poorly developed both conceptually and operationally. Usage of the term falls into three categories: (1) "teachable moment" is synonymous with "opportunity" (81%); (2) a context that leads to a higher than expected behavior change is retrospectively labeled a 'teachable moment' (17%); (3) a phenomenon that involves a cueing event that prompts specific cognitive and emotional responses (2%).

CONCLUSION

The findings suggest that the teachable moment is not necessarily unpredictable or simply a convergence of situational factors that prompt behavior change but suggest the possible creation of a teachable moment through clinician-patient interaction.

PRACTICE IMPLICATIONS

Clinician-patient interaction may be central to the creation of teachable moments for health behavior change.

A systematic review of the effectiveness of brief interventions with substance using adolescents by type of drug

The aim of this paper is to evaluate the effectiveness of brief interventions (BI) with adolescents (mean age <20) in reducing alcohol, tobacco or other drug (ATOD) use by means of a systematic review of BI for adolescent substance use in the English language literature up to 2002. We identified 11 studies involving 3734 adolescents. Follow-up ranged from 6 weeks to 24 months. Motivational interviewing was the predominant approach, underpinning eight studies: the remaining three provided personalized health information. Seven papers reported outcomes for alcohol interventions and four involved other substances (including one with separate alcohol outcomes). The overall effect size was d=0.126 with borderline homogeneity (Q=14.9, df=9, p=0.09). The effect size from the eight alcohol interventions (n=1,075) was classified as significant but "small" (d=0.275). The remaining non-alcohol studies were considered separately as interventions involving tobacco or multiple substance use. The two interventions with tobacco involved a substantial sample (n=2,626) but had a very small effect (d=0.037), while the two interventions addressing multiple substances involved few participants (n=110) but had a medium-large effect (d=0.78). Across a diverse range of settings (dental clinic, schools, universities, substance treatment centres) and, therefore, probably diverse clients, BI conferred benefits to adolescent substance users. BI had a small effect on alcohol consumption and related measures. The data for tobacco interventions suggested a very small reduction, particularly with general community interventions. The effect of BI with multiple substances appears substantial but the small sample cautions against expansive generalization.

Patterns and correlates of spit tobacco use among high school males in rural California

OBJECTIVE

To assess patterns and correlates of spit [smokeless tobacco (ST)] use among high school males in rural California.

METHODS

An 18-item, self-administered questionnaire was used to assess ST use among young males in 41 randomly selected high schools in 21 rural counties in California. To ensure confidentiality, students were instructed to seal their completed questionnaire in an attached envelope prior to returning it to the questionnaire administrator.

RESULTS

Overall prevalence of ST use was 9.8 percent, significantly increasing with year in school from 5 percent among freshmen to 15 percent among seniors. ST use was highest among rodeo athletes at 42 percent compared with <6 percent among nonathletes; ST use was significantly higher among smokers (32 percent) who were 2.5-30 times more likely to use ST compared with nonsmokers, depending on race/ethnicity as a result of a significant race/ethnicity x smoking interaction of degree/magnitude. In addition, students who believed there was no, or slight risk of, harm from ST use were significantly more likely to use ST than students perceiving moderate or great risk, depending on race/ethnicity (odds ratios 3.6-13). Among all ST users, 40 percent used ST on at least 5 days in the previous week, 80 percent of those reporting a brand used the brand Copenhagen, and 41 percent (189) used ST within 30 minutes of waking.

CONCLUSION

Dental public health practitioners, scholars, and policy-makers need to promote dental health through organized community efforts targeting high school male subgroups in rural areas that are at risk for ST-associated adverse health effects.

Interventions for smokeless tobacco use cessation

BACKGROUND

Use of smokeless tobacco (ST) can lead to nicotine addiction and long-term use can lead to health problems including periodontal disease and cancer.

OBJECTIVES

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

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, Web of Science, PsycINFO, Dissertation Abstracts Online, and Scopus. Date of last search: March, 2007.

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

Two authors independently extracted data.

MAIN RESULTS

Two trials of bupropion SR did not detect a benefit of treatment at six months or longer (Odds Ratio (OR) 0.86, 95% Confidence Interval (CI): 0.47 to 1.57). Four trials of nicotine patch did not detect a benefit (OR 1.16, 95% CI: 0.88 to 1.54), nor did two trials of nicotine gum (OR 0.98, 95% CI: 0.59 to 1.63). There was statistical heterogeneity among the results of 12 behavioural interventions included in the meta-analyses. Six trials showed significant benefits of intervention. In post-hoc subgroup analyses, behavioural interventions which include telephone counselling or an oral examination may increase abstinence rates more than interventions without these components.

AUTHORS' CONCLUSIONS

Behavioural interventions should be used to help ST users to quit and telephone counselling or an oral examination may increase abstinence rates. Pharmacotherapies have not been shown to affect long-term abstinence.