It is well documented that tobacco use affects virtually every organ in the human body causing an overall decrease in health as well as quality of life.11,14 In addition to being linked with numerous cancers and coronary conditions, tobacco use plays a strong role in the etiology of various oral conditions, including:1,2,6
- Oral Cancer
- Nicotine Stomatitis
- Teeth Staining
- Degeneration of salivary glands
- Delayed wound healing
United States smoking prevalence has slowly declined to about 20% in the last few decades, although over 44 million Americans still smoke. Among this group, over 70% say they would like to quit, but only 2.5% are able to do so themselves annually.3,5,15 An increasingly attractive venue for tobacco cessation is in the health-care setting where providers are seen as a credible source of cessation advice and patients are sensitive to their health at the time of the visit.2,6 In addition to being knowledgeable about the hazards of smoking, health-care providers are likely to have frequent contact with their patients which allows for easy follow-up opportunities.7
Despite the relative absence of tobacco cessation practices in dental offices, dentists are favorably situated to provide cessation assistance due to the regularity of visits.1,2 Most dental patients receive care on a biannual basis, providing a mechanism for long-term contact to assess visible changes in oral status.1,2,6 Dental visits differ from visits to other health-care providers in that they are usually preventive rather than problem oriented.1,10 Additionally, patients today are more concerned about cosmetic dentistry than ever before creating an opportunity to introduce cessation strategies for cosmetic reasons.2
Dental offices are such a promising avenue for providing tobacco cessation that many organizations have publically encouraged and supported the idea including the:2
- American Dental Association
- Agency for Healthcare Research and Quality
- Center for Disease Control and Prevention
- Public Health Service
Despite encouragement from these national organizations, surveys suggest only 30-50% of US dentists, along with only 25% of hygienists ask their patients about smoking.2,4,9 Other obstacles associated with dental cessation practices include:2,6,7,8,9
- Advice having reputation of being “rather ad hoc and somewhat superficial"
- Patient resistance
- Amount of time required
- Concerns about effectiveness
- Absence of educational materials
- Lack of reimbursement
A more alarming trend shows relatively few health-care professionals are familiar with tobacco use among their adolescent patients. Studies show very few dentists (26%) could estimate smoking prevalence within that age group, compared to 38% pediatricians and 48% of family practitioners.7 As a consequence, fewer than 1 in 10 dentists reported “always” counseling this age group while more than 3 in 10 reported “seldom or never” counseling them.7,12 Common excuses from dentists include:1,7
- “Counseling is ineffective in altering behavior of adolescents”
- “It’s difficult to know which of my patients are truly at risk”
- “I don’t feel qualified to counsel patients on this matter”
Despite a lack of knowledge being cited as a major barrier, a recent study found that 95.2% of dentists are willing or very willing to receive training in tobacco cessation.2 These studies indicate that dental professionals believe tobacco cessation should be a part of dental care, but that certain barriers (e.g. training, time, reimbursement, etc.) need to be overcome before cessation activities can be integrated into routine practice. Experts believe a curriculum change in dental schools that includes tobacco cessation training is paramount to improving cessation behaviors in practice.1,6 Additionally, cessation advice should not be the sole responsibility of the dentist. Instead, the work-load should be distributed across all practice staff as to minimize the burden for any one person. Front office staff can maintain tobacco-related documents in patients’ charts, acting as a prompt for discussion of tobacco use, while hygienists focus more on the actual cessation advice. Dental hygienists are best positioned to deliver brief tobacco cessation counseling for a variety of reasons including:1,6,7,13,14
- They have more time to spend with patients
- They are keen to learn and apply new skills
- This type of education fits well with the other health behavior messages delivered by the hygienist (e.g. brushing and flossing, etc.)
- The cleaning visit is especially suitable for tobacco intervention. It is a long, scheduled visit, and provides sufficient time for feedback on tobacco’s impact on oral health
The Clinical Practice Guidelines for Treatment of Tobacco Use and Dependence advocates the use of the ‘5 As’ of tobacco cessation intervention to be delivered by health-care practitioners.6 The 5 A’s consist of:2,5,6
- Ask patients routinely about their tobacco use status
- Advise all tobacco-using patients to quit
- Assess the readiness of tobacco users to quit
- Assist all tobacco users interested in quitting
- Arrange for patient follow-up care
One approach is based on the 5 As model of tobacco cessation, wherein the entire burden of the intervention falls on the dental practice. The second approach uses an abbreviated model (3 As), in which the dental practice is responsible for identifying and advising tobacco-using patients to quit, but refers proactive patients interested in quitting to a telephone tobacco quit line for counseling. For more information on the 5 A's please click here.
If dental practitioners provided cessation assistance routinely to their patients and achieved even modest success rates, the public health impact would be enormous. Researchers and clinicians must continue to work together towards universal adoption of effective tobacco cessation interventions at each clinical encounter.
Did you know that the Medicaid population is significantly more likely to use tobacco than the general population? Do you want to enhance your skills at reaching and intervening with Medicaid patients who use tobacco? MDQuit has an online training to teach you the strategies that can be utilized with all patients—regardless of their health insurance status. You can sign-up for this FREE self-paced online training by going to https://HABITSLabTraining.litmos.com/self-signup/ and entering the training code, "medicaid".
- Albert, D. A., Severson, H., Gordon, J., Ward, A., Andrews, J., & Sadowsky, D. (2005). Tobacco attitudes, practices, and behaviors: A survey of dentists participating in managed care. Nicotine & Tobacco Research, 7 (1), S9-S18.
- Albert, D., Ward, A., Ahluwalia, K., & Sadowsky, D. (2002). Addressing tobacco in managed care: A survey of dentists' knowledge, attitudes, and behaviors. American Journal Of Public Health, 92(6), 997-1001.
- Centers for Disease Control and Prevention . ( 2002 ). Cigarette smoking among adults. United States, 2000. MMWR Morbidity and Mortality Weekly Report, 51 , 642 – 645.
- Dolan TA, McGorray SP, Grinstead-Skigen CL, Meddenburg R. Tobacco control activities in U.S. dental practices. 1997; 128:1669-1679.
- Fiore, M. C., Jaen, C. R., Baker, T. B., Bailey, W. C., Benowitz, N. L., Curry, S. J., et al. (2008). Treating tobacco use and dependence: 2008 update—Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.
- Gordon, J. S., Lichtenstein, E., Severson, H. H., & Andrews, J. A. (2006). Tobacco cessation in dental settings: Research findings and future directions. Drug And Alcohol Review, 25(1), 27-37.
- Gregorio, D. I. (1994). Counseling adolescents for smoking prevention: A survey of primary care physicians and dentists. American Journal Of Public Health, 84(7), 1151-1153.
- Hastreiter RJ, Bakdash B, Roesch MH, Walseth J. Use of tobacco prevention and cessation strategies and techniques in the dental office. J Am Dent Assoc. 1994; 125:1475-1484.
- Jones RB, Pomrehn PR, Mecklenburg RE, Lindsay EA, Manley M, Ockene JK. The COMMIT dental model: tobacco control practices and attitudes. Dental Association 1993; 124;92-104.
- Manski, R. J., & Moeller, J. F. (2002). Use of dental services: An analysis of visits, procedures and providers, 1996. The Journal Of The American Dental Association, 133, 167–175.
- Salive M. C., Cornoni-Huntley J., LaCroix A. Z., Ostfield A. M., Wallace R. B., Hennekens C. H. Predictors of smoking cessation and relapse in older adults. American Journal Of Public Health 1992; 82: 1268–71.
- Seffrome JR, Stauffer DJ. Patient education on cigarette smoking: the dentist's role. The Journal Of American Dental Association 1976; 92:7514.
- Severson, H. H., Eakin, E. G., Stevens, V. J., & Lichtenstein, E. (1990). Dental office practices for tobacco users; independent practice HMO clinics. American Journal of Public Health, 80, 1503–1505.
- Tait, R. J., Hulse, G. K., Waterreus, A., Flicker, L., Lautenschlager, N. T., Jamrozik, K., & Almeida, O. P. (2007). Effectiveness of a smoking cessation intervention in older adults. Addiction, 102(1), 148-155.
- Tong, E. K., Strouse, R., Hall, J., Kovac, M., & Schroeder, S. A. (2010). National survey of U.S. health professionals' smoking prevalence, cessation practices, and beliefs. Nicotine & Tobacco Research, 12(7), 724-733.