Where to from Here? Alice M. Horowitz, Ph.D.; Ezra O. Ogwell, B.D.S., M.P.H., M.Phil. Dr. Horowitz is Senior Scientist, National Institute of Dental and Craniofacial Research, National Institutes of Health; and Dr. Ogwell is Managing Associate, Oral and Craniofacial Research Associates and University of Nairobi. Direct correspondence and requests for reprints to Dr. Alice M. Horowitz, National Institute of Dental and Craniofacial Research, National Institutes of Health, 45 Center Drive, Room 3AN-44, MSC 6401, Bethesda, MD 20892-6401; 301-594-5391 phone; 301-480-8254 fax;
[email protected].
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e have come a long way since the early days of tobacco cessation efforts. Numerous studies have been conducted, and guidelines have been developed, tested, and implemented.1-5 The purposes of this paper are two: to review what we in dentistry need to do to expand what current research tells us works, so that more oral health providers are involved in the process of tobacco use prevention and cessation; and, secondly, to identify research that is needed to enable us to do our part in continuing to reduce the use of tobacco in the population. We know that U.S. tobacco quit rates have averaged about 3 percent a year, which have slowed recently. We also know that the tobacco industry has a seemingly endless amount of money to design new ways to entice our youth into addiction. Their approaches are ever-changing and far-reaching. We also know that dentists and dental hygienists can be pivotal in helping individuals kick the habit. But it is no secret that relatively few dental providers have had training in tobacco cessation counseling, few practice it, and even fewer feel comfortable doing it.6-7 Moreover, many dental schools’ health history forms do not assess tobacco and alcohol use.8 Thus, a legitimate question is: what can we do to change this situation? In keeping with current practices of health promotion and disease prevention, we need to expand our efforts to reduce the use of tobacco through education, policy, practice, and research.9
Education Education at many levels concerning tobacco prevention and cessation is required to make further progress in this area. We are obligated to educate students, faculty, and staff of dental and dental hygiene schools as well as policymakers. Dental and dental hygiene schools need to incorporate into their curricula not just didactic instruction on the oral health impact of tobacco use, but also practical training in clinical and community prevention and intervention.
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Concomitantly, in dental and dental hygiene school clinics, there must be a systematic way to identify dental patient records regarding tobacco use status, counseling, nicotine management prescriptions, and referral to cessation specialists when necessary to be able to assess student performance in this area. Dental and dental hygiene schools need to think and act in ways that support trans-departmental and trans-discipline tobacco intervention activities. Schools must consider linking their faculty and students with broader community efforts in tobacco use interventions. Community-based programs work in other areas—such as the prevention and control of diabetes and high blood pressure.10 Similarly, community-based tobacco interventions also can and do work. In fact, community-based tobacco interventions are the approach that have provided the best results.1 Thus, schools and practitioners need to become aware of and involved in community-based tobacco cessation and prevention efforts. It is important for us to keep in mind that each day approximately 5,000 children and youths take up smoking.11-12 This statistic suggests strongly that pediatric departments of dental schools could be a pivotal link in preventing the onset of tobacco use. Children who attend these departments are at an especially vulnerable age, and dental personnel could be powerfully influential with them. Clearly, it would be valuable to work on prevention—to help prevent the onset of tobacco use, especially among children and youth, which is the time of life when most people get started and get hooked. Many medications can be prescribed for our patients to help manage nicotine addiction.2 Yet we also know that dentists traditionally do not write many prescriptions. Thus, prescribing skills should be honed and expanded to include nicotine replacement regimens, both prescription and over-the-counter products. Schools of dentistry should not permit their students to graduate without having excellent prescribing skills, which requires considerable experience.
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Policy Although education is key to making change, especially in pre-degree or certificate programs, education works best in combination with policies.9 In fact, education is necessary to both develop and implement policy. State and national boards need to include questions on tobacco use intervention and cessation. And tobacco counseling should be a part of the practical examination of all state boards. Dental and dental hygiene school policy is needed to ensure exit competency in tobacco intervention skills, thus preparing graduates both to pass the examinations and to apply the skills in practice. We know that in at least one area of prevention, when dental students are thoroughly grounded in the use of dental sealants, they also use them in practice.13-14 We need to do this with regard to tobacco cessation and oral cancer detection and prevention. Dental and dental hygiene students should not be allowed to graduate without these essential skills. In addition, to assist those providers already in practice, tobacco intervention and cessation continuing education (CE) courses should be required for dentists and dental hygienists for licensure and relicensure. It is very exciting that New York is the first state to take such action, in that legislation now requires dentists to have a course in tobacco cessation. The legislation is tied to the requirement of having a CE course in oral cancer prevention and early detection.15
Practice The need to apply what is now known about tobacco prevention and cessation is clear. Dental and dental hygiene students and practitioners on a routine basis need to practice assessing their patients regarding tobacco use and level of addiction and subsequently providing appropriate counseling. To expand what we already know and understand about tobacco intervention and cessation, we need to work with others. We know that we can increase quit rates with combined community efforts: a comprehensive approach is best, and it requires a substantial and sustained commitment. Moreover, we need to be alert to new marketing techniques used by the tobacco industry and to plan and implement counter interventions. We must
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be vigilant. We must obtain reimbursement for tobacco intervention. Most importantly, we must keep current with the research literature on the adverse health effects of tobacco use and its prevention and cessation.
Research Although a great deal of research has been conducted in tobacco use intervention, additional studies are needed to: • Determine the extent of training of counseling in tobacco cessation in dental and dental hygiene school curricula in pre- and post-graduate courses. • Assess undergraduate and continuing education curricula vis-à-vis tobacco prevention and cessation. • Assess undergraduate and continuing education curricula vis-à-vis prescribing practices in connection with nicotine management regimens. • Determine to what extent dental personnel can be effective in community-based tobacco intervention programs, which include prevention as well as cessation. • Determine the most effective approach to changing dental and dental hygiene curricula in connection with tobacco prevention and cessation. It is clear that we have come a long way in our tobacco prevention and cessation efforts, but we can accomplish much more! Dental and dental hygiene schools can have an enormous impact by developing and implementing policies and education that result in graduates who are well trained in providing comprehensive tobacco prevention and cessation counseling, especially in community-based efforts.
REFERENCES 1. Burns DM. Reducing tobacco use: what works in the population? J Dent Educ 2002;66(9):1051-60. 2. Kotlyar M, Hatsukami D. Managing nicotine addiction. J Dent Educ 2002;66(9):1061-73. 3. Gelskey S. Impact of a dental/dental hygiene tobacco cessation curriculum on practice. J Dent Educ 2002;66(9):1074-8. 4. Warnakulasuriya S. Effectiveness of tobacco counseling in the dental office. J Dent Educ 2002;66(9):1079-7. 5. Gansky SA, Ellison JA, Kavanagh C, Walsh MM, Hilton JF. Oral screening and brief spit tobacco cessation counseling: a review and findings. J Dent Educ 2002;66(9):1088-98.
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6. Horowitz AM, Drury TF, Goodman HS, Yellowitz JA. Oral pharyngeal cancer prevention and early detection. J Am Dent Assoc 2000;131:453-61. 7. Dolan TA, McGorray SP, Grinstead-Skigen CL, Mecklenburg R. Tobacco control activities in U.S. dental practices. J Am Dent Assoc 1997;128:1669-79. 8. Yellowitz JA, Goodman HS, Horowitz AM, Al-Tannir AA. Assessment of alcohol and tobacco use in dental schools’ health history forms. J Dent Educ 1995;59:1091-5. 9. Green LW, Kreuter MW. Health promotion planning: an educational and environmental approach. 3rd ed. Mountain View, CA: Mayfield Publishing Company, 1999. 10. Knowler WC, Barrett-Connor E, Fowler SE, et al. N Engl J Med 2002;346:393-403. 11. Incidence of initiation of cigarette smoking—United States, 1965-1996. Morb Mortal Wkly Rep 1998;47:83740.
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12. Everett SA, Warren CW, Sharp D, et al. Initiation of cigarette smoking and subsequent smoking behavior among U.S. high school students. Prev Med 1999;29:327-33. 13. Ripa LW. Teaching occlusal sealant therapy to dental students department of children’s dentistry, State University of New York at Stony Brook. J Public Health Dent 1983;43:43-52. 14. Ripa LW, Johnson RM. Utilization of preventive dental practices by graduates of one U.S. dental school. J Dent Educ 1991;55:367-71. 15. NY legislation re: oral cancer & tobacco cessation. At: www.senate.state.ny.us/. Accessed: August 31, 2002. 16. Tomar SL. Dentistry’s role in tobacco control. J Am Dent Assoc 2001;132:30S-5S.
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