Impact of a Dental/Dental Hygiene TobaccoUse Cessation Curriculum on Practice Shirley C. Gelskey, M.P.H., Ph.D. Abstract: Tobacco use is the chief avoidable cause of morbidity and mortality in North America and is associated with increased risk for oral cancer and increased prevalence and severity of periodontitis and other oral conditions. By delivering two- to threeminute tobacco-use cessation counseling (TUCC), oral health professionals can achieve quit rates substantially higher than the spontaneous quit rate. However, many clinicians report lack of training and knowledge in TUCC as barriers to providing cessation counseling. The purpose of this study was to evaluate whether implementation of a comprehensive, dental school-based, tobaccouse cessation program would increase the extent to which tobacco-using patients received TUCC. The school’s program was based on the critical administrative, cultural, structural, and policy components of effective TUCC interventions outlined by Fiore et al. A pre- and post-program telephone interview of tobacco-using patients assessed TUCC intervention by students. A significantly greater proportion of patients received TUCC post-program compared to pre-program in terms of consequences associated with tobacco use as well as advice to quit. A comprehensive TUCC program resulted in an improvement of 11.7 percent for consequences and 23 percent for advice to quit. Dr. Gelskey is Assistant Dean, Faculties of Medicine and Dentistry, and Professor and Head, Department of Dental Diagnostic and Surgical Sciences, Faculty of Dentistry, University of Manitoba. Direct correspondence and requests for reprints to her at the Department of Dental Diagnostic and Surgical Sciences, Faculty of Dentistry, University of Manitoba, 790 Bannatyne Ave., Winnipeg, Manitoba, Canada R3E 0W2; 204-789-3367 phone; 204-789-3913 fax;
[email protected]. Funding for this project was received from the University of Manitoba Professional Development Fund, the Faculty of Dentistry’s Dean’s Research Fund, and the Faculty of Dentistry Endowment Fund. Key words: tobacco, smoking, cessation, counseling, dental education
T
obacco use is the chief avoidable cause of morbidity and mortality in North America and is a known cause of cancer, heart disease, stroke, and chronic obstructive pulmonary disease.1 It is also associated with increased risk for oral cancer and increased prevalence and severity of periodontitis and edentulism.2-6 The 1999 Canadian Tobacco Use Monitoring Survey of Manitobans aged >18 indicated 23 percent were current tobacco users.7,8 An earlier study reported that 79 percent of Manitoba smokers want to quit.9 By delivering two- to three-minute tobacco-use cessation counseling (TUCC) to tobacco users as part of routine care, health professionals can achieve quit rates substantially higher than spontaneous quit rates.10 However, many health professionals report they do not provide TUCC because they lack training and knowledge of how to integrate it into practice.11,12 Practicing dentists know that TUCC should be given during dental appointments, and they say they want to receive the necessary training.13 The number of dental schools in North America that include tobacco-use cessation in their curricula has increased. In 1989, one-half to two-thirds of schools addressed the hazards of tobacco use, onethird introduced counseling techniques, and 19 percent required students to counsel patients about tobacco use.14,15 A more recent survey of American
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dental schools (92.6 percent response rate) indicated that while 56 percent delivered didactic content, 84 percent required students to inquire about patients’ tobacco use.16 Fiore et al. outlined the critical components of an effective tobacco-use cessation program: train student-clinicians in effective tobacco-use cessation counseling; provide them with institutional/clinical support; establish a clinical culture where TUCC is the standard of practice; and work with public/professional/corporate policymakers to establish protocols and policies that financially recognize and reimburse TUCC services. 17 The Dental School, Univeristy of Manitoba, Tobacco-Use Cessation Program was designed to include these elements. The purpose of this study was to evaluate whether implementation of a comprehensive tobaccouse cessation program would increase the extent to which tobacco-using patients received tobacco-use cessation counseling.
Methods In the summer of 1998, a chart audit was completed of all adults (>18 years of age) who received care in the University of Manitoba dental school’s
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clinic during the 1997-98 academic year (n=1,665). The audit was completed by a single individual trained by the principal investigator. Patient medical histories identified tobacco-use status. Patients were interviewed by telephone by a single independent research assistant asking two structured questions: “Did any student at the dental college tell you about the possible effects of smoking on oral/dental health?” and “Did any student advise you to quit smoking?”
Program Implementation In August 1998, the dental school implemented a comprehensive tobacco-use cessation program described previously.18 The program was based on recommendations contained in the Agency for Health Care Policy and Research Clinical Practice Guidelines and led by the principal investigator, who was trained through the Mayo Clinic Nicotine Dependence Seminar and Counselor Training and Program Development course and the National Cancer Institute’s program, “How to Help Your Patients Be Tobacco-Free.” Specific activities included: 1) The medical and periodontal histories required students to ask patients about tobacco-use status. 2) A chart labeling system displayed tobacco-use status. 3) The periodontal history and examination documented tobacco use, form used, and number/day and years used, along with the question, “ How interested are you in stopping your tobacco use. . . . Not at all, Somewhat, or Very?” In addition, TUCC was required in the periodontal treatment plan for tobacco users. Specific tobacco-use interventions were documented; these included: Discussed general Yes No Dates: consequences Discussed oral Yes No Dates: consequences Advised to quit Yes No Dates: Gave self-help material Yes No Dates: Referred: Freedom from Yes No Dates: Smoking Clinic Set “Quit Date” Yes No Dates: Followed up “Quit Date” Yes No Dates: Periodontal competency examinations evaluated TUCC procedures, and failure to provide TUCC resulted in failure of the competency. 4) A three-hour training session was incorporated
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into the dental and dental hygiene curricula. The objectives of the course were for the students to: a. Understand general/oral health consequences of tobacco use; b. Understand biological mechanisms of action of tobacco use on oral health; c. Understand physical/psychological/social factors involved in tobacco use; d. Describe role of dental professionals in TUCC; e. Understand “stages of change” model in TUCC; f. Understand role of pharmacological interventions including nicotine replacement therapy (NRT) as well as bupropion HCl (Zyban); g. Understand referral mechanisms to community smoking cessation resources that offer intensive individual or group TUCC; h. Be prepared to carry out the dental school’s tobacco-use cessation clinic protocol; and i. Be prepared to implement a TUCC program in their future dental practices. Topics included in the training session are shown in Table 1. 5) The dental school initiated the Freedom from Smoking Clinic, a group counseling program. Through a series of eight, two-to-three-hour sessions, participants developed an individual plan of action to quit. Information was provided about nicotine replacement therapy and non-NRT, including Zyban. The program emphasized stress management, relaxation techniques, healthy eating practices, and other positive lifestyle changes. It also utilized a “buddy system.” The cost of the program was $130 and included a personal workbook and guidance from a TUCC facilitator. 6) The dental school acted as a resource center for printed TUCC educational materials. Table 1. Tobacco cessation training session topics • • • • • • • • •
The prevalence of tobacco use, direct and impact on public health General/oral health consequences of tobacco use Why people smoke and why they quit Nicotine addiction, physical effects, and withdrawal Stages of change model and readiness to quit Counseling (ask, advise, assess, assist, arrange), selfhelp material, referral Pharmacological interventions: indications/ contraindications Clinic protocol for TUCC Design of TUCC program for the dental office
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7) In 1999, the dental school submitted a proposal to the Manitoba Dental Association (MDA) to initiate an MDA fee code for TUCC services. The fee code was implemented in 2001. 8) The dental school also received approval from the MDA, College of Physicians and Surgeons of Manitoba, and the Manitoba Pharmaceutical Association for dentists with approved TUCC training to prescribe bupropion HCl (Zyban) to help their patients quit tobacco use. A follow-up evaluation of the TUCC program was carried out in the summer of 2000, two years after it was implemented. A chart audit was completed of all adult patients (n=2,257) who received care in the clinic during the 1999-2000 academic year. A telephone interview was conducted among the 406 identified tobacco users. Chi-square analyses were used to determine the difference in the proportion of patients receiving TUCC in 1997-98 compared to those in 1999-2000.
(2.7 percent) individuals could not remember whether they had been informed of the consequences of tobacco use, and seven (1.7 percent) could not remember whether they had been advised to quit. There was a significantly greater proportion of patients who received TUCC post-program compared to the preprogram in terms of consequences of tobacco use (p= .004) and advice to quit (p< .001). A sub-analysis of repeaters or respondents who participated in both surveys (smokers interviewed both pre- and post-program, n=69) revealed a significantly greater proportion of them had received TUCC at follow-up than before (p=0.009 McNemer’s Test). A second subanalysis, excluding repeaters, also showed a significantly greater proportion of nonrepeating patients received one or both types of TUCC advice (consequences or quit) than in the pre-program population (p= 0.013 Chi-square test).
Discussion Results The dental school’s records indicated that 1,665 adults received care between August 1997 and May 1998. Of this number, eighty-six patient charts were those of dental/dental hygiene students, or they were incomplete, leaving 1,579 charts eligible for audit. The chart audit showed that 302 patients (19.13 percent) reported current tobacco use. When contacted by telephone, three tobacco users declined to be interviewed, leaving a response rate of 99.3 percent. Of 302 reported tobacco users interviewed (n=299), 256 (85.6 percent) also reported to be current tobacco users at interview. Of these 256 users, 117 (45.7 percent) said that they had been informed by a student of the oral consequences of smoking. Fewer individuals (41.0 percent) reported that they had been advised to quit smoking. Follow-up evaluation indicated that 2,257 adults (1,030 males [45.6 percent] and 1,227 females [54.4 percent]) received care between August 1999 and May 2000. Of these, 128 charts were those of students or incomplete, leaving 2,129 charts eligible for audit. The audit showed that 407 patients reported current tobacco use (19.12 percent). Of these who were subsequently interviewed, 406 again reported to be users, which was equally distributed between males and females. Fifty-seven percent of users (233) had been informed of the consequences of smoking while 65 percent had been advised to quit. Eleven
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This study investigated the prevalence of tobacco use among adults attending the dental school’s clinic and the extent of TUCC they received. The study also evaluated the effect of a comprehensive tobacco-use cessation program on TUCC activity by students. The prevalence of current tobacco use reported by patients attending the clinic in 1997-98 was similar to that (23 percent) reported by the 1999 Canadian Tobacco Use Monitoring Survey.7 The higher rate observed in the latter study may be explained by its inclusion of rural Manitobans, known to have higher rates of tobacco use, while most dental school patients reside in the city of Winnipeg.9 Due to the transient patient population, the study did not compare all patients’ pre- and postprogram receipt of TUCC. However, a comparison was possible of a cohort of sixty-nine patients who attended the clinic both pre- and post-program intervention. Of these repeaters, twenty-nine received advice about consequences or advice to quit before the program, while forty-four received this advice at follow-up (p= 0.009). Forty and twenty-five individuals either did not receive or did not recall receiving advice, respectively. The potential for contamination bias was assessed because those who participated in the second interview could have had their response contaminated by their participation in the pre-program interview. A sub-analysis that removed repeaters still showed that significantly more patients re-
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ceived TUCC post-program than pre-program (p= 0.013). These figures fall short of the U.S. Public Health Service’s objective that oral health care providers routinely provide TUCC for 100 percent of tobacco-using patients, but this study shows that a comprehensive program of TUCC can significantly increase tobacco counseling by students.19 The strength of the dental school’s program may be its multifaceted components. However, it is not possible to determine whether one component contributed to success more than others. Although it is uncertain whether revision to medical history forms influenced TUCC, revision of the faculty’s medical history did more accurately identify tobacco use status. Reported use was not validated biochemically through cotinine or carbon monoxide measurements. However an attempt was made to validate reported use (medical history) through telephone interviews. Naturally, accurate assessment of tobacco use is an essential first step in TUCC. The independent contribution to TUCC of the three-hour TUCC training session was not measured. However, pre- and post-session written tests showed an increase in student TUCC knowledge. Although knowledge alone is not sufficient, it is necessary to ensure effective counseling. Student experience in TUCC allows them to identify the stages of patient readiness for change and allows them to intervene comfortably. Three years of TUCC experience may eliminate another barrier to counseling: fear of alienating their patients. Understanding that TUCC requires minimal time may help eliminate another barrier reported by practitioners: unreasonable time commitment required.20 The dental school also initiated two tobaccorelated policy changes that may have increased TUCC activity. Approval was obtained for Manitoba dental graduates (since 1998) to prescribe buproprion HCl (Zyban) to help patients quit smoking, and a Manitoba Dental Association Fee Code for TUCC services was also established. It will be interesting to determine the impact of these policy changes on TUCC practice patterns of graduates in the future. This study had a number of limitations. While we would have liked to conduct a randomized, controlled study, it was not practical as it is not ethical to withhold tobacco counseling. This was therefore an intervention study of two cross-sectional patient populations. All consenting users were included in the study, so there was no control group. Without a control, it is not possible to prove that increased TUCC activity
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was due exclusively to the dental school’s program or to some intervening or systematic variables such as public health tobacco campaigns or tobacco legislation. Also, due to social desirability bias, tobacco use could have been underreported. However, the telephone interviews validated initial self-reported use. No biochemical assessment was made to confirm tobacco use. Another survey will be conducted during 2002 to compare actual TUCC practice patterns of dentists and dental hygienists who have graduated from the University of Manitoba over the past five years with those who graduated prior to the implementation of the TUCC program. In addition, a number of administrative and institutional modifications to the school’s program are planned and will be evaluated. One evaluation will be to assess the influence of formal TUCC training of clinical instructors.
Conclusion A dental school-based, tobacco use cessation program that increases student knowledge, creates a clinical environment, and provides TUCC experience was able to significantly increase the proportion of tobacco users receiving tobacco use cessation counseling.
Acknowledgments Appreciation goes to Dr. C. Kionke and Dr. E. Hui, research assistants, Faculty of Dentistry, and Ms. Mary Cheang, Biostatistics Consultant, Faculty of Medicine, University of Manitoba.
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East York, Ontario: an initial evaluation. J Can Dent Assoc 1995;61:65-7. 7. Canadian tobacco use survey, 1999-2000. Ottawa: Statistics Canada, 2000. 8. Gilmore J. Report on smoking prevalence in Canada, 1985-1999. Cat 82F0077XIE. Ottawa: Statistics Canada, 2000. 9. Young TK, Gelskey DE, MacDonald SM, Hook E, Hamilton S. The Manitoba heart health survey: technical report. Manitoba: Department of Community Health Sciences, Faculty of Medicine, University of Manitoba, 1991:46-9. 10. Li VC, Coates TJ, Ewart CK, Kim YJ. The effectiveness of smoking cessation advice given during routine medical care: physicians can make a difference. Am J Prev Med 1987;3:81-6. 11. Geboy MJ. Dentists’ involvement in smoking cessation counseling: a review and analysis. J Am Dent Assoc 1989;118:79-83. 12. Cummings KM, Giovino G, Sciandra R, Koenigsberg M, Emont SL. Physician advice to quit smoking: who gets it and who doesn’t? Am J Prev Med 1987;3:69-75. 13. Secker-Walker RH, Hill HC, Solomon LJ, Flynn BS. Smoking cessation practices in dental offices. J Public Health Dent 1987;47:10-20.
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14. Fried JL, Rubenstein-De Vore L. Tobacco use cessation curricula in US dental schools and dental hygiene programs. J Dent Educ 1990;54:730-5. 15. Cheney HG. Smoking policies of US dental schools. J Dent Educ 1990;54:216-7. 16. Grinstead CL, Dolan TA. Trends in U.S. dental schools’ curriculum content in tobacco use cessation. J Dent Educ 1994;58:663-7. 17. Fiore MC, Bailey WC, Cohen SJ, et al. Smoking cessation: clinical practice guideline, No. 18. AHCPR Publ. No. 96-0692. Rockville, MD: U.S. Department of Health and Human Services, PHS, Agency for Health Care Policy and Research, 1996. 18. Gelskey SC. Tobacco-use cessation programs and policies at the University of Manitoba’s faculty of dentistry. J Can Dent Assoc 2001;67:145-8. 19. U.S. Department of Health and Human Services. Healthy people 2000: national health promotion and disease prevention objectives. DHHS Publication No. 91-50212. Washington, DC: U.S. Government Printing Office, 1991. 20. Gerbert B, Coates T, Zahnd E. Dentists as smoking cessation counselors. J Am Dent Assoc 1989;118:29-32.
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