The use of tobacco products can lead to serious adverse oral health, as well as general health, consequences.1 Tobacco use is one of the most significant causative/contributing factors for both oral cancers2 and periodontal diseases.3 Oral disease treatment results are also not as successful with tobacco-using patients.
Studies have shown that a variety of clinicians, including members of the dental office team, can be effective in helping their patients become tobacco free. Most trials in dental settings report a quit rate comparable to what has been achieved by physicians.4 Dental offices/clinics have always emphasized prevention, have personnel with educating and motivating skills, see their patients on a recurring basis for fairly long appointments, and therefore are ideal settings to encourage and assist their patients in attempts to eliminate tobacco from their lives. The entire office team should be involved, but dental hygienists are in an ideal position to play a key role in an office program.
The American Dental Association’s position statement on tobacco “urges its members to become fully informed about tobacco cessation intervention techniques to effectively educate their patients to overcome their addiction to tobacco.”5
Unfortunately, a number of published research studies and surveys have shown that tobacco use interventions are not a routine in the majority of oral health care providers’ practices.6 In order to improve office interventions with tobacco-using patients, training in nicotine dependence treatment must begin in the health professional schools. During the last few years, U.S. dental schools have increased the amount of effort devoted to tobacco cessation curricula.7,8
Why Should Dentistry Be Involved?
Tobacco use causes serious damage to oral health. Oral health and wellness are the dental profession’s responsibility. Helping tobacco users to become tobacco-free is ethical, evidence-based, practical, cost effective, and the right thing to do. When we assist our patients with tobacco cessation, we improve their long-term oral health and treatment results, and at the same time add quality and years to their lives. What an extremely satisfying and rewarding aspect of dentistry.
This paper discusses how the resources of the University of Minnesota School of Dentistry Tobacco Cessation Program can be used to help plan and organize dental office brief interventions with tobacco-using patients.
School of Dentistry Tobacco Use Cessation Program
The University of Minnesota School of Dentistry has a comprehensive tobacco use cessation and prevention program that has been adding additional components since it started in the early 1990s. This program operates under the Division of Periodontology, Department of Preventive Sciences, and its Director was given the time and support by the Division to develop and expand the program. Our program includes didactic and clinical curricula, a web site, an individual tobacco cessation counseling clinic, research, and continuing education/outreach training.
The dental student lectures are presented throughout their four years of dental school and the dental hygiene lectures during their last two years of clinical education. Topics covered include tobacco use prevalence, the tobacco industry influence, policy and media advocacy, risks of smoking and smokeless tobacco use with emphasis on oral cancer and periodontal diseases, benefits of a tobacco-free lifestyle, nicotine addiction, stages of behavioral change, clinical cessation and prevention strategies, behavioral modification, pharmacotherapy, and dental office protocols. These various tobacco-related topics are presented during lecture courses in periodontology, pediatric dentistry, health ecology, patient management, dental hygiene, AEGD, and graduate periodontology.
All dental and dental hygiene students perform brief tobacco cessation interventions with all of their patients who use tobacco. One sensitive way of opening a discussion of their patients’ tobacco use is, “If we would help you quit, would you be interested?” Those patients who are interested in quitting fill out a tobacco use assessment form, and the students then follow the “5 A’s” by writing comments on a brief intervention form (Figure 2). This includes follow-up on their patients’ progress. These interventions are done in any of our dental/dental hygiene clinics. Both dental and dental hygiene students have a graduation/competency requirement to discuss at least one of their interventions with the program director.
Because of this experience, the students become more knowledgeable about nicotine dependence and are more comfortable in communicating with their tobacco-using patients. The students are finding that most of their tobacco-using patients are open to discussing their tobacco use concerns, and if they are approached in low-key, non-judgmental, respectful, and caring manner, they appreciate the help and support and are quick to spread the word. Increased referrals are a definite benefit.
Tobacco Program Web Site
To further enhance our tobacco cessation program and to provide easy access to information, a web site located at www.umn.edu/perio/tobacco was established (Figure 1). The web site is used by the students as a resource and as required reading for the various tobacco-related lectures. The Web site offers material relevant to:
• an overall description of the program
• general information about our dental school program and student clinical protocols,
• didactic components, including lecture outlines and seminar handouts,
• information about our individual counseling clinic, and
• tobacco-related resources, which include online links to a number of educational, professional, and governmental organizations that are involved with tobacco control.
The didactic components include the following headings and outlines:
• tobacco use prevalence and risks,
• adolescent tobacco use,
• effects of tobacco use on the oral cavity: tobacco-induced and associated oral conditions and the effects of smoking on periodontal diseases,
• fact sheets on smokeless tobacco, cigars, secondhand smoke, and hazardous chemicals in smoke,
• nicotine addiction and stages of change, including how to help in various stages of change,
• benefits of quitting and what happens after you quit,
• dependency questionnaires, including Fagerstrom nicotine dependency and psychological
“why do you smoke?” questionnaires,
• clinical practice guidelines, including AHRQ/Public Health Clinical Practice Guidelines, why should we be involved, and perceived barriers to cessation in practice,
• how to set up an office program: clinical protocols, the 5 A’s, using 5 A’s chart stickers and follow-up system, an extended intervention form, useful tobacco cessation pamphlets, example of a listing of quit tobacco programs and phone helplines, and office team responsibilities,
• successful patient interactions, including tobacco users’ common questions and concerns and a web article demonstrating brief interventions with tobacco users in various stages of change,
• pharmacotherapy including information about nicotine replacement products and Zyban, patient handouts on how to use the nicotine patch, gum, lozenge, nasal spray, inhaler, and Zyban, drug interactions, and prescription writing, and
• the tobacco industry wars.
The web site has been very useful for the students as a replacement for paper handouts and as up-to-date resources for interventions in the clinic.
Practicing dental professionals may also find the 5 A’s form and other information useful for setting up an office brief tobacco cessation intervention program as well as instructive direction on successful patient interactions.
Of special interest in setting up an office program would be the outline on the web site, Using 5 A’s chart stickers and follow-up system. The protocols in this outline show how the 5 A’s brief intervention, follow-up forms, and call reminder index cards can be used.
Figure 2 shows the 5 A’s form that can be made into a chart sticker or added to the electronic patient record. Individual offices will want to alter these forms to fit into their clinic routines. The 5 A’s include:
• ASK about type of tobacco used, how much, and for how long; reasons for wanting to quit; and information about previous quit attempts.
• ADVISE about the oral effects of smoking and smokeless tobacco use and the benefits of cessation.
• ASSESS their willingness to quit.
• ASSIST them, depending on their willingness to quit, by referral to counseling programs or phone helplines, setting a quit date if ready, and recommending pharmacotherapy when appropriate.
• ARRANGE for follow-up to support their efforts.
Intervention forms, a list of local quit tobacco use programs and phone helplines, and cessation pamphlets should be available in the office. An excellent referral source for those interested in more extensive counseling is the free Minnesota tobacco helpline, 1-888-354-PLAN. Helpline information pamphlets for the office can be obtained by calling (952) 767-1400. Examples of quit programs and pamphlets are on our web site. Although tobacco interventions are not usually a covered benefit, the ADA insurance code D1320 (tobacco counseling for the control and prevention of oral disease) should be used. Many of the medical insurance plans in Minnesota do cover pharmacotherapy for tobacco cessation. It is both appropriate and legal for dentists to prescribe nicotine replacement products and Zyban. When this is done, progress notes should indicate that pharmacotherapy was prescribed for the control and prevention of oral disease (ADA code D1320). Our web site contains information about the use and prescribing of these products.
Individual Counseling Clinic
In 1997, an individual tobacco cessation counseling clinic was opened at the School of Dentistry. The University of Minnesota Oral Health Research Center and the Erwin Schaffer Periodontal Research Chair provided funding for the clinic. The clinic is a customized, multi-component tobacco cessation program that provides individual counseling and long-term follow-up. Individuals may refer themselves to the program or be referred by their dentists, dental hygienists, physicians, nurses, or other health care professionals.
Tobacco use history, nicotine dependence, motivation, and self-assessment questionnaires are sent to an individual before the first appointment.
The first session includes a comprehensive interview and assessment. Motivational interviewing techniques, including reflective listening, are used during the session.
The initial assessment includes personal reasons for wanting to quit, psychological reasons for use, stage of readiness, degree of dependence including use of a breath carbon monoxide monitor, previous attempts, triggers to use, and benefits of and barriers to quitting. The counselor helps the individual set up his or her own “customized” treatment plan. Possible options are discussed, including behavioral modification strategies, coping skills, support networks, and monitored use of FDA-approved tobacco cessation pharmaceutical products. Follow-up includes other sessions as needed and/or telephone counseling.
The fees for the individual counseling appointment and follow-up appointments are reasonable. To find out more about the program or make an appointment, please call (612) 626-0440.
Continuing Education and Outreach
Dr. Eric Stafne has been involved in a number of areas of tobacco control. He was a member of the coordinating and advisory committee of the Minnesota ASSIST (American Stop Smoking Intervention Study) Coalition. He co-chaired the Health Care Settings Subcommittee of the Minnesota Tobacco Settlement Foundation’s Cessation Advisory Committee. He was involved with the American Cancer Society Tobacco Control Committee and the University of Minnesota Academic Health Center Tobacco Strategy Team. Dr. Stafne is presently a member of the Society for Research on Nicotine and Tobacco and is representing dentistry on the Planning Committee of the Association for the Treatment of Tobacco Use and Dependence.
Dr. Stafne gives a number of lectures and workshops on tobacco prevention and cessation to various local, state, and national organizations. He has presented continuing education training sessions to private and managed care offices and clinics, study clubs, medical, nursing, dental, dental hygiene, dental assisting, pharmacy, and other health care organization meetings, and state and national tobacco control conferences.
Research and Publications
Dr. Stafne has been a dental consultant for a grant investigating adolescent tobacco cessation in dental clinics using motivational interviewing. He was also the trainer and consultant for a grant evaluating changes in a managed care dental clinic system that involved routine tobacco cessation interventions and follow-up.
At this time the authors are in the process of evaluating the outcomes of the students’ interventions as well as evaluating a number of factors involved with individual counseling techniques and pharmacotherapies.
A selected number of tobacco-related printed/digital papers that the authors have published are included in the references.9-12
When dentists and dental office team members assist their patients in becoming tobacco free, they are eliminating causative/contributing factors for a number of oral conditions, including cancer and periodontal diseases. These tobacco cessation services, when successful, can also improve the outcome of dental treatment and at the same time add quality and years to patients’ lives. Dental offices that would like to provide and document tobacco cessation services will find the University of Minnesota School of Dentistry web site www.umn.edu/
perio/tobacco a useful resource. For some tobacco-using patients who are interested in quitting, our Individual Counseling Clinic at (612) 626-0440 is a possible option, and referrals are welcome. For further information, please contact Dr. Stafne at firstname.lastname@example.org.
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2. Mecklenburg RE, Greenspan D, Kleinman DV
et al. Tobacco effects in the mouth: an NCI
and NIDR guide for health care professionals. Bethseda, Maryland: NIH, 2000, NIH pub.
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4. Fiore MC, Bailey WC, Cohen SJ et al. Treating tobacco use and dependence: clinical practice guidelines. Rockville, Maryland: U.S. Department of Health and Human Services, Public Health Services, 2000.
5. American Dental Association, 1996. ADA
position statement: summary of policy and recommendations regarding tobacco.
6. Dolan TA, McGorrray SP, Grinstead-Skigen CL et al. Tobacco control activities in U.S. dental practices. JADA 1997;128:1,669-1,679.
7. Baker GJ, Williams KB. Tobacco use cessation activities in U.S. dental and dental hygiene student clinics. J Dental Education 1999; 63(11):828-838.
8. Christen AG. Tobacco cessation, the dental profession, and the role of dental education.
J Dent Educ 2001;65(4):368-374.
9. Stafne EE, Bakdash B. Tobacco cessation intervention: How to communicate with tobacco-using patients. J Contemporary Dental Practice, Vol. 1, No. 4, fall 2000.
10. Stafne EE. Cigarette smoking and periodontal diseases: The benefits of smoking cessation. Northwest Dentistry Sept-Oct1997;76(5):25-29.
11. Hastreiter RJ, Bakdash B, Roesch MH, Walseth J. Use of tobacco prevention and cessation strategies and techniques in the dental office. JADA Nov 1994;125(11):1,475-1,464;.
12. Stafne EE. The role of the dental office in tobacco cessation: A practical approach. Northwest Dentistry Jan-Feb 1993;72(1): 17-21.