smoking cessation as a dental intervention

7/27/2019 Smoking Cessation as a Dental Intervention

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Smoking cessation as a dental intervention — Views of the profession

F. Stacey,1 P. A. Heasman,2 L. Heasman,3 S. Hepburn,4 G. I. McCracken5 and P. M. Preshaw6

Objective To undertake a questionnaire-based survey to determine theattitudes and activities of dental professionals in primary care in theNorthern Deanery of the UK in relation to providing smoking cessationadvice.Methods Questionnaires for dentists, hygienists and dental nurseswere sent to hygienists to distribute to other members of the team. The

information collected included: smoking status of the professionals andthe practice; roles of the dental team in giving smoking cessation advice;levels of training received; and potential barriers to giving this brief intervention.Results Over 90% of practices were smoke-free environments andsignificantly more dental nurses (23%) were smokers compared todentists (10%) and hygienists (7%) (p<0.01). The majority of dentists andhygienists enquired about smoking status of their patients and all threegroups believed that hygienists and dentists should offer brief smokingcessation advice. Potential barriers to delivering smoking cessation advicewere identified: lack of remuneration; lack of time; and lack of training.Conclusion Dental teams in primary care are aware of the importanceof offering smoking cessation advice and, with further training and

appropriate remuneration, could guide many of their patients whosmoke to successful quit attempts.

INTRODUCTIONSmoking cessation advice has been suggested as a component

of an overall oral health assessment in Options for change.1 Inaddition to the general health benefits of stopping smoking uponthe increased risks of cancer, respiratory diseases and circulatory

disorders, there are benefits more directly associated with theoral environment. Tobacco smoking has been identified as the

1,2*-6School of Dental Sciences, University of Newcastle upon Tyne, Framlington Place,University of Newcastle upon Tyne, Newcastle-upon-Tyne, NE2 4BW*Correspondence to: Professor Peter HeasmanEmail: [email protected]

Refereed paperAccepted 27 September 2005DOI: 10.1038/sj.bdj.4813829© British Dental Journal 2005; 201: 109-113

most important risk factor for oral cancer.2 Smoking has also

been shown to increase the risk of periodontal destruction, evenin the presence of good plaque control.3 Therefore the role of the

dental team in promoting smoking cessation advice (SCA) is rel-evant to both the general and specialty based dental disciplinesto encourage our patients to stop smoking.

This role has been investigated previously in questionnairesurveys undertaken in Scotland2 and the Oxford region.4,5 These

questionnaire surveys, however, invited responses only from gen-eral dental practitioners, although all members of the dental team

may promote this aspect of health care. Indeed, three North Ameri-can studies have shown that dental hygienists can have a strategicinput into SCA.7-9 There is also considerable evidence to indicate

that aspects of smoking cessation training have been successfully incorporated into undergraduate curricula for all members of the

dental team.10,11 The aim of this questionnaire study, therefore, wasto determine the views and activities of dentists, dental hygienists

and dental nurses with respect to the delivering of smoking cessa-tion interventions in their own practices.

MATERIALS AND METHODSThis was a questionnaire-based evaluation for which the

Newcastle and North Tyneside Research Ethics Committee provided a favourable opinion.

Study cohortThe primary sampling frame for the study comprised dental hygi-

enists. All dental hygienists working in the Northern Deanery of the UK were identified from the General Dental Council’s Roll

of dental hygienists. The questionnaires were then sent in packsof three to each hygienist with written information about the

study and specific instructions to complete the hygienist’s ques-tionnaire. The hygienist was also requested to distribute similar

but specifically designed questionnaires to one dentist and onedental nurse in one practice.

QuestionnaireThe questionnaires consisted of closed, 6-point, Likert-type

questions. They were reviewed, revised and piloted by anindependent evaluator with experience in questionnaire design.

I N BR I EF

• The findings of this research confirm that dentists, hygienists and dental nurses

appreciate the importance of raising their patients’ awareness regarding the role of

smoking in dental disease.

• Clinicians may be able to identify their own current barriers to providing smoking

cessation advice to patients and then to consider how such barriers may be overcome.

•The paper will hopefully stimulate dentists to consider further training in the area of smoking cessation possibly for themselves and also for other members of their team.

RESEARCH

BRITISH DENTAL JOURNAL VOLUME 201 NO. 2 JUL 22 2006 109



The recipients were required to either highlight answers or makea given response numerically. Return of the questionnaires was

requested within four weeks in a stamped-addressed envelopethat was provided. All questionnaires had an identifier to moni-

tor returns. After four weeks, those dental hygienists who hadnot returned the questionnaires were followed up once by letter.

If the dental hygienist was unable to return all three completedquestionnaires then they were asked to return those that had

been completed. The questionnaires for each professional groupwere designed to collect information with respect to:Smoking status of the dental team member and the practice;

Perception of their own role in giving SCA;Perception of other team members’ roles in giving SCA;

Their own level of training in providing SCA;Perceived barriers to giving SCA.

Respondents were also given an opportunity to make individualopen comments in relationship to smoking cessation.

Statistical analysis

All data were entered numerically into a spreadsheet and a cod-ing framework was devised to identify the questions within theoutput of the programme. SPSS version 10.0 statistical software

package was used to analyse the data including inter-groupanalysis of variance. Frequencies and percentages were used todetermine distributions of the responses for each of the vari-

ables. Percentages for each variable were based on the number of respondents for each question. Chi-square tests were undertaken

using Minitab 13 for Windows.

RESULTSOne hundred and eighteen dental hygienists (70% of the totalsample), 100 dentists (60%) and 106 dental nurses (63%) returned

their questionnaires. The detailed responses from the question-naires are presented in Tables 1 to 3.

Ninety-two per cent of dental practices were reported to besmoke-free environments. Significantly more dental nurses (23%)

were current smokers compared with dentists (10%) and dentalhygienists (7%) (p< 0.01) (Table 1).

Eighty-two per cent of dentists thought that they had a role toplay in providing SCA but only 63% admitted to being actively

involved. The respective data for hygienists were 91%, 55%; andfor dental nurses 28%, 21%. More dentists (63%) and dental hygi-

enists (55%) offered SCA compared with dental nurses (21%) (p<0.001) (Table 1). More dental hygienists (96%), and dental nurses(92%) thought dentists should offer SCA than dentists did them-

selves (82%) (p = 0.002) and more dental hygienists (47%) thanboth dentists (39%), and dental nurses (28%), thought that dental

nurses should offer SCA (p = 0.017). Around 90% of all membersof the dental team believed that dental hygienists should offer SCA

(dental hygienists 91%, dentists 89% and dental nurses 89%). Moredentists (15%, and 11% respectively) than either dental hygienists(10% and 8%) or dental nurses (5% and 2%) thought that recep-

tionists and practice managers should offer SCA (p = 0.042 and p =

0.031 respectively) (Table 1).More nurses (70%) than either dentists (4%) or dental hygienists(0%) never enquire about their patients’ smoking status (p< 0.001)

(Table 1) and fewer dental nurses (26%) than either dentists (42%)or dental hygienists (47%) had knowledge of SCA support agenciesand services (p = 0.005).

Ninety-two per cent of dentists enquired about the smoking sta-tus of patients who presented with white lesions and 67% of those

presenting with periodontal disease (data not in Tables). Dentalhygienists enquired about smoking status in 74% of patients pre-

senting with periodontal disease.Lack of training was regarded as a major potential barrier

to giving SCA and it was considered ‘very important’ by all

respondents (Table 2). Four per cent of dentists had received SCA training prior to qualification and 26% had received training since

Table 1 Smoking cessation views and activities of the dental team

Responses of:Dentists(n = 100)

Dental hygienists(n = 118)

Dental nurses(n = 106)

Do you smoke?Yes

10%

No

75%

Ex-

smoker

15%

Yes

7%

No

82%

Ex-smoker

11%

Yes

23%

No

63%

Ex-smoker

14%

Do you enquire about your patients’ smokingstatus?

Always34%

Sometimes62%

Never4%

Always38%

Sometimes62%

Never0%

Always30%

Sometimes0%

Never70%

Do you currently offersmoking cessationadvice?

Yes

63%

No

37%

Yes

55%

No

45%

Yes

21%

No

79%

Who do you thinkshould offer advice?

Dentist 82% 95% 92%

Hygienist 89% 91% 89%

Dental nurse 39% 47% 28%

Receptionist 15% 10% 5%

Practice manager 11% 8% 2%

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110 BRITISH DENTAL JOURNAL VOLUME 201 NO. 2 JUL 22 2006



to the provision of SCA in general dental practice. Previous UK questionnaire studies have sought information from dentists

only.4-6 The favourable response rate (60-70%) suggested thatthe dental hygienists provided a good initial sampling frame.

The questionnaires from the three professional groups show that10% of dentists, 7% of dental hygienists and 23% of dental nursessmoke. As one in 10 dentists are current smokers this may map to

the 8% of dental practices which are not smoke-free. A significantly higher number of dental nurses currently smoke compared to other

members of the dental team. A majority of dental hygienists havebeen previously trained as dental nurses and it may be that becom-

ing better informed of the risks of smoking, for example duringdental hygiene training, has reduced smoking in this group.

Dentists and dental hygienists believe that they, as professionalgroups, have a vital role to play in SCA but this was not necessarily reflected in their current activities. Eighty-two per cent of dentists

believe that they should offer SCA but only 63% stated that they were actively involved. The same was true of dental hygienists

with a perceived role expressed by 96% compared with only 55%being engaged in SCA activity. Only 28% of dental nurses feel thatthey had a role but, encouragingly, 21% of them reported offer-

ing some SCA. Thirty-nine per cent of dentists and 47% of dentalhygienists also believe that dental nurses have a greater role to

play. Studies have shown that dentists who smoke are less likely tooffer SCA than those who do not smoke5,6,12 and as 23% of dental

nurses in the survey were current smokers (and a further 14% of them being ex-smokers), this may be, at least in part, the reason for

the low percentage of dental nurses who perceived that they havea role in SCA

All groups are consistent in thinking that dental hygienists

have a role to play in giving SCA and dentists, as team leaders, areregarded by virtually all PCDs as having an important role. Den-

tists also seem keen to involve other members of the dental team inSCA including receptionists and practice managers. This attitude

qualification (data not in Tables). The respective data for dentalhygienists and dental nurses were 17%, 28% and 8%, 5%. Lack of remuneration was also regarded a significant barrier to giving SCA

but only by dentists (p < 0.001) (Table 2). Another barrier to giving SCA volunteered by respondents was

‘lack of time’. This was an issue expressed more often by dentalhygienists (20%), than either dentists (10%) or dental nurses (7%)

(p = 0.01).The responses in Table 3 indicate clearly that all members of the

dental team believe that both they and general medical practition-ers have an important role to play in the delivery of smoking ces-sation advice.

DISCUSSION

The aim of this questionnaire-based study was to ascertain theattitudes and activities of the whole dental team in relationship

Table 2 Barriers to smoking cessation advice as perceived by dentists, dental hygienists and dental nurses

Likert scale0not important

1 2 3 45 very important

Lack of training

Dentist 5% 0% 5% 18% 28% 44%

Hygienist 0% 2% 4% 19% 12% 63%

Nurse 0% 2% 5% 19% 14% 60%

Little chance of success

Dentist 20% 7% 15% 29% 15% 14%

Hygienist 12% 7% 17% 39% 17% 8%

Nurse 11% 6% 16% 32% 19% 16%

Lack of Remuneration *

Dentist 16% 2% 7% 14% 26% 35%

Hygienist 31% 9% 10% 21% 13% 16%

Nurse 42% 2% 4% 13% 15% 24%

Possibility of losing patients

Dentist 44% 13% 11% 17% 7% 8%

Hygienist 24% 18% 23% 19% 12% 4%

Nurse 28% 10% 15% 25% 10% 11%

Not perceivedas their role

Dentist 39% 10% 12% 22% 12% 5%

Hygienist 41% 14% 9% 18% 9% 8%

Nurse 29% 10% 13% 23% 11% 14%

Responses were measured on a Likert scale with 0 corresponding to ‘not important’ and 5 to ‘very important’.

*Significantly more dentists than dental hygienists and dental nurses thought that lack of remuneration was a major barrier to providing SCA in dental practice (p<0.001).

Table 3 Perception of the importance of the smoking cessation role forthe dental team and general medical practitioners

Responses from DentistsDentalhygienists

Dental nurses

Yes No Yes No Yes No

‘Is it importantfor the dentalteam to offersmokingcessationadvice?’

96% 4% 94% 6% 89% 11%

‘Is it important

for doctors tooffer smokingcessationadvice?’

100% 0% 100% 0% 99% 1%

RESEARCH




would enhance the team approach and enable a more completeand structured programme for SCA to be established in a primary

care setting. All team members could have a role, including admin-istrative involvement.13

Approximately 30% of each professional group always enquireabout the smoking status of their patients. The profile for den-tists and dental hygienists is very similar, although a significant-

ly greater number of dental nurses never enquire about smokingstatus of patients. These observations are consistent with the data

showing that 28% of dental nurses think they should have a roleand 21% who are actively involved. Nevertheless, as even brief

advice does have an effect in motivating smokers to quit, this couldcertainly be imparted effectively by dental nurses.14

The difference between the perceived role of the dental profes-sionals and their actual activities suggests that there are barriersto offering SCA. All respondents suggested that lack of training

was a ‘very important’ barrier and minimal SCA training had beenundertaken either pre- or post-qualification by any of the mem-

bers of the dental team who responded. Only 4% of dentists hadreceived SCA training as an undergraduate. To some extent, den-tists had recognised this lack of training as 26% had undertaken

postgraduate training in SCA. Seventy per cent of respondents,however, have had no training in SCA. More dental hygienists had

received training than the other groups: 45% in total; 17% duringthe dental hygiene course and 28% had received further training

after graduation. This may reflect an increase in the availability of local courses in SCA for DCPs and, perhaps, a desire amongst den-

tal hygienists to receive training as part of their continued profes-sional development. This lack of training was further highlightedby the observation that less than half of respondents knew of any

supporting agencies and services to which they could refer their patients for SCA. A fully integrated and successful approach to the

effective delivery of SCA is only likely to be realised if the commis-sioners of health care and smoking cessation services are aware of

this problem and then provide information for the dental team toallow easy and efficient referral of dental patients.

Thirty-five per cent of dentists also highlighted ‘lack of remu-neration’ as a ‘very important’ barrier to offering SCA, although

this was not very important to the PCDs (16% dental hygienists,24% dental nurses). The dentist, as the team leader, is more likely to be concerned as budget holder for the practice.

In North America, there has been a poor uptake of smok-ing cessation programmes in primary dental care.15 Lack of time

was a major obstacle for those attempting their implementation.Respondents in our study confirmed that ‘lack of time’ indeed was

a significant obstacle to the delivery of SCA (dentists 10%, 20%dental hygienists and 7% dental nurses). One fifth of dental hygi-

enists highlighted ‘time’ as a ‘very important’ barrier to providingthe service; given as additional comments by the dental hygien-ists. Another issue highlighted by dentists was moving into an area

that they did not feel confident to handle, and that there were per-sonal issues perpetuating a patient’s smoking habit. While this is

undoubtedly true, many dental patients welcome being asked howthey feel about their smoking habit.16

Direct comparisons can be made between the responses of the

dentists in this survey and those of dentists in previous studies inScotland4 and the Oxford region5,6 (Table 4). It should, however, be

noted that the previous studies did not elicit responses from dentalcare professionals.

The percentages of practices operating a ‘no smoking’ policy intheir waiting area were almost identical: 92% (Oxford), 96% (Scot-

land) and 92% (current survey) respectively. This had increasedslightly to 95% in the more recent Oxford survey. The percentageof dentists smoking was also similar: 10% (Oxford), 12% (Scot-

land), and 9% (current survey) respectively. The same percentageof dentists (82%) in the Oxford and current surveys thought that

they had a role to play in SCA compared to only 55% of Scottishdentists. The Scottish study is the oldest (1995) and this figure may

Table 4 Comparison of responses from smoking cessation questionnaires from four UK studies2-4 and the current survey

Study Scotland-19952 Oxford-19973 Oxford-20034 Current survey

Is yours a

‘no smoking’practice?

Yes96% Yes92% Yes95% Yes

Do you smoke?Yes12%

No71%

Ex17%

Yes9%

No62%

Ex28%

Yes8%

No62%

Ex28%

Yes10%

No75%

Ex

Do you currentlyoffer SCA?

Yes86%

No14%

Yes*82%

No18%

Yes92%

No8%

Yes63%

No37%

Do you routinelyenquire aboutpatients’smoking status?

Always6%

Sometimes*58%

Never35%

Always18%

Sometimes Never82%

Always48%

Sometimes Never51%

Always34%

Sometimes62%

Never4%

Do you routinely

enquire aboutthe smokingstatus of patients withperiodontaldisease?

Always**

Sometimes**

Never**

Always51%

Sometimes39%

Never10%

Always75%

Sometimes21%

Never4%

Always67%

Sometimes Never33%

Do you thinkdentists have arole to play inSCA?

Yes55%

No45%

Yes82%

No18%

Yes89%

No11%

Yes82%

No18%

*The responses have been merged for comparative purposes only.

**Respondents were not asked specifically about smokers with periodontal disease, although, when asked for comments, 50% thought smoking an important aetiological factor

in periodontal disease.

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112 BRITISH DENTAL JOURNAL VOLUME 201 NO. 2 JUL 22 2006



now have increased and be more in line with the data of morerecent surveys. Scotland also has one of the higher incidences of

smoking per capita in the UK and this may make the task seemeven more daunting for dentists.

Enquiries about patients’ smoking status varies across the UK regions with 34% of dentists in the North of England ‘always’

and 62% ‘sometimes’ recording smoking status. In Scotland, therespective data were 6% and 58% and in Oxford, only 18% of den-

tists, in 1997, said they ‘always’ or ‘almost always’ enquired. Thishad, however, increased to 48% in 2003.

Sixty-seven per cent of dentists in this survey always enquire

about the smoking status of patients with periodontal disease. Thedata for the Oxford studies were 51%5 and 75%6 respectively — an

increase of 24% over six years. Scottish dentists were not specifi-cally asked about their smoking enquiries to patients with peri-

odontal disease but 50% did note that they thought that this wasan important issue.4

Dentists’ opinions on DCPs having a role in SCA were only

sought in this survey and in Scotland (not shown in Table 4).

Eighty-nine per cent of dentists thought that hygienists had a roleand 39% thought that dental nurses had a role. In Scotland 66% of dentists thought that DCPs collectively had a role.4 Again, this dif-

ference may be due to changing views over time and the perceivedwidening of the role of DCPs in particular. Geographical variationmay also be contributory.

With training and appropriate remuneration, the dental teamcan guide their smoking patients to successful quit attempts. Hygi-

enists may already be able to devote a proportion of their time atsome appointments to discuss smoking cessation. The magnitude

of the effect of smoking as a risk factor for periodontal disease,however, suggests that a successful quit attempt is likely to have

significant long-term benefit in maintaining a functioning denti-tion and dental health. The engagement of the entire dental team

in delivering this brief intervention is, therefore, essential.

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7. Secker-Walker R H, Chir B, Solomon L J et al. Comparisons of the smoking cessationcounselling activities of six types of health professionals. Prev Med 1994; 23:800-808.

8. Severson H H, Andrews J A, Lichtenstein E, Gordon J S. Smokeless tobacco cessationthrough dental offices: An intervention that works. J Dent Res 1998; 77: 82.

9. Severson H H, Andrews J A, Lichtenstein E et al. Using the hygiene visit to deliver atobacco cessation program: results of a randomised clinical trial. J Am Dent Assoc 1998; 129: 993-999.

10. Skegg J A. Dental programme for smoke-free promotion: attitudes and activities of dentists, hygienists and therapists at training and 1 year later. New Zealand Dent J 1999; 95: 55-57.

11. Yip J K, Hay J L, Ostroff J S et al. Dental students’ attitudes toward smoking cessationguidelines. J Dent Educ 2000; 64: 641-650.

12. Telivuo M, Vehkalahti M, Lahtinen A, Murtomaa H. Finnish dentists as tobaccocounsellors.Comm Dent Oral Epidemiol 1991;19: 221-224.

13. Cohen S J, Stookey G K, Katz B P et al. Helping smokers quit: a randomised controlledtrial with private practice dentists. J Am Dent Assoc 1989; 118: 41-45.

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15. Cohen S J, Kelly S A, Eason A A. Establishing smoking cessation programs in dentaloffices. J Am Dent Assoc 1990; Supplement:28S-31S.

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smoking cessation as a dental intervention

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