Increasing Tobacco Intervention Strategies by Oral Health Practitioners in Indiana

Discussion

As tobacco use is a well-known risk factor for a myriad of oral and maxillofacial conditions, addressing patient tobacco use is a part of preventive dental practice and advising patients to quit is a professional responsibility of the dental team. In general, tobacco users expect and are comfortable receiving such advice.^24,25 Campbell et al found that most patients believed that dental offices should provide tobacco interventions, and support for such was equal between tobacco users and non-users.²⁶ Further, a recent systematic review concluded that brief tobacco use cessation counseling conducted by oral health professionals was found to be effective at 12 months or longer.²⁷ However, dental professionals have been largely inactive in direct counseling of patients to quit tobacco.²⁸ Major constraints cited against the implementation of tobacco counseling in oral health care settings include suboptimal attitudes, insufficient training and lack of reimbursement.^29-32

The continuing education program described here sought to enhance Indiana oral health care providers' understanding of tobacco dependence and treatment and encourage them to provide tobacco cessation interventions. The program reached over 600 practitioners, primarily dental hygienists whose role focuses on patient education and disease prevention. In the short-term, the program appeared to be effective at increasing attendees' knowledge, especially on tobacco's oral health effects, nicotine addiction, and how tobacco cessation medications work.

Participants indicated that the program was effective in teaching communication strategies to employ with tobacco users; this should have improved attendees' confidence in approaching patients about quitting tobacco. Immediately after the program, nearly 98% of participants planned to use these communication techniques in practice. However, 3 months later, enthusiasm for applying these communication strategies seemed to decrease: 78% reported applying these skills, 15% were undecided and 6% were not employing them in patient interactions.

Immediately post-program, nearly 90% of dentists indicated that they provided or planned to provide patient tobacco cessation resource materials, primarily in treatment or reception rooms. Although materials were distributed by multiple personnel, the dental hygienist and dentist were primary. Findings were similar at follow-up. The principal barriers to providing patient resources were a lack of time to discuss and distribute materials to patients, lack of patient acceptance, the cost of materials, and difficulty locating and obtaining resources. This finding was problematic because the continuing education program provided numerous free resources (educational posters, pamphlets, quitline information, etc.) to attendees and links to the Indiana State Department of Health Tobacco Prevention and Cessation Commission website where a plethora of patient referral and education materials could be obtained at no charge.

Immediately post-program, participants reported enhanced awareness of tobacco cessation referral resources, and the majority (90%) planned to refer patients to county Tobacco Prevention and Cessation counselors or the Indiana quitline. At follow-up, only 60 and 40% reported making referrals to the quitline and Tobacco Prevention and Cessation counselors, respectively. The Ask-Advise-Refer approach with quitline referral was the most popular interventional strategy, probably due to its efficiency. Unfortunately, the more proactive “FAX to Quit” strategy (faxing patient information to the quitline and allowing a quitline counselor to begin patient counseling within 48 hours) was reportedly used by very few practitioners. The reasons for not referring to Tobacco Prevention and Cessation counselors included use of the quitline instead, patient lack of interest in counseling, and misplacing Tobacco Prevention and Cessation counselor contact information. Although the continuing education program provided clinicians the opportunity to meet their county Tobacco Prevention and Cessation partner and obtain their contact and service information, some clinicians may have found that patients preferred the quitline's convenience or anonymity over in-person counseling.

Although the CE program appeared to increase participants' knowledge of cessation pharmacotherapy, immediately after the program at least 10% of the participants did not feel confident in their knowledge of the dosing or adverse effects of the medications discussed. This suggests the program did not adequately address this issue, and may explain, in part, why at 3 months very few dentists reported recommending/prescribing tobacco cessation medications to their patients.

Despite emphasis during the course, even immediately after the continuing education program, nearly 25% of attendees did not plan to take an active role in implementing a tobacco cessation program in their office. At 3 months, relatively few participants reported adopting specific formal office protocols and practices for providing tobacco interventions with patients.

Teaching oral health care professionals about tobacco use and dependence, and how to implement tobacco cessation interventions, does not necessarily assure that they will change their practice behaviors and begin to utilize the learned concepts and skills with their patients. This continuing education program emphasized the “team approach” to tobacco cessation interventions which outlined suggested roles and responsibilities for each member of the dental team, including the dentist, dental hygienist, assistant and non-clinical staff. First suggested in Christen's how-to model, most cessation programs conducted in dental offices stress the pivotal role of the team care approach that involves all dental practice members.³³ Among the keys to success, working as team where all staff are involved and invested in the program, and identifying an office champion (coordinator) who has overall responsibility for the program can make a positive impact in enhancing patients' quit attempts.^26,34 As the dental hygienist typically has more patient contact time than the dentist, and has the most training and expertise as an oral health educator, it is recommended that the dental hygienist serve as the coordinator of the office tobacco cessation program. Given that health care is moving toward an inter-professional model of care delivery, dental hygienists may have more opportunities to work in a variety of settings as part of a health care team. Their expertise in educating patients and their families on the connection between oral and systemic health and the impact of tobacco use on oral health, and motivating patients in adopting healthy behaviors allows them to provide a unique and vital contribution to the health care team.

This study had several limitations, most notably the self-report nature of the survey and a decrease in response rate from the initial survey to the 3-month follow-up survey. However, demographically, initial and follow-up participants had similar characteristics. Another limitation was an inability to systematically track participant referrals to the quitline or Tobacco Prevention and Cessation counselors and, ultimately, obtain information on patient quit rates other than anecdotal, self-report information. Further, survey results revealed some potential areas for improvement in the continuing education program itself. The pharmacotherapy section of the course may need to be revised for better participant comprehension, and include an open discussion of perceived barriers to the use of pharmacotherapy strategies. Although the continuing education program contained interactive components and question and answer periods, more role-playing and active learning techniques could be employed to further enhance skill development.

As Berwick noted, it is helpful to understand not only whether interventions work but in what context.³⁵ Amemori compared the effect of an educational intervention on increases in provision of patient tobacco interventions by Finnish dentists and dental hygienists' across 3 study groups: control group, those who received tobacco dependence education and cessation training, and a group that received tobacco dependence education/cessation training with monetary compensation for cessation counseling that was provided.³⁶ Findings revealed that the educational session was effective in increasing providers' self-efficacy and skills in counseling.³⁶ Compared to dentists, dental hygienists were more active in counseling and their counseling performance showed greater increases in cessation numbers in both intervention groups. However, similar to the present study, the educational intervention's positive effects on clinician tobacco cessation activities faded rapidly 2 months post-continuing education course. Remarkably, compared to tobacco dependence education/cessation training alone, the incentive of receiving payment for counseling did not result in increased practitioner tobacco intervention activities. Future studies should focus on identifying what factors, beyond knowledge acquisition, enhance oral health care providers' motivations and willingness to engage in tobacco cessation interventions.