REVIEW ANALYSIS & EVALUATION

ARTICLE TITLE ANDBIBLIOGRAPHICINFORMATION

Improving the effectiveness oftobacco use cessation (TUC).

Needleman IG, Binnie VI, Ainamo A,Carr AB, Fundak A, Koerber A, et al.

Int Dent J 2010;60(1):50-9. Erratum in: IntDent J 2010 Jun;60(3):140.

REVIEWER

Scott L. Tomar, DMD, MPH, DrPH

PURPOSE/QUESTION

What is the effectiveness ofinterventions delivered by dentalprofessionals or in a dental practicesetting in increasing quit rates bytobacco users

SOURCE OF FUNDING

Dental products industry,nongovernmental organizations

TYPE OF STUDY/DESIGN

Systematic review with meta-analysis of data

LEVEL OF EVIDENCE

Level 2: Limited-quality, patient-oriented evidence

STRENGTH OFRECOMMENDATION GRADE

Grade B: Inconsistent or limited-quality patient-oriented evidence

J Evid Base Dent Pract 2012;12:62-641532-3382/$36.00� 2012 Elsevier Inc. All rights reserved.doi:10.1016/j.jebdp.2012.03.012

Tobacco-Use Interventions Delivered byOral Health Professionals may IncreaseTobacco Cessation Rates

SUMMARY

Selection CriteriaThis publication included an update of a previously published systematicreview on the effectiveness of brief tobacco-use cessation interventions indental settings.1 Electronic searches were conducted in the Cochrane To-bacco Addiction group trials register, the Oral Health Group trials register,and an unspecified number of other databases through June 2008. Searchterms were not reported. Two reviewers screened the list of the unreportednumber of retrieved records and abstracted the full texts of included stud-ies. Two studies were added2,3 to the 6 studies4-9 that had been included inthe earlier systematic review.1 The remainder of the article discussed thevarious forms of pharmacotherapy intended to treat tobacco use, and a re-view of studies that compared quit rates for in-office cessation counselingby an oral health care professional with referral to cessation specialists.

Key Study FactorThe primary study factor in this review was brief tobacco-use interventionsdelivered in dental settings or delivered by oral health care professionals.Studies included in the review were randomized and pseudo-randomizedtrials in which participants reporting use of any type of tobacco productand interventions were delivered by dental professionals, and any interven-tion to promote tobacco-use cessation in which a component was deliveredby an oral health care professional in a dental practice setting. Inclusioncriteria also included assessment of tobacco cessation status at least6 months after delivery of the intervention; biochemical verification wasnot required.

Main Outcome MeasureThe principal outcome variable was tobacco use cessation status at12 months after intervention, although the definitions varied across stud-ies: some studies measured point prevalence of cessation, some used con-tinuous abstinence, and the studies differed on the type of tobaccoabstinence (ie, all tobacco vs cigarettes or smokeless tobacco only).When multiple measures of tobacco abstinence were reported in a study,the reviewers selected the more stringent one (ie, continuous abstinence).The outcome measure of each study was expressed as an odds ratio esti-mate, calculated as follows: (number of quitters in the treatment group /number of smokers in the treatment group) / (number of quitters in thecontrol group / number of smokers in the control group).

Main ResultsEight studies were included in the systematic review, including 5 that wereconducted in dental office settings and 3 conducted in schools by oralhealth care professionals. Three of the dental office–based studies testedcessation interventions among cigarette smokers; the remaining 5 studies(including all school-based interventions and 2 office-based interventions)

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE

were conducted among smokeless tobacco users. Poolingof the studies by using a weighted random effects modelsuggested that tobacco-use interventions conducted byoral health care professionals increase tobacco absti-nence (odds ratio [OR] = 1.60; 95% confidence interval[CI]: 1.09, 2.35) at 12 months or longer. Summary mea-sures differed by type of tobacco use: for smokelesstobacco users, the pooled OR = 1.86 (95% CI: 1.10,3.14) and for cigarette smokers, pooled OR = 1.09(0.71, 1.69).

ConclusionsThe authors concluded that interventions for tobacco useconducted in the dental setting or delivered by oralhealth care professionals in a school setting increase theodds of quitting tobacco use for at least 12 months. How-ever, the supporting evidence is drawn primarily from in-terventions on smokeless tobacco use; the authors notedthat the literature does not yet support the effectivenessof interventions on cigarette smoking conducted in den-tal settings.

COMMENTARYANDANALYSIS

The present review added little to the previously pub-lished Cochrane systematic review1 on the effectivenessof tobacco-use interventions delivered by dental healthcare professionals. Although 2 newer studies were addedto that earlier review, the absence of detail on search strat-egies precludes an assessment of the thoroughness andrelative lack of bias of the updated search. Both of themore recent studies2,3 involved smoking interventionsbut were relatively small studies (n = 116 and 82,respectively) and therefore carried little statistical weightcompared with the earlier study7 (n = 4029) that alsohad been included in the prior systematic review. The un-fortunate reality is that smoking cessation rates in bothstudies that reported 12-month outcomes2,7 were verymodest, ranging from 2% to 7% in the interventiongroups and 2% to 4% in the ‘‘usual care’’ or controlgroup. The study by Ebbert et al3 was a 6-month pilot studyintended to test the feasibility of engaging smokers ina telephone quit line through private practice dental of-fices; all participants in both the intervention and controlgroups received brief cessation counseling from a dentalhygienist, but those in the intervention group also re-ceived a proactive call from a cessation counselor withMayo Clinic’s Tobacco Quitline. No difference in quitrates were observed in the 2 groups, but the study was nei-ther intended nor powered to detect that difference. Thereviewers’ search strategy apparently missed amuch larger(n = 2177) study of proactive quitline referral in privatedental offices that found higher quit rates among smokerswho received quitline counseling or brief counseling bytrained dentists and dental hygienists, compared withsmokers in the offices randomized to usual care.10

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Tobacco use is the world’s leading preventable cause ofdeath, killing nearly 6 million people per year and caus-ing hundreds of billions of dollars of economic damageworldwide.11 Reducing tobacco use clearly should be a pri-ority in nearly all nations and among all health care pro-fessionals. It has long been noted that dental settingsprovide potentially important venues for intervening intobacco use: many tobacco users visit a dentist eachyear, young people in early stages of tobacco use may bemore likely to regularly see a dentist than a physician, pa-tients are relatively receptive to health messages duringperiodic check-up visits, and tobacco use has major nega-tive impacts on oral health and the prognosis of dentaltreatment.12,13 Discouragingly, fewer than one-third ofUS dentists and dental hygienists are aware of the exis-tence of evidence-based US Public Health Service ClinicalPractice Guidelines for tobacco intervention, have everreceived cessation training, or assist smokers in quitting.14

Some surveys of dental professionals have identified po-tential barriers to providing tobacco-use interventionsfor patients, such as lack of reimbursement, patient resis-tance, or the amount of time required.14-16 However,interpersonal communication is given minimal attentionin the curricula in schools of dentistry,17 there are no na-tional standards or clinical competencies for tobacco ces-sation in dental education,18 and few dental hygieneprograms teach intervention techniques, such as motiva-tional interviewing or have clinical competencies on to-bacco cessation.19

Although much more can be done to increase the fre-quency and effectiveness of tobacco-use interventions de-livered by oral health care professionals, major reductionsin the prevalence of tobacco use are far more likely to re-sult from comprehensive population-based tobacco con-trol policies and initiatives.20 The declines in smokingthat have been occurring in many developed nationsare largely attributable to combinations of broad educa-tional and policy initiatives, including widespreadsmoke-free regulations, significant increases in tobaccoprices through taxation, enforcement of minors’ accesslaws, and theory-based countermarketing.21 In addition,the overwhelming majority of tobacco users who quit doso without professional assistance or medications.22 Ces-sation efforts by health care professionals with their indi-vidual patients certainly can and should be a componentof a broad effort to reduce or eliminate tobacco use in so-ciety. The importance of such clinical interventions bydental professionals is recognized by a developmentalOral Health Objective (OH-14.1) in Healthy People2020, ‘‘Increase the proportion of adults who received in-formation from a dentist or dental hygienist focusing onreducing tobacco use or smoking cessation in the pastyear.’’23 However, it is at least as important for those pro-fessionals to be part of community-based efforts, such asserving on tobacco-free coalitions, advocating for govern-mental policies that support best practices in tobacco

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control, and working to eliminate tobacco industry influ-ence in legislative bodies and community organizations.

REFERENCES

1. Carr AB, Ebbert JO. Interventions for tobacco cessation in the dentalsetting. Cochrane Database Syst Rev 2006;(1):CD005084.

2. Binnie VI, McHugh S, Jenkins W, Borland W, Macpherson LM. Arandomised controlled trial of a smoking cessation intervention de-livered by dental hygienists: a feasibility study. BMC Oral Health2007;7:5.

3. Ebbert JO, Carr AB, Patten CA, Morris RA, Schroeder DR. Tobaccouse quitline enrollment through dental practices: a pilot study. JAm Dent Assoc 2007;138(5):595-601.

4. Andrews JA, Severson HH, Lichtenstein E, Gordon JS, Barckley MF.Evaluation of a dental office tobacco cessation program: effects onsmokeless tobacco use. Ann Behav Med 1999;21(1):48-53.

5. Gansky SA, Ellison JA, Kavanagh C, Hilton JF, Walsh MM. Oralscreening and brief spit tobacco cessation counseling: a review andfindings. J Dent Educ 2002;66(9):1088-98.

6. Gansky SA, Ellison JA, Rudy D, Bergert N, Letendre MA, Nelson L,et al. Cluster-randomized controlled trial of an athletic trainer-directed spit (smokeless) tobacco intervention for collegiate baseballathletes: results after 1 year. J Athl Train 2005;40(2):76-87.

7. Severson HH, Andrews JA, Lichtenstein E, Gordon JS, Barckley MF.Using the hygiene visit to deliver a tobacco cessation program: resultsof a randomized clinical trial. J Am Dent Assoc 1998;129(7):993-9.

8. Stevens VJ, SeversonH, Lichtenstein E, Little SJ, Leben J. Making themost of a teachablemoment: a smokeless-tobacco cessation interven-tion in the dental office. Am J Public Health 1995;85(2):231-5.

9. Walsh MM, Hilton JF, Masouredis CM, Gee L, Chesney MA,Ernster VL. Smokeless tobacco cessation intervention for college ath-letes: results after 1 year. Am J Public Health 1999;89(2):228-34.

10. Gordon JS, Andrews JA, Crews KM, Payne TJ, Severson HH. The 5A’svs 3A’s plus proactive quitline referral in private practice dental of-fices: preliminary results. Tob Control 2007;16(4):285-8.

11. World Health Organization. WHO Report on the Global TobaccoEpidemic, 2011: Warning About the Dangers of Tobacco. Geneva:World Health Organization; 2011.

12. Tomar SL. Dentistry’s role in tobacco control. J Am Dent Assoc2001;132(Suppl):30S-5.

13. Albert DA, Severson HH, Andrews JA. Tobacco use by adolescents:the role of the oral health professional in evidence-based cessationprograms. Pediatr Dent 2006;28(2):177-87.

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14. Tong EK, Strouse R, Hall J, Kovac M, Schroeder SA. National surveyof U.S. health professionals’ smoking prevalence, cessation practices,and beliefs. Nicotine Tob Res 2010;12(7):724-33.

15. Dolan TA, McGorray SP, Grinstead-Skigen CL, Mecklenburg R.Tobacco control activities in U.S. dental practices. J Am Dent Assoc1997;128(12):1669-79.

16. Albert DA, Severson H, Gordon J, Ward A, Andrews J, Sadowsky D.Tobacco attitudes, practices, and behaviors: a survey of dentists par-ticipating in managed care. Nicotine Tob Res 2005;7(Suppl 1):S9-18.

17. Yoshida T, Milgrom P, Coldwell S. How do U.S. and Canadian dentalschools teach interpersonal communication skills? J Dent Educ2002;66(11):1281-8.

18. Gordon JS, Albert DA, Crews KM, Fried J. Tobacco education in den-tistry and dental hygiene. Drug Alcohol Rev 2009;28(5):517-32.

19. Davis JM, Koerber A. Assessment of tobacco dependence curricula inU.S. dental hygiene programs. J Dent Educ 2010;74(10):1066-73.

20. National Cancer Institute. Greater than the sum: systems thinking intobacco control. Tobacco Control Monograph No. 18. Bethesda,MD: U.S. Department of Health and Human Services, NationalInstitutes of Health, National Cancer Institute. NIH Pub.No. 06-6085 2007. Available at: http://cancercontrol.cancer.gov/tcrb/monographs/18/m18_complete.pdf.

21. Chapman S. The inverse impact law of smoking cessation. Lancet2009;373(9665):701-3.

22. Chapman S, MacKenzie R. The global research neglect of unassistedsmoking cessation: causes and consequences. PLoS Med 2010;7(2):e1000216.

23. USDepartment of Health andHuman Services. Healthy People 2020topics and objectives: oral health. Washington, DC: US Departmentof Health and Human Services. Available at: http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=32;

2012. Accessed January 20, 2012.

REVIEWER

Scott L. Tomar, DMD, MPH, DrPHProfessor, University of Florida College of Dentistry, Departmentof Community Dentistry and Behavioral Science, 1329 SW16th Street, Room 5188, PO Box 103628, Gainesville, FL32610-3628, Phone: 352-273-5968, Fax: 352-273-5985stomar@dental.ufl.edu

June 2012