How Effective are Smoking Cessation Programs Provided by Dental Staff? Antony Mitilineos, Tae Wook Kwon, Jimmy Duong, Wendy Zhang, Jessica Milne, Hasti Sarabi

ABSTRACT Background: The detrimental health effects of smoking are well known, and many smokers wish to quit. It is the responsibility of healthcare professionals, as a preventative measure, to offer assistance to patients in achieving this goal. There are many smoking cessation programs designed for this purpose, and they include but are not limited to the 5A’s (Ask, Advise, Assess, Assist, and Arrange), the 3 A’s (Ask, Advise, Assess), referrals to quitline programs, and Nicotine Replacement therapy (NRT). There is an increasing interest in the role dental staff can play in administering such programs. Objective: To determine the effectiveness of smoking cessation programs offered by dental staff. Methods: A systematic, electronic literature search was conducted using PubMed and OVID database. The review was inclusive to randomized control trials observing individuals who smoked tobacco that were over the age of 18 and were willing to quit. The “Checklist to Assess Evidence of Efficacy of Therapy or Prevention” was used to critically appraise the studies in order to determine which studies were relevant. Results: Four articles met the inclusion criteria and checklist cutoff score of 11/18 for the systematic review. The studies reviewed looked various smoking cessation methods and smoking cessation was measured using self-report surveys, with or without biochemical verifications. The articles reviewed demonstrate that smoking cessation interventions offered by dental staff were more effective than usual care. Conclusions: Abstinence rates were higher for the intervention groups, making evident the potential dental staff have in assisting patients who wish to quit. Keywords: dentistry, dentist, dental hygienist, dental clinic, dental staff, smoking cessation, smoking prevention and control, smoking and counseling

University of Toronto, Faculty of Dentistry, March 2012 DEN 207Y1- Community Dentistry DDS II

INTRODUCTION Smoking is one of the most damaging habits in the present day. The detrimental health

effects of smoking are well known, as 50% of smokers will die prematurely by a disease directly

caused by their tobacco use, making the treatment of tobacco dependence the chief public health challenge of our time1.

Tobacco is the leading cause of preventable death in Canada3,4. In 2012, approximately

37,000 Canadians will die due to smoking2. Many smokers (70%) desire to quit smoking and on average make 7-9 attempts to quit before succeeding cessation5. Only 5% of smokers who quit

unaided will succeed5. Relapse is common, however each attempt and cessation period increases the chance of ultimate success1,6. It has been shown that smokers who receive assistance from health

care providers are more successful at quitting than without support6,7,8. Tobacco use cessation

requires repeated interventions, support, maintenance and prevention of relapse in order to be

successful6,7,8,9.

Dental care settings provide an attractive avenue to promote smoking cessation programs10.

At least half of cigarette smokers visit the dentist each year11. Smoking is associated with various

forms of oral diseases12 (cancer and periodontal) and can result in premature tooth loss, impaired

wound healing after tooth extraction and impaired effects of dental treatments such as root canals and implants6,13,14. Other clinical manifestations of tobacco use include leukoplakia, nicotinic

stomatitis, halitosis, discoloration of the gums and teeth, gingival attachment loss, and decreased sensations of taste and smell6,8. Patients who smoke and have poor oral health are receptive to

potential oral and overall health benefits which can be used to motivate patients to quit. However, many oral health care workers are reluctant to provide assistance beyond asking and advising patients to quit15, due to the many barriers exist such as: financial reimbursement issues, time constraints, lack of confidence and knowledge, and the additional responsibility 16,17,18. Dental

practitioners may also feel that cessation programs are not effective due to variation in patient’s motivation to quit and become frustrated with people who smoke19.

Intervention strategies have been designed to help clinicians identify and enhance the level

of motivation to quit smoking by using the stages of change model8.9. The five stages of change for

people who want to quit smoking include precontemplation, contemplation, preparation, action, and maintenance; each stage has specific intervention goals that are enforced by the health care

provider8,9. Currently it is estimated that 35% of smokers are in the precontemplation stage, 37% are in the contemplation stage, and only 19% of smokers are prepared to quit5. The Clinical Practice

Guideline for Treating Tobacco Use and Dependence published by the U.S Public Health Service Report developed a simple template that health care providers can follow by using the 5A’s of

tobacco cessation steps; Ask, Advise, Assess, Assist, and Arrange 8,9. Practitioners seem to have

accepted the responsibility of the first two A’s, but are reluctant to assess the motivation of the patient and provide assistance to ensure long-term smoking cessation success is achieved 18.

The purpose of this review is to update the previous evidence assessing smoking cessation

interventions from two previous reviews, Cochrane Systematic review (2006) and Neddleman et al. (2010)20,21. The updated search identified two additional publications, Hanioka et al. (2010) and

Gordon (2010) for inclusion to add to the previous studies22,23. The studies chosen for the purpose of

this paper mainly focus on smoking cessation whereas those chosen for the Cochrane review have

greater emphasis on smokeless tobacco users. It is important to continue examining the effectiveness of smoking cessation provided by dental staff because only a minority of smokers are asked or even given advice about quitting from there dentist24. According to Cromwell (1997), smoking cessation counseling is one of the most cost effective interventions a clinician can perform, however many

remain unaware, lack education, and motivation to integrate counseling into practice25. As health

care professionals, dentists are of great importance in the role they have to help patients cease tobacco use, and ultimately improve their health. OBJECTIVES

The objective of this study was to conduct a systematic review of the current literature to

determine the effectiveness and clinical applicability of smoking cessation intervention provided by dental staff. METHODS The original PICOC statement (Population, Intervention, Control, Outcome, Critical Appraisal

Criteria) was “Are smoking interventions provided by dental health professionals more effective than those provided by other health care professionals?” Due to a lack of literature, we modified the

statement to “Are smoking interventions provided by dental health professionals more effective than usual care?”

In order to compile a list of keywords to be used in the systematic search, a preliminary non-

systematic search was conducted, in which group members searched several databases such as

Medline, Scholars Portal, and PubMed (which included a MeSH term search). Please refer to table 1 in the appendix. These key words were then used in a systematic search using PubMed as well as OVID to search for relevant literature. The search was made more specific by applying the filters “English Language” and “Human subjects”.

When looking at treatment efficacy, the ideal study design is a randomized controlled trial.

Our review looked at research that administered this type of study design, and excluded all other

study designs. The literature reviewed included individuals 18 years or older, who smoked tobacco, and who indicated a desire to quit. Several different types of interventions were administered, including nicotine replacement therapies, smoking counseling and smoking counseling in

combination with referral to smoking quitlines. Smoking counseling included trained personnel that provided motivation and various resources to the individual that wanted to quit, while quitlines are

similar confidential telephone services that aid in tobacco cessation. Smoking cessation was

measured using self-report surveys, with or without biochemical confirmation. Refer to table 2 in the

appendix.

The PubMed and OVID search produced 331 and 254 results, respectively. These articles

were then imported into Refworks and the duplicates were eliminated, resulting in a total of 373

articles. From these articles, all members of the group read through the titles and found 20 articles that were potentially relevant. The group then assessed the abstracts of these 20 articles and 7

articles were considered to be relevant. These remaining 7 articles were critically appraised and

scored according to the “Checklist to assess Evidence of Efficacy of Therapy or Prevention” (Table 3). Two members scored each article independently, and where there was a discrepancy in scoring, a group discussion was carried out until an agreement was reached. A cut off score of 11 was used, whereby all articles that received a score lower than 11 were not used the final report. Of the 7

articles critically appraised, 4 articles were deemed acceptable. Evidence was extracted from all 7 articles and summarized (Tables 4 and 5). RESULTS The final literary search provided us with 4 articles to be used in the systematic review.

Table 4 displays the general results for each of the studies used, while Table 5 displays the rejected

studies.

All the articles accepted were randomized control trial studies. Each examined the

effectiveness of smoking cessation programs provided in a dental setting, in comparison to usual care or no intervention. Within the articles reviewed, usual care indicated that dental staff underwent no training specific to smoking cessation intervention and carried out their usual dental treatment routine with the patients.

All the articles showed that smoking cessation intervention by dental staff was more

effective than usual care or no intervention. The two studies conducted by Gordon and his group in

2007 and 2010 had a comparatively large sample size (n=2673 and n=1644). These studies

presented a smoking cessation counseling treatment of either 5 A’s (with or without nicotine

replacement therapy adjunct) or 3 A’s in combination with quitline, which were provided by dental staff in the intervention group, and determined the effectiveness against usual care. They showed

that among tobacco users (both smokers and chewers), differences between the intervention groups and the usual care group were not significant. However, they showed that cigarette smokers in the two intervention conditions quit at a significantly higher rate (8.1%) than those under usual care (5.1%)27. Furthermore, patients from the intervention groups who also received further quit-line

counseling quit at higher rates than those that did not27. Gordon et al also displayed that individuals in the intervention group showed significantly higher abstinence rates than usual care at the 7.5-

month follow-up for both point prevalence (11.3% vs. 6.8%, respectively) and prolonged abstinence

(5.3% vs. 1.9%, respectively), supporting the effectiveness of tobacco cessation services delivered via the dental health care practitioner in a public health setting22.

The other studies conducted by Binnie et al. in 2007 and Hanioka et al. in 2010 were smaller

in nature. Of the studies presented, the study by Binnie et al. showed the strongest evidence. Binnie

et al. conducted a randomized control trial with 116 smokers randomly allocated to either usual care or smoking cessation intervention consisting of 5A’s and nicotine replacement. Outcome measures were done periodically by self-report at three, six, and twelve months, but were verified

biochemically by cotinine (COT) and by level of carbon monoxide in the participants’ exhaled air

samples. The quit rates for the intervention group were higher at every period of time. The smoking cessation of intervention group versus usual care was: 15% vs. 9% at 3 months, 10% vs. 5% at

6months, and 7% vs. 4% at 12months, respectively26. Therefore, Binnie et al. demonstrated that the

higher percentage of people quit in the intervention group compared to the control group, and

moreover, people attempt to quit for at least one week in their intervention participants than the

control participants. In the study by Hanioka et al., 56 dental patients participated in a randomized

control trial where they were allocated to either no intervention or smoking cessation intervention

(which included counseling and nicotine replacement therapy). The continuous abstinence rates for the intervention group were 51.5%, 39.4%, and 36.4% for the 3-month, 6month, and 1 year times respectively. The abstinence rates for the non-intervention group were consistent at 13%23.

Abstinence was verified chemically in each case, testing salivary cotinine levels. The abstinence rates

were higher for the intervention group, showing that the intensive smoking cessation intervention in dental setting was therefore effective. DISCUSSION The purpose of this study was to conduct a systematic review of the literature to determine

whether smoking cessation intervention performed by dental staff is effective. All literature reviewed suggested that some form of intervention was more effective in comparison to baseline or usual care. The methods of intervention that were used in the four articles discussed include: nicotine

replacement therapy, the 5 A’s, proactive telephone counseling with 3 A’s, and smoking cessation counseling by dental staff. All four articles presented in this review concluded that some form of smoking intervention resulted in higher tobacco quit rates.

All four studies used are randomized control trials; they have a high research design level of

evidence (level of evidence=I) and therefore the strength of their results is high. In addition, based on the Canadian Task Force level of recommendation for clinical preventive action, the articles by

Hanioka et al. and Gordon et al. (2007) had fair evidence (level B), whereas Binnie et al. and Gordon

et al. (2010) have a good evidence (level A) to recommend smoking cessation intervention in dental settings28.

However, all four articles discussed in this review presented several possible sources of bias,

which may have compromised the validity and reliability of their results. In general, participant

selection criteria and eligibility varied greatly across the four studies, based on the factors that were unique to each study, such as location, age, race etc. For example, Hanioka et al. conducted their

study with only Japanese candidates while Gordon et al had participants from the United States22,23,27. There was no standardization of a patient demographic, which may skew results due to confounding variables such as cultural differences. Furthermore, there was a total lack of blinding in all the

articles reviewed, further introducing bias. The nature of the intervention used makes it difficult to conduct the study under blinding condition for the patient as well as the practitioner. Additionally,

several studies reviewed had a significantly small sample size. Gordon et al. (2007) had a sample size that was half of the anticipated recruitment due to the natural disaster Hurricane

Katrina27. Similarly, the study conducted by Hanioka et al. suffered a significant loss to follow up (27%) to an already small sample size of 5623. Moreover, Binnie et al. had only involved 116

participants along with substantial loss to follow up, which were assumed to be failure of smoking

cessation26. In addition, the results of some of the studies measure tobacco cessation validation with

self-reports and surveys completed by participants. This makes the results more subjective than using biochemical evidence, such as measuring nicotine metabolite level. In addition, more

information seems to be required for defining “usual care” since this can vary widely among different dental care providers. Some individuals may be more effective in providing “usual care” in smoking cessation compared to others and this makes the control group inconsistent within each study as well as across the four studies reviewed.

In addition to the sources of bias in each study used, there are other possible factors in the

review process of this paper that may have compromised validity and reliability. The Cochrane

review on “interventions for tobacco cessation in the dental setting” was completed in 2006 and this greatly limited the availability of articles to be used for our review 20. All the articles chosen for our review were published post 2006 to prevent any overlap with the Cochrane review and this

significantly reduced the availability of information, limiting the results. For this reason, it was

necessary to use two articles done by the same author, Gordon, which in turn, further decreased the external validity of this review. Ideally, multiple RCT’s ought to be conducted by numerous

researchers with higher sample sizes as to give a broader perspective on the topic and consequently increase the external validity of the results.

The results of the 4 different articles used in this review are in agreement with each other.

They all support the effectiveness of tobacco cessation programs provided by dental

professionals. The results from the four articles are in partial agreement with the results from the

Cochrane review by Carr A and Ebbert J (2006) 20. However, it is not possible to assume a complete

agreement since our review focuses more on the cessation of cigarette smoking, unlike the Cochrane review, which puts more emphasis on smokeless tobacco.

Each of the four articles proposed their recommendations based on their results. Hanioka et

al. concluded that smoking cessation intervention by dental staff is effective for of long-term

abstinence rate23. For this reason, they recommended smoking cessation counseling by dental staff and state that dental clinics can serve as a facility for smokers to be motivated to quit

effectively. Similarly, Binnie et al. also indicate that the dental team should participate in helping tobacco users to achieve abstinence26. However, they also suggest that more multi-centered randomized controlled trials involving biochemical verification of abstinence need to be

conducted. In addition to cessation programs involving counseling by dental staff, Gordon et al. (2007) state that the referral to tobacco quitlines can be effective as an adjunct

therapy27. Considering the low participation rate of quitlines, Gordon et al. recommend the regular

5A’s along with proactively referring the users to quitline is the most effective smoking cessation

program offered by dental caregivers. Another study done by Gordon et al. (2010) does not

recommend any specific treatment modalities, but found that the 5A’s in combination with quitline

was once again effective22. Gordon et al. still stresses the effectiveness of tobacco cessation services

delivered in public dental clinics and its potential to help tobacco users to quit.

Effective treatments for tobacco addiction exist and they should be offered to all tobacco

users. Dental staff should incorporate at least the first 3A’s (ask, advise, assist) into their routine

dental practice to assess the motivation of patients to quit tobacco. If the tobacco user is interested in

quitting, the next step should determine the most effective and tailored type of counseling to be used

such as practical and social support with treatment or provided outside treatment through

quitlines27. Furthermore, the clinician should provide the patient with the option to use Nicotine

replacement therapy and inform them of the various drugs available along with possible side-effects.

The 2008 update to the Clinical Practice Guideline for Treating Tobacco Use and Dependence

provides specific recommendations regarding brief and intensive tobacco-cessation interventions as well as system-level changes designed to promote the assessment and treatment of tobacco use8, 9.

This evidence-based blueprint enables clinicians to treat the deadly chronic disease of tobacco addiction effectively. Studies conclude that brief counseling (e.g. 3As) and at least one form of

nicotine replacement therapy is sufficient to enhance tobacco cessation8. However, there is a dose-

response relationship between the intensity of tobacco dependence counseling and its effectiveness9.

Clinicians must learn to provide tobacco users counseling in both a timely and effective manner to

benefit both the patient and clinician. There are many resources available to dental staff to provide them with self-training and continued education to enhance their confidence in providing tobacco cessation interventions. Organizations such as the Ontario Dental Association (ODA) provide

resources such as pamphlets that can be mailed to a dentist or downloaded electronically. The

Ontario Dental Association is also associated with various cessation programs throughout Ontario,

like the T.E.A.C.H. program that offers additional resources for tobacco cessation through the Centre

of Addiction and Mental Health29. The ODA is also affiliated with Health Canada, the American Dental Association, the Canadian Cancer Society, the Lung Association, which provide outlets for smoking

cessation resources29. It is imperative that more research to be done to examine how effective treatments can be implemented in real-world clinical settings.

One important aspect of implementing smoking cessation intervention in dental clinics is the

factor of cost effectiveness. Although the four articles did not investigate the cost effectiveness of

smoking intervention, Hanioka et al. did acknowledge that smoking-cessation counseling by dentists and dental hygienists requires a certain time commitment. Therefore, they recommended further

studies investigating how much patients can save on dental expenditures by either preventing dental

disease or by improving their oral health due to their smoking cessation23.

It is beneficial for dentists to put in the time for smoking cessation intervention with their

patients. Interventions should be provided by dental staff who are educated in tobacco cessation programs. The patient’s motivation to quit should accurately be assessed, as this helps tailor the

intervention and make it more effective. Cessation counseling, even as brief as 3 minutes, has been

shown to be effective, thus any small time spent on smoking cessation will be effective8,9 . It would

also be advantageous to research the effectiveness of pharmacotherapies delivered by dental staff.

Smoking cessation drugs, such as Champix, are becoming increasingly popular and more developed in the market today. Drugs are useful tools for smoking cessation intervention. New

pharmacotherapies can significantly increase the long-term quit rate, but they work best in

conjunction with counseling. Dentists are unique in the health care field because they can prescribe

pharmacotherapy and it would be valuable to examine the effectiveness of prescribing patients with

other smoking cessation drugs besides nicotine replacement therapy. This would be relevant for

future implications of smoking cessation intervention by dental staff. CONCLUSION

In conclusion, the results from this review support the effectiveness of tobacco cessation

intervention in the dental setting. It is evident that dental professionals have the potential in helping tobacco users by effectively delivering smoking cessation programs. Future research should further clarify the timeliest and most cost effective ways to deliver such programs, as the public health benefits would be well worth this endeavor. AKNOWLEDGEMENTS We would like to thank the following personnel, as their input and guidance was critical to this evidence based research: -Dr. Dick Ito

-Dr. Amir Azarpazhooh

-Helen He

-Faculty of Dentistry, University of Toronto

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19. Campbell HS, Sletten M, Petty T. Patient perceptions of tobacco cessation services in dental offices. Journal of the American Dental Association 1999; 130(2):219-226. 20. Carr A, Ebbert J. Interventions for Tobacco Cessation in the Dental Setting. The Cochrane Collaboration 2009

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27. Gordon JS, Andrews JA, Crews KM et al. The 5A’s vs. 3A’s plus proactive quitline referral in private practice dental offices: preliminary results. Tobacco Control 2007; 16: 285-288. 28. Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Working Group, 2011. Retrieved February 15, 2012 from

29. Ontario Dental Association: Tobacco Cessation. Retrieved February 27, 2012 from

APPENDIX Table 1. MeSH Terms

OR

AND Population Dentistry Dentists Dental Hygienists Dental Clinics Dental Staff

Outcome Smoking Cessation Smoking/prevention and control Smoking AND Counseling

Table 2- PICOC Statement Parameters PICOC parameter Inclusion Population Smokers who want to quit Intervention Smoking Counseling Smoking Counseling combined with quitlines NRT Control Usual Care Outcome Smoking Cessation Critical appraisal criteria Randomized Controlled trials

Exclusion People Under 18

Table 3- Checklist for the critical appraisal of relevant articles. 1.Was the study ethical? 2.Was a strong design used to assess efficacy? 3.Were outcomes (benefits and harms) validly and reliably measured? 4.Were interventions validly and reliably measured? 5.What were the results? • Was the treatment effect large enough to be clinically important? • Was the estimate of the treatment effect beyond chance and relatively precise? • If the findings were “no difference” was the power of the study 80% or better? 6.Are the results of the study valid? • Was the assignment of patients to treatments randomized? • Were all patients who entered the trial properly accounted for and attributed at its conclusion? • Was lost to follow-up less than 20% and balanced between test and controls? • Were patients analysed in the groups to which they were randomized? • Was the study of sufficient duration? • Were patients, health workers and study personnel “blind” to treatment? • Were the groups similar at the start of the trial? • Aside from the experimental intervention, were the groups treated equally? • Was care received outside the study identified and controlled for? 7.Will the results help in caring for your patients? • Were all clinically important outcomes considered? • Are the likely benefits of treatment worth the potential harms and costs?

Figure 1- Selection Process

Articles after database search (Pubmed) 331 articles remain

Articles after database search (OVID) 254 articles remain

Articles after eliminating duplicates (via Refworks) 373 articles remain

212 articles eliminated

Title Review 20 articles remain

253 articles eliminated

Abstract Review 9 articles remain

11 articles eliminated

Full Text Critical Appraisal 7 articles remain

2 articles eliminated

Assessment of Validity 4 articles suited for systematic review

3 articles eliminated

Table 4- Evidence Based Table For RCT Studies used in Systematic Review

Author, Date Binnie et al., 2007.

Population

Intervention

-116 smokers aged 18yrs+ -patients at Periodontology consultant clinic at outpatient dental hospital -Russia

- dental practitioner advice to quit base on 5A’s and offered NRT

-dental patients 18 yrs. and older -14 public health clinics: Mississippi (6), Oregon (4), New York (4) -ethnicities: nonHispanic Whites, Hispanics, nonHispanic African Americans

-5 “A”s of the Clinical Practice Guideline for Treating Tobacco Use and Dependence -also including nicotine replacement therapy

N=59

Control

-Usual Care N=57

N=2673

N=1434

-intervention group had a higher quit rate than usual care at 3, 6, and 12mo 3mo- 15% vs. 9% 6mo- 10% vs. 5% 12mo- 7% vs. 4%

N=116

Gordon et al., 2010

Outcome

-Usual care N=1203

-intervention tx participants had significantly higher abstinence rates at 7.5 month follow up for both point prevalence and prolonged abstinence -PP=11.3% vs. 6.8% -PA=5.3% vs. 1.9%

Critical appraisal comments, Strength of evidence and classification Checklist Score: 13.5/18 Level of Evidence: I Level of Recommendation: A - Trained dental staff have the potential to offer smoking cessation interventions effectively -self-reported smoking cessation, verified by salivary cotinine and CO measurements -more RCTs should be conducted -hygienists delivered both intervention and control (no blinding) Checklist Score: 13/18 Level of Evidence: I Level of Recommendation: A

-confounding ethnicity with location (study did not appear effective for Hispanics) -limited number of Hispanics in sample -loss to follow up was 26% -lack of blinding -care received outside not controlled for (NY quit smoking campaign may attribute to higher cessation in usual care group)

Conclusion -Trained dental staff could help patients quit smoking as they can offer smoking cessation intervention effectively -RCT, good evidence

-intervention appears effective at facilitating cessation among low income dental patients who are interested in quitting -RCT, strong evidence

Hanioka et al., 2010

-adult dental patients from 30 dental clinics in Japan (Hiroshima and Nagasaki)

-smoking cessation counseling, free nicotine transdermal patches

-No treatment

-1652 tobacco using patients from 68 dental practices in Mississippi

Intervention 1: a combination of quitting advice from dental practitioner and proactive telephone counseling (3A’s)

-Usual Care

N=56

Gordon et al., 2007

N=1644

N=33

N=628

Intervention 2: Intervention given by a dental practitioner based on the 5A’s of the Clinic Practice Guideline N=585

N=23

N=431

-abstinence rates at 3, 6, and 12mo was 51.5%, 39.4%, and 36.4% respectively for the intervention group -abstinence rates for non-intervention was the same 13% for 3, 6 and 12 mo

-Smokers in the two intervention conditions quit at a higher rate than those in usual care -8.1% (intervention) vs. 5.1% (non-intervention) quit rate

Checklist Score: 11.5/18 Level of Evidence: I Level of Recommendation: B -small sample size total (non-int