For this special report, JADA asked five dental professionals known for their work in tobacco-use cessation to share their thoughts on the roles that dentists and organized dentistry play in helping patients on the road to a tobacco-free life.
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WILLIAM BENSON, D.M.D.
A private practitioner from Haverhill, Mass., Dr. Benson chairs the Massachusetts Dental Society’s Council on Access, Prevention and Interprofessional Relations. Under his direction, the council is developing Web-based and print materials on tobacco-use cessation for patients and professionals. Dr. Benson also is a member of the Massachusetts Coalition of Oral Health.
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ARDEN G. CHRISTEN, D.D.S., M.S.D., M.A.
Dr. Christen is a professor in the Department of Oral Biology, Indiana University School of Dentistry, Indianapolis. A long-time consultant to the National Cancer Institute, he served as technical expert to Surgeon General C. Everett Koop’s Advisory Committee, which developed the 1986 report, "Health Consequences of Using Smokeless Tobacco." Dr. Christen also coauthored a 1990 Surgeon General’s report titled "The Health Benefits of Smoking Cessation." Today, he is co-director of the Indiana University Nicotine Dependence Program and a consultant to the ADA in smoking cessation and tobacco education. He is a past member of the Advisory Committee on Chemical Dependency Issues, ADA Council on Dental Practice.
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KAREN M. CREWS, D.M.D.
Dr. Crews is a professor in the Department of Diagnostic Sciences, University of Mississippi School of Dentistry, Jackson. Since 1995, she has represented the American Association of Dental Schools on the National Dental Tobacco-Free Steering Committee and has been a member of the National Coalition on Smoking and the Health of Women and Girls. She has written and lectured extensively on the hazards of tobacco use and the benefits of tobacco-use cessation.
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THERESA E. MADDEN, D.D.S., PH.D., M.S.
Dr. Madden chairs the Department of Periodontology, School of Dentistry, Oregon Health Sciences University, Portland. She is a past member of the ADA’s Dentists’ Well-Being Advisory Committee (formerly the Advisory Committee on Chemical Dependency Issues) and is a current member of the Oregon Dental Association’s Well Being of Dentists Committee. From 1992-96, Dr. Madden served as dental consultant to the Medical Specialists Center for Substance Abuse Prevention, U.S. Department of Health and Human Services. She has conducted workshops and lectured widely on substance abuse and tobacco addiction.
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ROBERT E. MECKLENBURG, D.D.S., M.P.H.
Dr. Mecklenburg is coordinator of Tobacco and Oral Health Initiatives for the Tobacco Control Research Branch of the National Cancer Institute. A former chief dental officer of the U.S. Public Health Service, he is current chairman of the National Dental Tobacco-Free Steering Committee. Dr. Mecklenburg has written extensively on tobacco-related topics and conducted more than 70 one-day professional education programs on tobacco for medical and dental clinicians. He also has lectured on tobacco at more than 30 professional meetings.
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WHY SHOULD A PRACTICING DENTIST GET INVOLVED IN TOBACCO-USE CESSATION?
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Dr. Mecklenburg: First, it is ethical to integrate this service into clinical practice. Ignoring tobacco use when providing periodontal services would be akin to ignoring caries when providing restorations. Attention must be given to the underlying cause of tobacco-use–related oral health problems and risks to certain treatments and prognoses.
Second, as a member of civil society, helping people quit is the right thing to do. Tobacco use can subvert reason, emotion and physiology so that few who are tobacco-dependent can successfully quit without help. Anyone would feel terrible if people whom he or she could have helped quit, but didn’t, became disabled or died as a result of a tobacco-caused disease.
Third, helping people quit is good risk management. Some patients might become unhappy enough to complain loudly and often, or possibly litigate, when they find that a tobacco-related oral condition progressed without their receiving from their dentists words of caution and offers to help.
Dr. Crews: Approximately 26 percent of dental patients use tobacco. Because dentists are prevention-oriented and professionally trained to diagnose abnormal conditions associated with or caused by tobacco use, they have a unique opportunity to discuss with patients the benefits of quitting, as well as the deleterious effects of continued tobacco use.
Dr. Benson: Preventive dentistry should include more than dental sealants and fluoride. Tobacco use adversely affects the oral tissues and the periodontium and causes oral cancer. Tobacco-use cessation assists in a public health effort to curb a leading cause of death. We are here to help our patients toward health. Many general health issues, especially tobacco use, can have a bearing on dental treatment.
Dr. Madden: Recently, we [School of Dentistry, Oregon Health Science University] surveyed a random sample of 400 adult Oregonians about their beliefs concerning several important oral health topics and the expectations they have of their dentists.
Ninety-three percent believed smoking or chewing tobacco presented serious oral health risks, and 60 percent believed that dentists and hygienists should provide more information about tobacco to their patients than we are presently providing.
Dr. Christen: As health care providers, we need to make a positive impact on both the general and oral health of our patients. As we address issues concerning tobacco-use cessation, we have the opportunity to positively affect both arenas.
We are helping to improve life quality and increase longevity when we provide tobacco-use cessation assistance services for our patients. While preserving oral structures is a primary goal of modern dentistry, enhancing and preserving lives is the ultimate treatment benefit we can offer.
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HOW DOES TOBACCO-USE CESSATION IMPROVE THE DENTAL PRACTICE?
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Dr. Madden: Engaging in tobacco-use intervention improves the status of a dental practice in so many ways. Tobacco-free patients gain superior benefits from their periodontal care and are less likely to be troubled by other oral diseases.
When tobacco-use control literature is displayed in the reception area, the dentist is perceived as one who cares about the health of the whole person, is up-to-date in comprehensive health education activities, and is seen as an integral part of the overall health care team. Such activities increase respect toward the dentist held by the patients, staff and the community.
Dr. Christen: As dentists become knowledgeable and skillful in delivering this health care service, they have the opportunity to receive secondary, practice-building benefits: the gratitude and loyalty of patients whom they are helping, and financial remuneration through the fees that they charge. As these recovering individuals share their success stories, they attract new patients to the practice.
Dr. Mecklenburg: Cessation assistance services are of greatest advantage to dentists who keep patients in their practices for years. A higher percentage of nonusers in a practice means that fewer patients require medical management for their frail cardiovascular systems, pulmonary diseases or tobacco-related chemistry that affects medication options and strengths.
An immediate benefit to the practice is simply asking patients about their tobacco-use status and advising users to quit. This conveys the impression that the dentist is aware of a major public health problem and interested in protecting the patient’s total health and well-being.
There is another intangible benefit: what other dental service allows one to save lives—virtually every week?
Dr. Crews: Implementation of a tobacco treatment program requires little or no overhead expense and can be a significant practice builder.
All tobacco use negatively affects the oral cavity. These effects range from mild to life-threatening: halitosis, abrasion, delayed wound healing, chronic periodontal disease, tobacco keratosis, and oral and pharyngeal cancers. Because these conditions directly affect the dental care delivery system, tobacco use should be considered a risk factor when planning treatment of patients who require periodontal therapy, oral surgery, implants or any esthetic procedures.
Dr. Benson: We incorporated tobacco-use cessation [counseling] after we obtained an intraoral camera. Our dental hygienists routinely find dark stains on patients’ teeth. We will ask, "Is that tobacco stain or is it coffee or tea?" This helps us learn about their tobacco use in a gentle fashion.
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WE KNOW THAT MOST DENTISTS DO NOT ROUTINELY TALK TO THEIR PATIENTS ABOUT TOBACCO USE. WHY IS THAT?
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Dr. Christen: They may believe that tobacco is not a dental health issue; lack the confidence to tackle the problem; view their solitary efforts as relatively fruitless; perceive this effort as being too time-consuming and professionally demanding and, thus, financially counterproductive; or conclude that the program is unrealistic.
Fifteen years of accumulated scientific evidence shows that well-trained oral health care professionals can effectively help many of their patients quit tobacco use. A structured set of sequential procedures is now being used to teach dental professionals how to establish a practical, efficient and low-key tobacco-use cessation program. This plan involves minimal time and disruption in office routine, yet it is highly effective.
In addition, dentists should consider referring selected patients to tobacco-use cessation programs in their communities. I am a co-director of a nicotine-dependence program at Indiana University. Our program, staffed by doctors and counselors from the Indiana University schools of medicine and dentistry, treats about 16 to 20 patients a week. Most of the patients are from Indiana, but some come from neighboring states.
About 25 percent of our patients are referred by practicing dentists. Often, we speak to local dentists on the telephone about their tobacco-using patients and help them to design a treatment plan that can be instituted in the dental practice itself.
We stress to oral health care providers that they are uniquely positioned to inform their patients of their specific tobacco-related oral conditions and to help them quit.
Dr. Benson: A couple of years ago, I wondered if this was an area for me as a dentist. I learned that it is very desirable to get involved from Dr. Paul Vankevic (a Navy friend and classmate), from Dr. Robert Mecklenburg and from the members of my Massachusetts Dental Society council. It has been rewarding to learn firsthand about how tobacco use adversely affects patients’ oral health and to help patients make a positive life change.
Dr. Crews: Today’s practicing dentists more than likely do talk to their patients about tobacco use, but more dentists need to employ a routine system in their practices. We teach a systematic approach to our University of Mississippi dental students.
For example, dentists can use a health history questionnaire with questions about tobacco use and desire to quit. For tobacco users, dentists should mention tobacco-related oral conditions at every visit. Clearly, patients receiving surgical therapy should be advised not to use tobacco as part of their postoperative care.
Addressing tobacco use is not new to dentistry. An organized approach is all that is needed. The U.S. Public Health Service’s "five A’s" are not complicated to implement:
- – ask every patient about tobacco use (health history and patient interview);
- – advise every patient to stop (after oral examination, during dental hygiene visit);
- – assess patients’ willingness to make a quit attempt;
- – assist patients interested in quitting (set a quit date; prescribe pharmaceuticals as necessary);
- – arrange for follow-up contact (staff member calls one or two days before quit date and three days after quit date; patients using nicotine replacement or other pharmaceutical treatments are scheduled for short, monthly follow-up appointments).
Dr. Mecklenburg: A decade ago, few dentists would approach the subject, but that situation is rapidly changing. The 1997 ADA Survey of Dental Practice showed that 58 percent of dentists "routinely" or "most of the time" asked patients about their tobacco use and advised them to quit. The ratio is higher among younger dentists.
Most dental schools now teach brief, practical, effective clinical cessation methods. The global standard—the 1996 clinical practice guideline, "Smoking Cessation," published by the Agency for Healthcare Research and Quality (formerly the Agency for Health Care Policy and Research)—has helped dentists focus on sound methods. It was just upgraded and released in June by the Surgeon General as "Treating Tobacco Use and Dependence: A Clinical Practice Guideline." (Editor’s note: The new guideline is available at "www.surgeongeneral.gov/tobacco"; it also can be obtained by calling 1-800-358-9294.)
Once, dentists might not have understood the connections between tobacco and oral health, or feared offending patients, or didn’t know what to do. That changed as dentists realized the connection, found their fears to be groundless and learned that logical steps to help patients are easily merged into daily practice.
Dr. Madden: I believe that fear of a negative reaction by the patient is the biggest barrier. If dentists understand the multistep process of change that successful quitters have gone through, they will be more versatile and comfortable in advising their patients. Put yourself in the patient’s place and imagine how you would want it discussed, and it will become extremely easy and rewarding.
Dentists should be reimbursed for tobacco-use cessation counseling. In Oregon, we are working with the [state] Health Division to outline parameters for such reimbursement, and I hope that other states and third-party carriers are heading in a similar direction.
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WHAT IS ORGANIZED DENTISTRY DOING TO HELP CURB TOBACCO USE?
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Dr. Mecklenburg: The ADA has a record of achievement as a leader, not a follower, among the health professions. For decades, the House of Delegates has adopted policies to guide practicing dentists, Association management and the public.
The addition of a tobacco-use counseling code in its dental procedures codes, tobacco-use questions to the ADA Health History Form and a tobacco-use cessation chapter in the ADA Guide to Dental Therapeutics have made it much easier for dentists to adopt and routinely use cessation assistance services. Through council activities, the ADA constantly seeks fresh ways to help strengthen dentists’ ability to help their patients quit and avoid tobacco use.
The ADA has joined with many other organizations that are committed to reducing child and youth tobacco initiation and addiction. It champions fair recognition of spit tobacco and tobacco-free education, service programs and public policy. The ADA provides public education about tobacco and oral health, and promotes research in tobacco dependence and treatment. These are examples, not an exhaustive list of ongoing ADA activities to curb tobacco use.
Dr. Crews: Major dental organizations—as evidenced by resolutions, policies and position statements—recognize tobacco use as an important health care issue. It began in 1964, when the ADA issued a statement that encouraged its members to advise patients of the health hazards of tobacco use.
Since then, the ADA has issued resolutions opposing any type of tobacco use and has urged members to become fully informed about tobacco-use intervention techniques.
In 1989, the National Dental Tobacco-Free Steering Committee was established under the auspices of the National Cancer Institute. Committee members represent national dental organizations that elect to participate. The goal of this committee is to ensure that dental organizations and oral health teams are routinely involved in helping patients and the public to be tobacco-free.
Dr. Benson: I am chair of the Massachusetts Dental Society’s Council on Access, Prevention and Interprofessional Relations. We are in the process of putting tobacco-use cessation information on our Web site. There will be a consumer section and a professional section.
We also will be sending out a laminated sheet to our member dentists and their staffs with a short description of the U.S. Public Health Service’s "ask, advise, assess, assist and arrange" tobacco-use cessation procedures. We also are devoting an upcoming issue of Journal of the Massachusetts Dental Society to this topic.
Dr. Christen: The dental profession is working to keep this topic before fellow professionals and the general public. The National Dental Tobacco-Free Steering Committee is supported by the National Cancer Institute, and has been dealing directly with tobacco-use issues over the past 10 years. As a result, at least 50 dental organizations have developed policy statements about every aspect of tobacco usage.
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HOW CAN ORGANIZED DENTISTRY ENCOURAGE MORE DENTISTS TO BECOME INVOLVED IN TOBACCO-USE CESSATION?
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Dr. Crews: Organized dentistry has laid the groundwork via policy statements and resolutions. However, financial reimbursement still is a barrier to the effective implementation of tobacco-use treatment in the dental setting.
Adding this voice to legislative and other grass-roots efforts should facilitate the willingness of third-party payers to cover these services, thus providing incentives for both patients and practitioners.
Dr. Madden: Organized dentistry should continue to take a proactive role among other community groups in tobacco-use control.
An important opportunity for dental professionals [is] to take part in a community-based interdisciplinary faculty fellowship to become more proficient in preventing tobacco, alcohol and other substance [abuse] problems. It is sponsored by the Health Resource Service Administration and the Association for Medical Education and Research in Substance Abuse.
Several of the interviewees on this panel [Drs. Christen, Crews and Madden] are available to give interested readers details of the fellowship, which is open to dentists across the country who are willing to commit one day per week for two years to this prestigious and important endeavor.
Dr. Mecklenburg: I believe the ADA has acted wisely and well in building infrastructure to make it easy for dentists to learn about, evaluate and adopt tobacco-use cessation assistance services. The ADA has a balanced public education and public policy strategy. Its opportunities for doing still more are common to all health professions.
All clinicians need to know these facts:
- – Tobacco dependence is a chronic, progressive, relapsing disease; achieving and sustaining abstinence requires repeated reinforcement.
- – The period of active central nervous system, or CNS, recovery during cessation takes months, and recovery is lifelong because of permanent CNS changes resulting from tobacco exposure. No quick, one-shot treatment can be recommended.
- – Dentists can be as effective as any other health care providers in helping patients stop using tobacco. It is the methods used, not the practitioner’s discipline, that make the difference.
- – Treatment includes providing support to patients, encouraging support from patients’ family and friends, and helping patients cope with the situations that lead to relapse.
- – Immediate quality-of-life benefits—such as mental and physical performance, reproductive health and social advantages of being tobacco-free—should be emphasized over the long-term threats of disease and death.
- – FDA-approved pharmacotherapy increases quit rates, but is only one of several measures.
- – Patients who are parents or parents-to-be need special help to quit. Fetal and infant exposure to tobacco can lead to lifelong impairment of cognitive, emotional and physical abilities.
Dentists’ involvement in tobacco-use cessation is not something that is entirely under their own control. Patients must want the service. Several surveys over many years show that most do. Others can be gently persuaded. Even many youths in their mid-and late teens want to quit.
Third-party carriers must support the service. Organized dentistry can help third-party carriers recognize that when scientifically sound methods are used, cessation assistance services are to their benefit, too.
Dr. Benson: Our goal is to make it convenient for dentists and their staffs to get involved with tobacco-use cessation for their patients. It only takes a few minutes and is easily incorporated into the patient-care routine.
Dr. Christen: The ADA must continue to play a leading role in coordinating its anti-tobacco use activities with other health agencies and public interest groups.
Currently, the ADA is working toward this goal through its active participation with the National Dental Tobacco Free-Steering Committee. Dental schools also must teach their students about the dangers of using tobacco products and the strategies that are helpful for cessation.
It is vital to inform various dental groups about the most current, state-of-the-art intervention and prevention strategies so that dentists can treat and refer their tobacco-using patients.
Additionally, dentists should be reminded that some population subgroups (children, women and girls, non-Caucasians, people in lower socioeconomic strata, and chemically addicted or emotionally troubled people) are particularly susceptible to tobacco use.
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HOW WOULD YOU LIKE TO SEE THE TOBACCO SETTLE-MENT MONEY USED?
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Dr. Madden: I would like to see it used to reim-burse dentists and other health professionals for engaging in tobacco-use cessation counseling; for health care and disease prevention, particularly of tobacco-related problems; and particularly for prevention programs that work. State officials need to be knowledgeable about which prevention strategies have been shown to work and which ones do not.
Dr. Mecklenburg: Multi-state settlement agreement monies were secured with a promise to the public that they would be used to reduce tobacco use, tobacco addiction and, in the long term, the awful consequences to users and the costly burden on the public.
The focus was on protecting children from demand for and access to tobacco and on helping users who want to quit. Centers for Disease Control and Prevention guidelines stated that no less than 25 percent of monies to states should be used for such purposes.
Yet, the tobacco industry has quietly and effectively influenced legislators to use the money for everything and anything, projects tall and small, grand and bland, as long as they provide no threat to their conducting business as usual. Only a few state legislatures have overcome tobacco industry influence, partly because the public has urged dedicated use of the money for tobacco-use prevention and cessation programs.
Dentists also should focus on nonsettlement means to finance tobacco-use cessation assistance services such as charging patients, making it a component of other services, including it in benefits packages and using other innovative means.
Financing cessation assistance services should not be a hang-up. Primary dentist priorities must be protecting patients’ oral health, treating tobacco dependence, and preventing tobacco-related disability and premature death and financial losses by users, their families and their communities.
Dr. Benson: We are fortunate in Massachusetts to have a fantastic television, radio, billboard and magazine campaign that is encouraging tobacco users to quit. It also motivates and educates people to avoid starting its use. This program is funded with tobacco tax revenue and was developed by the Massachusetts Department of Public Health’s Tobacco Control Program directed by Dr. Gregory Connolly.
Dr. Christen: I believe that the majority of the tobacco settlement money should be used for resolving health issues, especially those related to tobacco use.
In Indiana, I am now serving a four-year term as a member of the governor-appointed Tobacco Use Prevention and Cessation and Advisory Board. Fortunately, Indiana lawmakers, in a bipartisan effort, have elected to spend 100 percent of the settlement money for health concerns, including tobacco-use control.
Tobacco use causes 10,000 deaths in Indiana annually. For the fiscal year that begins on July 1, the state will spend $35 million for tobacco education, prevention and control; $27 million for health care (which includes the treatment of smoking-related illnesses and development of community health centers and rural and medically underserved areas); $20 million for prescription drugs for the low-income elderly; and $28 million for the Children’s Health Insurance Program.
The national tobacco settlement, made with seven tobacco companies, is expected to bring Indiana an estimated $4.2 billion through the year 2025. In addition, 40 to 50 percent of the state’s tobacco dollars will be placed in an invested trust fund.
Dr. Crews: Mississippi is a good example of a state that has adopted a strategic approach. Through the guidance of the Partnership for a Healthy Mississippi, an integrated group of programs has been developed and implemented.
In our school nurse programs, school nurses provide educational programs to youths, coordinate with community-based coalitions to implement tobacco-use prevention programs with the school and provide basic health care to students.
Law enforcement reduces minors’ access to tobacco via retail education, increased compliance checks, coordination with faith- and community-based organizations, implementation of [various] programs and penalties for sales to minors.
Age-specific programs target schoolchildren according to grade. Community/Youth Partnerships have been organized to provide programmatic service to each county in the state. A primary objective of these partnerships is to change the culture by recruiting and mobilizing youth to create a tobacco-free environment.
Faith-based organizations provide life-skills development programs to youth to teach and reinforce effective decision-making and esteem-building skills.
Statewide partners, such as the American Lung Association, provide technical assistance to Community/Youth Partnerships and other partners. Targeted projects, such as [those of] the Boy Scouts, have an existing youth audience into which tobacco-use prevention programs can be implemented. Mississippi also has a variety of health care programs involved in the tobacco-use cessation cause.
Finally, a media campaign has been developed to target youth and their influencers, and to deliver a strong tobacco-use prevention message.
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