The Journal of the American Dental Association
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

J Am Dent Assoc, Vol 132, No suppl_1, 30S-35S.
© 2001 American Dental Association
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by TOMAR, S. L.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by TOMAR, S. L.

ARTICLES

JADA Continuing Education

Dentistry’s role in tobacco control



SCOTT L. TOMAR, D.M.D., Dr.P.H.


   ABSTRACT
TOP
 ABSTRACT
OPPORTUNITIES FOR CHANGE
 CONCLUSION
 REFERENCES
 
Background. Cigarette smoking remains the nation’s leading preventable cause of premature mortality. Tobacco use also is responsible for 75 percent of deaths resulting from oral and pharyngeal cancer, more than one-half of the cases of periodontitis and numerous other oral health effects.

Methods. The author summarized the prevalence of tobacco use in the United States, evaluated recent literature on the status of tobacco control activities in dental schools and dental practice, and reviewed new guidelines on clinical and community-based interventions for tobacco use.

Results. Nearly 25 percent of adults and 35 percent of high-school students smoke cigarettes, and many use other forms of tobacco. More than one-half of adult smokers and nearly three-fourths of adolescents see a dentist each year. However, more than 40 percent of dentists do not routinely ask about tobacco use, and 60 percent do not routinely advise tobacco users to quit. Meanwhile, less than one-half of dental schools and dental hygiene programs provide clinical tobacco intervention services.

Conclusions. At least 50 dental organizations have adopted policy statements about tobacco use, but much work needs to be done in translating those policy statements into action. Tobacco use remains prevalent in the United States, and dentistry has not yet maximized its efforts to reduce it.

Practice Implications. The recently issued U.S. Public Health Service guidelines on treating tobacco use and dependence provides evidence-based, practical methods for dentists and other primary care providers to incorporate into their practice. Because dentists and dental hygienists can be effective in treating tobacco use and dependence, the identification, documentation and treatment of every tobacco user they see need to become a routine practice in every dental office and clinic.

Use of tobacco has a devastating effect on the health and well-being of the public. More than 400,000 Americans die each year as a direct result of cigarette smoking, making it the nation’s leading preventable cause of premature mortality.1 The direct medical care costs for smoking-attributable disease in this country exceeds $72 billion per year.2 Worldwide, the picture is even more bleak; with current smoking patterns, about 500 million people alive today will eventually be killed by tobacco use.3 By 2030, tobacco is expected to be the single biggest cause of death worldwide, accounting for about 10 million deaths per year. One-half of these deaths will occur among people 35 to 69 years of age, losing an average of 20 to 25 years of life.

Dental schools need to incorporate into their curricula not just didactic instruction on the oral health impact of tobacco use, but practical training in clinical intervention.

The effects of tobacco use on the public’s oral health also are alarming. All forms of tobacco—including cigarettes, cigars, pipes and smokeless tobacco—have been established as causal for oral and pharyngeal cancer and are responsible for more than 75 percent of deaths caused by these malignancies in the United States.4 The evidence is sufficient to consider smoking a causal factor for adult periodontitis,5 and one-half of the cases in this country may be attributable to cigarette smoking.6 Tobacco use substantially worsens the prognosis of periodontal therapy and dental implants, impairs oral wound healing and increases the risk of the patient’s experiencing a wide range of oral soft tissue changes.7

Unfortunately, tobacco use remains highly prevalent in the United States. Nearly one in four adults smoke cigarettes,8 and almost 10 percent of men smoked at least one cigar in the past month.9 Among high-school students in 1999, nearly 35 percent overall said they smoked cigarettes, more than 25 percent of boys and 10 percent of girls said they smoked cigars, and more than 14 percent of boys in high school said they used snuff or chewing tobacco.10

These statistics provide a compelling case for a concerted effort by organized dentistry and individual dentists to help reduce tobacco consumption. There is some evidence that dentistry is moving in that direction; at least 50 dental organizations have adopted policy statements about tobacco use. But much work needs to be done to translate those policy statements into action. The American Dental Association’s 1997 Survey of Current Issues in Dentistry: Tobacco Use Cessation Efforts Among Dentists11 reported that more than four of 10 dentists do not routinely ask about tobacco use (which was virtually unchanged from 1994), and six of 10 dentists do not routinely advise tobacco users to quit. Disappointingly, just 24 percent of smokers who had seen a dentist in the past year reported that their dentist had advised them to quit, and only 18 percent of smokeless tobacco users reported that their dentist ever had advised them to quit.12 Slightly more than one-half of dental schools include didactic training in counseling tobacco users to quit,13 and less than one-half of dental schools and dental hygiene programs provide clinical tobacco intervention services to any significant extent.14 As many as 25 percent of dental schools use health history forms that do not even ask about tobacco use, and another 25 percent ask about it with just a single question.15

The quit strategies are designed to be brief, requiring three minutes or less of direct clinician time.


   OPPORTUNITIES FOR CHANGE
TOP
 ABSTRACT
 OPPORTUNITIES FOR CHANGE
CONCLUSION
 REFERENCES
 
The dental office provides an excellent venue for providing tobacco intervention services, as more than one-half of adult smokers and nearly three-fourths of all adolescents see a dentist each year.12,16 Dental patients are particularly receptive to health messages at periodic checkups, and oral effects of tobacco use provide visible evidence and a strong motivation for tobacco users to quit. The recently issued U.S. Public Health Service, or PHS, guidelines on treating tobacco use and dependence provide evidence-based, practical methods for dentists and other primary care providers to incorporate into their practices.17 Because dentists and dental hygienists can be effective in treating tobacco use and dependence, the identification, documentation and treatment of every tobacco user they see need to become a routine practice in every dental office and clinic. Tobacco intervention must be viewed as an integral part of quality dental care.

Many tobacco users visit a dental office every year, so it is important that dentists and dental hygienists be prepared to intervene with those who are willing to quit. The five major steps (the "5 As") to intervention in the primary care setting are listed in Table 1Go. It is important for the dental care provider to ask the patient if he or she uses tobacco, advise him or her to quit, assess willingness to make a quit attempt, assist the patient in making a quit attempt and arrange for follow-up contacts to prevent relapse. The strategies are designed to be brief, requiring three minutes or less of direct clinician time. Office systems that institutionalize tobacco use assessment and intervention will greatly foster the adoption of these strategies.


View this table:
[in this window]
[in a new window]
  		TABLE 1 STRATEGIES FOR HELPING PATIENTS QUIT USING TOBACCO.

 
The first step in the process is to identify patients who use tobacco and to characterize their patterns of consumption and tobacco use history. An officewide system should be implemented to ensure that tobacco-use status is queried and documented at every patient visit. In a clear, strong and personalized manner, dental care providers should urge every tobacco user to quit. Dentists and dental hygienists should assist their patients who want to quit using tobacco by helping them with a quit plan, providing practical counseling, offering social support, helping them identify external sources of social support, and recommending or prescribing the use of nicotine replacement therapy or buproprion SR (sustained-release buproprion). Buproprion SR is the first nonnicotine medication shown to be effective for smoking cessation and approved by the U.S. Food and Drug Administration for that purpose.

For patients who use tobacco but are not ready to make a quit attempt, dental professionals should provide a brief intervention designed to promote the motivation to quit. Patients unwilling to make a quit attempt may lack information about tobacco’s harmful effects, may lack adequate financial resources, may have fears or concerns about quitting or may be demoralized by previous relapses. These patients may respond to a motivational intervention built around the "5 Rs": relevance, risks, rewards, roadblocks and repetition (Table 2Go). Dental professionals can encourage their patients to identify reasons why quitting is personally relevant. Patients can be educated on the oral health risks of tobacco use, and dental care providers often can point out clinical changes in patients’ mouths. Dentists and dental hygienists can highlight rewards that patients can experience from quitting and can help the patient identify roadblocks to quitting. For a detailed description of the components of an effective tobacco intervention treatment plan and a review of the evidence supporting those recommendations, readers should consult the U.S. PHS guidelines.17


View this table:
[in this window]
[in a new window]
  		TABLE 2 THE "5 Rs" OF ENHANCING MOTIVATION TO QUIT TOBACCO USE

 
Relative to other reimbursed treatments, treatment of tobacco use and dependence is a highly cost-effective intervention,17 and dentists should be fairly compensated for this service. Organized dentistry needs to take an active role in promoting reimbursement by dental care plans to dentists for tobacco-dependence treatments.

In addition to helping current users quit, dental offices may provide an excellent setting for delivering tobacco prevention messages to young people.18–21 Adolescents substantially underestimate their personal risk of disease or death from the use of tobacco19,20 and overestimate the ease of quitting.21 Health care providers can play an important role in educating their patients (including nonusers) on the risks of using tobacco. One unique aspect of dentistry is that some of the adverse health effects of tobacco use are clinically apparent in the oral cavity in even relatively early stages of use.22,23 Oral manifestations can help personalize the interventions and increase their effectiveness, particularly among young users in the early stages of tobacco initiation.24,25

To help achieve individual behavioral change, whole communities must change the way tobacco products are marketed, sold and used.25 At the community level, local dental societies and dentists can become involved in local tobacco control coalitions, which function to mobilize and empower the community to make the changes that support nonuse of tobacco. Community-based programs have included activities such as educating the public on the health hazards of environmental tobacco smoke, promoting smoke-free restaurants, and encouraging policies and programs that support prevention and cessation of tobacco use.

Dental schools need to incorporate into their curricula not just didactic instruction on the oral health impact of tobacco use, but practical training in clinical intervention (for example, role-playing discussions between dentists and patients). The next generation of dentists and dental hygienists should graduate with competency in assessing and treating tobacco use.


   CONCLUSION
TOP
 ABSTRACT
 OPPORTUNITIES FOR CHANGE
 CONCLUSION
REFERENCES
 
We are at a unique point in time in the history of attempting to reduce tobacco use. There is potentially more money available than ever for the full range of tobacco control activities, and the majority of Americans favor reduction of societal tobacco use and decreased exposure to environmental tobacco smoke. A great deal has been learned about what is effective in communities and clinical settings. The few states that have implemented comprehensive tobacco control programs have seen significant reductions in the prevalence of smoking, particularly among young people.26

Dental practice in the 21st century will increasingly move from a restorative orientation to one of broader promotion of health and well-being. It is unconscionable to not include aggressive tobacco intervention in that new paradigm. To paraphrase the Massachusetts Tobacco Control Program, it’s time we made tobacco history.27


   FOOTNOTES
 

Dr. Tomar is an associate professor, University of Florida College of Dentistry, Division of Public Health Services and Research, 1600 S.W. Archer Road, P.O. Box 100404, Room D8-38, Gainesville, Fla. 32610, e-mail "stomar{at}dental.ufl.edu". Address reprint requests to Dr. Tomar.


   REFERENCES
TOP
 ABSTRACT
 OPPORTUNITIES FOR CHANGE
 CONCLUSION
 REFERENCES
 

  1. Cigarette smoking-attributable mortality and years of potential life lost: United States, 1990. MMWR Morb Mortal Wkly Rep 1993;42: 645–9.[Medline]

  2. Miller LS, Zhang X, Rice DP, Max W. State estimates of total medical expenditures attributable to cigarette smoking, 1993. Public Health Rep 1998;113:447–58.[Medline]

  3. The World Bank. Curbing the epidemic: governments and the economies of tobacco control. Tob Control 1999;8(2):196–201.[Free Full Text]

  4. Reducing the health consequences of smoking: 25 years of progress—a report of the surgeon general: 1989. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1989. DHHS publication (CDC) 89-8411.

  5. Gelskey SC. Cigarette smoking and periodontitis: methodology to assess the strength of evidence in support of a causal association. Community Dent Oral Epidemiol 1999;27(1):16–24.[Medline]

  6. Tomar SL, Asma S. Smoking-attributable periodontitis in the United States: findings from NHANES III—National Health and Nutrition Examination Survey. J Periodontol 2000;71:743–51.[Medline]

  7. Position paper: tobacco use and the periodontal patient. Research, Science and Therapy Committee of the American Academy of Periodontology. J Periodontol 1999;70:1419–27.[Medline]

  8. Cigarette smoking among adults: United States, 1998. MMWR Morbid Mortal Wkly Rep 2000;49:881–4.[Medline]

  9. State-specific prevalence of current cigarette and cigar smoking among adults: United States, 1998. MMWR Morbid Mortal Wkly Rep 1999;48:1034–9.[Medline]

  10. Healton C, Messeri P, Reynolds J, et al. Tobacco use among middle and high school students: United States, 1999. MMWR Morbid Mortal Wkly Rep 2000;49:49–53.[Medline]

  11. American Dental Association. 1997 Survey of current issues in dentistry: Tobacco use cessation efforts among dentists. Chicago: ADA Survey Center; 1998.

  12. Tomar SL, Husten CG, Manley MW. Do dentists and physicians advise tobacco users to quit? JADA 1996;127:259–65.[Abstract/Free Full Text]

  13. Grinstead CL, Dolan TA. Trends in U.S. dental schools’ curriculum content in tobacco use cessation 1989–93. J Dent Educ 1994;58: 663–7.[Medline]

  14. Barker GJ, Williams KB. Tobacco use cessation activities in U.S. dental and dental hygiene student clinics. J Dent Educ 1999;63:828–33.[Medline]

  15. Yellowitz JA, Goodman HS, Horowitz AM, al-Tannir MA. Assessment of alcohol and tobacco use in dental schools’ health history forms. J Dent Educ 1995;59:1091–6.[Abstract]

  16. National Center for Health Statistics. Health: United States, 2000 with adolescent chartbook. Hyattsville, Md.: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2000. DHHS publication 00-1232.

  17. Fiore M., Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: Clinical practice guideline. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service; 2000. Available at: "www.surgeongeneral.gov/tobacco_treating_use.pdf". Accessed Sept. 21, 2001.

  18. Hovell MF, Jones JA, Adams MA. The feasibility and efficacy of tobacco use prevention in orthodontics. J Dent Educ 2001;65:348–53.[Abstract]

  19. Romer D, Jamieson P. Do adolescents appreciate the risks of smoking? Evidence from a national survey. J Adolesc Health 2001;29:12–21.[Medline]

  20. Jamieson P, Romer D. What do young people think they know about the risks of smoking? In: Slovic P, ed. Smoking risk, perception, and policy. Thousand Oaks, Calif.: Sage Publications; 2001:51–63.

  21. Preventing tobacco use among young people: A report of the Surgeon General. Washington: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1994.

  22. Tomar SL, Winn DM, Swango PA, Giovino GA, Kleinman DV. Oral mucosal smokeless tobacco lesions among adolescents in the United States. J Dent Res 1997;76(6):1277–86.[Abstract/Free Full Text]

  23. Hashim R, Thomson WM, Pack AR. Smoking in adolescence as a predictor of early loss of periodontal attachment. Community Dent Oral Epidemiol 2001;29:130–5.[Medline]

  24. Walsh MM, Hilton JF, Masouredis CM, Gee L, Chesney MA, Ernster VL. Smokeless tobacco cessation intervention for college athletes: results after 1 year. Am J Public Health 1999;89:228–34.[Abstract/Free Full Text]

  25. National Association of County and City Health Officials. Program and funding guidelines for comprehensive local tobacco control programs. Washington: National Association of County and City Health Officials, Tobacco Prevention and Control Project; 2000.

  26. Best practices for comprehensive tobacco control programs. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1999. Available at: "www.cdc.gov/tobacco/bestprac.htm". Accessed Sept. 21, 2001.

  27. Massachusetts Department of Public Health. Massachusetts Tobacco Control Program. Available at: "www.state.ma.us/dph/mtcp/home.htm". Accessed Sept. 21, 2001.




This article has been cited by other articles:


Home page
 Journal of the American Dental AssociationHome page
E. Applebaum, T. N. Ruhlen, F. R. Kronenberg, C. Hayes, and E. S. Peters
Oral Cancer Knowledge, Attitudes and Practices: A Survey of Dentists and Primary Care Physicians in Massachusetts
J Am Dent Assoc, April 1, 2009; 140(4): 461 - 467.
[Abstract] [Full Text] [PDF]

Home page
 Journal of the American Dental AssociationHome page
K. M. Crews, C. E. Sheffer, T. J. Payne, B. W. Applegate, A. Martin, and T. Sutton
A survey of oral and maxillofacial surgeons' tobacco-use-related knowledge, attitudes and intervention behaviors
J Am Dent Assoc, December 1, 2008; 139(12): 1643 - 1651.
[Abstract] [Full Text] [PDF]

Home page
 Journal of the American Dental AssociationHome page
S. Hu, U. Pallonen, A. L. McAlister, B. Howard, R. Kaminski, G. Stevenson, and T. Servos
Knowing how to help tobacco users: Dentists' familiarity and compliance with the clinical practice guideline
J Am Dent Assoc, February 1, 2006; 137(2): 170 - 179.
[Abstract] [Full Text] [PDF]

Home page
 Journal of the American Dental AssociationHome page
B. A. Dye, N. M. Morin, and V. Robison
The relationship between cigarette smoking and perceived dental treatment needs in the United States, 1988-1994
J Am Dent Assoc, February 1, 2006; 137(2): 224 - 234.
[Abstract] [Full Text] [PDF]

Home page
 J Dent EducHome page
J. M. Davis, M. S. Stockdale, and M. Cropper
The Need for Tobacco Education: Studies of Collegiate Dental Hygiene Patients and Faculty
J Dent Educ., December 1, 2005; 69(12): 1340 - 1352.
[Abstract] [Full Text] [PDF]

Home page
 Journal of the American Dental AssociationHome page
C. KUNZEL, E. LALLA, D. A. ALBERT, H. YIN, and I. B. LAMSTER
On the primary care frontlines: The role of the general practitioner in smoking-cessation activities and diabetes management
J Am Dent Assoc, August 1, 2005; 136(8): 1144 - 1153.
[Abstract] [Full Text] [PDF]

Home page
 Journal of the American Dental AssociationHome page
G. F. CANNICK, A. M. HOROWITZ, T. F. DRURY, S. G. REED, and T. A. DAY
Assessing oral cancer knowledge among dental students in South Carolina
J Am Dent Assoc, March 1, 2005; 136(3): 373 - 378.
[Abstract] [Full Text] [PDF]

Home page
 Journal of the American Dental AssociationHome page
N.-C. GELLRICH, M. M. SUAREZ-CUNQUEIRO, A. BREMERICH, and A. SCHRAMM
Characteristics of oral cancer in a central European population: Defining the dentist's role
J Am Dent Assoc, March 1, 2003; 134(3): 307 - 314.
[Abstract] [Full Text] [PDF]

Home page
 Journal of the American Dental AssociationHome page
J. J. SCIUBBA
Oral cancer and its detection: History-taking and the diagnostic phase of management
J Am Dent Assoc, November 1, 2001; 132(suppl_1): 12S - 18S.
[Abstract] [Full Text] [PDF]

Home page
 Journal of the American Dental AssociationHome page
Perform a death-defying act: The 90-second oral cancer examination
J Am Dent Assoc, November 1, 2001; 132(suppl_1): 36S - 40S.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by TOMAR, S. L.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by TOMAR, S. L.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS