A large body of evidence supports the effectiveness of brief interventions by dental and other health care providers in treating tobacco use and dependence.

Advice alone results in a small (approximately 2.5 percent) but reliable increase in patient quit rates, while consistent performance of PHS guideline interventions with patients yields 12-month quit rates approaching 15 percent.^6,14,15 Because patients receiving treatment from OMS often face immediate, significant and distressing consequences of tobacco use from compromised wound healing and/or surgical intervention as a result of tobacco-induced diseases, OMS are well-positioned to facilitate patients’ tobacco-use cessation efforts. The extensive reach of this profession into the population of tobacco users, many of whom may have difficulty quitting on their own, suggests the potential for OMS to contribute greatly to the health of their patients, as well as to reduce the prevalence of tobacco-related disease.

Although the PHS guideline for the treatment of tobacco use and dependence has made evidence-based, effective, efficient clinical recommendations available for more than a decade, dental providers continue to provide an insufficient level of assistance.^16–22 Treatment for tobacco use and dependence is not routine in dentistry, and it appears to vary according to specialty.

In a national survey of general practitioners, pediatric dentists and periodontists, 33 percent of general practitioners asked most or nearly all of their patients if they smoked, 2 percent of pediatric dentists asked patients and 71 percent of periodontists asked most or nearly all of their patients.¹⁶ In the same study, 65 percent of general practitioners advised most or nearly all of their patients who reported that they smoked to stop, 79 percent of pediatric dentists advised patients and 75 percent of periodontists advised patients who smoked to stop.¹⁶

Similar studies indicated that between 33 and 56 percent of general practitioners almost always or always ask about and document tobacco use and 33 to 63 percent almost always or always advise patients who smoke to quit.^16–20 Conversely, nearly all periodontists in a United Kingdom study reported that they ask about tobacco use "regularly."²¹ Although some studies reported that 29 to 41 percent of general practitioners and nearly one-half of periodontists assist tobacco-using patients most of the time, other studies reported that few general practitioners (15 percent and less) assist by providing any type of cessation intervention.^16–21 So although there appears to have been an upward trend in the frequency with which dental providers asked and advised tobacco users in the previous two decades, it is difficult to ascertain if there has been a similar upward trend in the frequency with which they assisted patients as well.²²

OMS may be an exception to this. A 1987 study reported that 71 to 83 percent of OMS assist patients with tobacco-use interventions and 38 to 42 percent assist patients by providing counseling, referrals or both.²³ However, the response rate for this survey was low (28 percent) and the frequency with which these interventions were conducted is unknown.²³ These results suggest that OMS may provide treatment for tobacco use at a frequency greater than that of general practitioners and similar to that of periodontists, perhaps because they are confronted frequently with the more advanced consequences of tobacco use, as well as the direct effects of tobacco use on surgical treatment outcomes (such as delayed wound healing and surgical removal of malignancies caused by tobacco use), or perhaps because they received more training in tobacco-use cessation interventions. However, the nature of the evidence to date does not adequately support this conclusion.

Dentists generally report a number of barriers to treating patients who use tobacco and are dependent on it, including lack of knowledge, negative attitudes, lack of resources, lack of reimbursement, lack of counseling skills and low treatment-related self-efficacy (that is, the provider’s confidence in his or her ability to deliver an effective intervention), as well as perceived patient indifference, staff limitations and other factors.^19,21,24 The majority of dentists and other dental providers report having received no formal training in treating tobacco use and feel unprepared to assist patients in stopping tobacco use.^7,19,24 Although provider training alone is not always sufficient to establish measurable decrements in the prevalence of tobacco use in some patient populations, practitioners who have received training are more likely to deliver tobacco-use interventions than are those who have not, and training remains a key strategy for enhancing provider performance and proficiency.^7,19,25–29

Practitioners who have received training are more likely to deliver tobacco-use interventions than are those who have not.

This study assessed OMS’ tobacco-use–related knowledge, attitudes, practice-related behaviors and training in the treatment of tobacco use and dependence. This study also examined the role of training on OMS’ perceptions and practices regarding the management of tobacco use and dependence.

	SUBJECTS AND METHODS

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION CONCLUSION References

 
Participants. In 2003, we contacted members (N = 5,234) of the American Association of Oral Maxillofacial Surgeons (AAOMS) by mail to participate in this study. AAOMS represents 90 percent of practicing OMS in the United States.

Survey measure. The survey was a 38-item, two-page questionnaire printed in the Scantron format (Scantron, Irvine, Calif.) based on previously used and validated instruments.^19,30 The questionnaire gathered information about age, sex and ethnicity, as well as tobacco-use background, knowledge, attitudes and practice-related behaviors. We assessed perceived role with three items rated on a five-point scale ranging from "not at all" to a "great extent." We assessed perceived effectiveness of treatment with two items rated on a five-point scale ranging from "not at all effective" to "very effective." In addition, we assessed intervention behaviors with 14 items rated on a four-point scale that addressed the proportion of tobacco-using patients provided with various intervention components ranging from "none" to "all." We assessed perceived barriers with eight items rated on a four-point scale ranging from "strongly disagree" to "strongly agree." Finally, we assessed self-efficacy with four items rated on a five-point scale ranging from "not at all confident" to "very confident." The response sets were Likert-type scales that began with 1 = "not at all," "none" or "strongly agree" and ended with 4 = "strongly disagree" or 5 = "great extent," "very effective" or "very confident."

Procedure. The institutional review board at the University of Mississippi Medical Center, Jackson, approved this study. We mailed dental providers a cover letter explaining the purpose of the study, the survey instrument and a stamped return envelope. We placed no identifying information on the questionnaire or in the study database. We assigned a code to each provider, which was placed on the survey. As surveys were returned, we deleted all corresponding information in the mailing database to ensure that those who responded did not receive additional mailings and could no longer be identified. We made two attempts to solicit surveys during a three-week period.

Data analysis. We conducted data analysis by using statistical software (SPSS version 12, SPSS, Chicago).³¹ We conducted descriptive analyses of all survey items. To improve the clarity of our findings, we collapsed some response categories: we combined "great extent" and "considerable extent" into "great or considerable extent," "very effective" and "quite effective" became "very or quite effective," "most" and "all" became "most or all," "strongly agree" and "agree" became "strongly agree or agree" and "very confident" and "quite confident" became "very or quite confident."

The prediction analysis used forced-entry logistic regression to predict a dichotomous category of frequency of intervening (0 to 50 percent or 51 to 100 percent). We entered sex, ethnicity (white or nonwhite), training (yes or no), awareness of PHS guideline (yes or no), tobacco-use status (current, former, never), region (Mid-Atlantic, Midwest, Northeast, South, Southwest and West), years in practice and age as factors or covariates into the model. We considered a factor or covariate to be significant if the –2 log-likelihood ² ratio test P value was less than .05. We used follow-up one-way analyses of variance (ANOVAs) and follow-up Pearson ² analyses with standardized residuals (R) to identify sources of significant differences:

	RESULTS

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION CONCLUSION References

 
Respondent sample characteristics and general knowledge. Overall, 2,740 (52.4 percent) of the 5,234 survey recipients responded; 96.5 percent of them were men, 91.9 percent were white and 97.9 percent did not use tobacco. The mean age of respondents was 56.0 years (standard deviation [SD] = 8.7 years), and the mean number of years in practice was 19.6 (SD = 10.5 years). Respondents were from all 50 states and the District of Columbia and were well-distributed across the six regions of the country: Mid-Atlantic (12.4 percent), Midwest (21.8 percent), Northeast (19.8 percent), South (19.4 percent), Southwest (10.7 percent) and West (16.0 percent).

Only 21.9 percent of respondents reported that they assisted tobacco-using patients at least 51 percent of the time; 14.5 percent reported having an awareness of the PHS clinical practice guideline; and 8.7 percent reported having received training in treating tobacco use and dependence.

Provider attitudes and behaviors. Perceived role. Approximately one-third (36.8 percent) of respondents indicated that it was their role to assist patients in quitting, and 24.5 percent indicated that it was their role to assist patients in remaining abstinent ("stay quit") to a great or considerable extent.

Perceived effectiveness. Few respondents perceived that treatment for tobacco use and dependence was effective. Only 18.0 percent indicated that counseling to stop tobacco use was "very or quite effective," and 10.6 percent indicated that counseling patients to remain abstinent ("stay quit") was "very or quite effective."

Intervention behaviors. Although 90.1 percent of respondents asked their patients about and documented tobacco use most or all of the time, only 63.3 percent advised tobacco users to quit, 40.3 percent assessed patients’ interest in quitting and 36.7 percent addressed cessation with uninterested patients most of the time. Less than 15 percent of respondents provided any substantial assistance with any one of the following most of the time:

– developing strategies to prevent relapse;

– educational materials;

– counseling;

– prescribing tobacco-use cessation medication.

About 15 percent of respondents arranged for referrals for appropriate services most or all of the time. Table 1 provides the details.

Trained versus untrained providers. Respondents with formal training in providing treatment for tobacco dependence were more likely than respondents without training to report that they counsel at least 51 percent of their patients (²₃ = 63.13, P < .01 [n = 2,524]) (Figure 1); to view their role as including assisting patients to quit (²₄ = 37.95, P < .01 [n = 2,559]) (Figure 2); to agree less frequently that tobacco-use treatment services were not part of their professional responsibilities (²₃ = 62.23, P < .01 [n = 2,525]) (Figure 3, page 1649); to agree that patients desire treatment services (²₃ = 22.04, P < .01 [n = 2,512]) (Figure 4, page 1649); to view counseling to be more effective (²₄ = 23.59, P < .01 [n = 2,558]; 26.5 percent trained versus 17.0 percent untrained answered "very or quite effective"); and to express greater self-efficacy in their ability to assist patients in quitting (²₄ = 127.17, P < .01 [n = 2,552]; 45.8 percent trained versus 17.0 percent untrained feel "very or quite confident"). OMS with training also were much more likely to be aware of the PHS Clinical Practice Guideline (²₁ = 203.23, P < .01 [n = 2,515]; 27.7 percent trained versus 5.1 percent untrained).

View larger version (46K): [in this window] [in a new window]   Figure 1. Frequency with which trained and untrained providers assist at least 51 percent of tobacco users (in response to the question, "What percentage of tobacco-using patients do you currently assist with cessation or encourage to stay off tobacco?").

View larger version (47K): [in this window] [in a new window]   Figure 2. Frequency with which trained and untrained providers reported that it is their role to assist patients to a great or considerable extent (in response to the question, "To what extent is it your role as an oral and maxillofacial surgeon to assist patients to stop using tobacco?").

View larger version (46K): [in this window] [in a new window]   Figure 3. Frequency with which trained and untrained providers agreed that treatment for tobacco dependence is not part of one’s professional responsibilities (in response to the statement, "I do not see providing tobacco-use cessation services as part of my job.").

View larger version (46K): [in this window] [in a new window]   Figure 4. Frequency with which trained and untrained providers agreed that patients desire treatment for tobacco dependence (in response to the statement, "Most patients want to be provided with tobacco-use cessation services.").

Prediction analysis. The results of the logistic regression likelihood ratio test revealed sex (P = .049), training (P < .001) and tobacco-use status (P < .001) to significantly predict frequency of providing tobacco-use interventions. Ethnicity (P = .264), awareness of the PHS guideline (P = .806), region of the country (P = .229), years in practice (P = .264) and age (P = .914) did not account for a significant proportion of the variance. Female OMS were more likely to assist at least 51 percent of patients (²₁ = 6.84, P < .01 [n = 2,250]; 33.0 percent of women versus 21.4 percent of men). OMS with training were more likely to assist at least 51 percent of patients (²₁ = 40.68, P < .01 [n = 2,524]; 39.2 percent with training versus 20.2 percent without training) (Figure 1). OMS who currently used tobacco were less likely to provide treatment services to at least 51 percent of patients (²₂ = 12.94, P < .01 [n = 2,533]); 1.9 percent of current users, 21.6 percent of former users and 22.3 percent of never users provided treatment.

Given the above relationships, we conducted additional analyses to ascertain relationships between training, sex and tobacco-use status. ² analyses revealed that women were more likely to have received training (²₁ = 8.90, P < .01 [n = 2,551]; 17.4 percent of women versus 8.3 percent of men) and former tobacco users were less likely to have received training (²₂ = 9.88, P < .01 [n = 2,533]; 9.2 percent of never users, 5.1 percent of former users and 7.4 percent of current users). Sex was unrelated to tobacco-use status (²₁ = 1.82, P = .40 [n = 2,576]). ANOVAS revealed that OMS with training were significantly younger (F_1,2446 = 16.236, P < .001) and had fewer years in practice (F_1,2531) = 38.62, P < .001) than OMS without training. The mean age of OMS with training was 48.6 years versus 51.2 years for those without training. The mean number of years in practice for OMS with training was 15.5 versus 20.0 for those without training.

	DISCUSSION

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION CONCLUSION References

 
To our knowledge, this is the first comprehensive examination of tobacco-use–related knowledge, attitudes and intervention behaviors among OMS in the United States. This sample of OMS respondents likely is representative of practicing OMS. The AAOMS membership encompasses 90 percent of all practicing OMS in the country. Respondents were comparable in terms of sex distribution (3.5 percent of members were female versus 4.0 percent of respondents).³² All six regions in the United States also were well-represented. With 52 percent of the AAOMS membership responding, this sample is one of the largest groups of dental providers responding to a survey about tobacco-use practices to date.

The vast majority of OMS (90.1 percent) appear to ask about and document tobacco use most of the time. OMS appear to be doing an exemplary job of identifying tobacco users, similar to periodontists.^16,21 In contrast, general practitioners appear to ask patients much less frequently (33 to 45 percent).^17–20 Similar to the national sample,¹⁶ 63.3 percent of OMS in our study advise tobacco users to quit most of the time. OMS appear to assist tobacco-using patients about as frequently as do general practitioners, but less frequently than do periodontists.¹⁶ The content of the assistance OMS provide is less than adequate, with less than 15 percent providing any substantial assistance with any one intervention, including the following:

– developing strategies to prevent relapse;

– educational materials;

– counseling;

– prescribing tobacco-use cessation medication.

Given the impact of tobacco use on wound healing, as well as the other serious health sequelae they are likely to encounter, OMS may have a heightened awareness of tobacco use by their patients, and thus do an exemplary job of identifying tobacco users. However, OMS, like other dentists, appear to provide little in the way of intervention assistance.

In general, health care providers ask and advise more frequently than they assess, assist and arrange.^6,14 Although the pattern for OMS is similar, the frequency of interventions conducted by OMS appears to drop precipitously after advise. As voiced by many others,^16,17,24 this pattern is a significant concern in that it is likely to yield much lower patient quit and abstinence rates than are possible.

Dental providers report a number of negative attitudes toward discussing tobacco use with patients, including that the discussions are too time-consuming, they lacked confidence in their ability to convey this information, the discussions are outside their responsibilities, and discussions intrude on patients’ privacy or are otherwise inappropriate.^19,21,24 OMS endorse similar concerns, but at a higher frequency than that reported by other dental providers. For OMS, as with other health care providers, training and awareness of the PHS guideline were associated with reports of fewer perceived barriers and increased self-efficacy, as well as viewing the topic as part of a needed and appreciated discussion between provider and patient.²⁷

In our study, only 8.7 percent of OMS reported having received any training in treating patients who used tobacco, a figure that is lower than that typically cited for other provider populations.^7,19,24 Not surprisingly, awareness of the PHS guideline (at 14.5 percent) was related strongly to training. Although awareness of the PHS guideline alone was not significantly associated with a higher frequency of providing interventions, it was associated with a higher perceived effectiveness with regard to treating patients who used tobacco and with viewing the provision of these services as part of one’s responsibilities. Thus, efforts to increase awareness of the PHS guideline for OMS and for all dental providers appear worthwhile. Perhaps with awareness of the PHS guideline may come a greater likelihood of seeking training.

Training. OMS with training were remarkably different from those without training (Figures 1 through 4). They were nearly twice as likely to assist 51 percent or more of their patients; more than one-third more likely to view cessation services as part of their professional role; nearly 50 percent more likely to agree that patients desire treatment for tobacco use; more than twice as likely to express greater self-efficacy; and more likely to view counseling as being more effective. OMS without training were nearly twice as likely to view cessation services as being outside of their professional responsibilities. Clearly, training is strongly associated with the likelihood of OMS’ providing treatment for tobacco use and dependence.

The findings from the logistic regression indicate that sex, training and tobacco-use status predicted OMS’ provision of services. Women were more likely to provide interventions and were more likely to have had training; however, with just 17.4 percent of women (as opposed to 8.7 percent of OMS overall) reporting having received formal training, the rate for women still is lower than that for the national sample of periodontists and most other health care providers.^7,16,19 Similar to other providers, OMS who currently used tobacco were much less likely to provide interventions, regardless of other factors.^19,22 It is interesting to point out that younger OMS and those with fewer years of practice were more likely to have received training, suggesting a cohort effect, a more recent increase in the availability of training in treating patients with tobacco dependence or both during early career development.

Across studies, dental providers were less likely to have received training in treating patients who use tobacco, were less likely to provide treatment for tobacco use, and indicated more perceived barriers and lower levels of perceived effectiveness and self-efficacy than did physicians and nurses.^19,22 However, 71.4 percent of OMS in our study expressed a willingness to learn more about how to better provide treatment for tobacco use, despite the fact that only 28.3 percent agreed that most patients desired such services. This suggests that OMS may readily take advantage of training opportunities.

Considerable attention has been paid to training providers in tobacco-use cessation interventions, and substantial evidence in the literature suggests that such training is associated with positive changes in provider behaviors.^{16,19,22,25–29,33,34} The results of this study are consistent with those in the literature in that regard. However, we must be mindful that these data are correlational in nature, and, thus, we cannot assume direct evidence for causal relationships. Nevertheless, this investigation suggests strongly that training OMS in the treatment of patients who use tobacco is likely to be well-received and have a desirable effect.

Study limitations. This study yielded a significant response rate with evidence of representativeness from a large sample of practitioners. Nevertheless, respondents may have had more interest in tobacco use and its treatment than did nonrespondents; had fewer demands on their time; had stronger concerns about tobacco use; been more likely to have received training; and been more likely to perform tobacco-use interventions. If so, we might accept these results somewhat tentatively.

A second limitation concerns the lack of detail regarding the type of training received. Training opportunities range from distance learning to intensive workshops, and greater specification may have yielded clearer findings regarding the relationship between training and intervention behaviors.

	CONCLUSION

TOP ABSTRACT SUBJECTS AND METHODS RESULTS DISCUSSION CONCLUSION References

 
These findings indicate that similar to other dentists, OMS are appropriately concerned about their patients’ tobacco use. OMS are identifying tobacco users at a greater frequency than are many other dental providers. Understanding how OMS accomplish this may provide important motivational or procedural information for the general practice of dentistry. However, OMS are not advising, assessing, assisting or arranging for follow-up at adequate levels, despite the fact that tobacco use directly affects many of their patients’ outcomes. Understanding the barriers to engaging in these interventions also may serve to inform the general practice of dentistry.

The vast majority of OMS in this study expressed a desire to increase their proficiency in providing treatment for tobacco use and dependence. The low frequency with which OMS engage in such treatment combined with the fact that those with training intervene more often highlights the need to increase awareness and availability of targeted training opportunities for dental students, OMS residents, OMS and all dentists and other dental providers. Younger practitioners appear to be more likely to have received training, indicating that perhaps the process of training dentists in dental school or in residency is having an impact. Efforts to provide training experiences for dentists are critical to achieving continued progress in reducing the prevalence of tobacco-related disease in our society.