Colorado Dental Practitioners’ Attitudes and Practices Regarding Tobacco-Use Prevention Activities for 8- Through 12-Year-Old Patients
Kelly R. Kast, MSPH,
Rob Berg, DDS, MPH, MS, MA,
Ann Deas, MSPH,
Dennis Lezotte, PhD and
Lori A. Crane, PhD, MPH
 |
ABSTRACT
|
|---|
Background. Tobacco use is a leading risk factor for oral morbidities and mortalities such as oral cancers and periodontitis. This study characterizes the factors related to dentists and hygienists conducting tobacco-use prevention counseling with 8- through 12-year-old patients.
Methods. The study used a mailed survey of dentists (n = 434), orthodontists (n = 91) and hygienists (n = 160) practicing in Colorado to collect data on the practitioners’ tobacco-use prevention counseling activity, demographic characteristics, barriers to counseling and attitudes toward tobacco use. The authors used multiple logistic regression to determine which variables were associated independently with a dental practitioner’s counseling children.
Results. The response rate was 25.6 percent. Prevalence of tobacco-use prevention counseling for children was low (38 percent for dentists and 44 percent for hygienists). Among dentists, the perception of tobacco use in children as a problem, perceived effectiveness of counseling and perceived role of a dental practitioner in counseling children were associated positively with counseling. Lack of skills was associated negatively with counseling. Among hygienists, perceived role in counseling children was associated positively and lack of time was associated negatively with counseling.
Conclusions. Few dental practitioners counsel 8- through 12-year-old patients about tobacco use. Factors related to counseling appear to be amenable to education of dentists, in particular, regarding the importance of the problem, the effectiveness of counseling and skill development.
Clinical Implications. Preventing tobacco use among children is integral to promoting patients’ oral health. Training dentists through continuing education should increase the frequency of tobacco-use prevention counseling with children by both dentists and hygienists.
Key Words: Tobacco-use prevention; children; adolescents; surveyAbbreviations: ADA: American Dental Association. • HONC: Hooked On Nicotine Checklist.
The American Dental Association (ADA) urges dentists to maintain a knowledge base that will allow them to recognize nicotine use by their adolescent patients and to engage in primary prevention of this use.1 On the basis of data from the 2002–2004 National Survey on Drug Use and Health, researchers estimated that 12.3 percent of U.S. adolescents aged 12 to 17 years have smoked one or more cigarettes in the past month.2 Two questions in that survey were designed to measure whether nonsmokers would smoke a cigarette if offered and the likelihood of whether they would smoke a cigarette in the next 12 months. Overall, 22.2 percent of those who had never smoked were considered susceptible to start smoking cigarettes.
Findings from the National Longitudinal Survey of Youth indicated that in 1998, the mean age of first smoking a cigarette was 13.7 (standard deviation, 2.41) years.3 A study based on a series of interviews done from 1998 to 2000 with 164 Massachusetts adolescents aged 11 to 15 years who had used cigarettes at least twice identified the early or intermittent stage of smoking as the most effective time for prevention interventions.4 In that study, the investigators used a measure called the Hooked On Nicotine Checklist (HONC) to assess nicotine dependence. Among those who eventually became nicotine-dependent according to the results of HONC, the pattern of tobacco use changed dramatically after the subject reported one or more symptoms from the checklist for dependency. Before reporting a symptom of dependency, 31 percent of the study participants reported smoking at least daily for at least 30 days. Subesquent to reporting the first symptom of dependency, 48 percent of the subjects smoked at least daily for at least 30 days.
Evidence from a meta-analysis indicated that smoking cessation counseling for adolescents has been effective, increasing quit rates by approximately 46 percent.5 However, a recent literature review6 indicated that school-based, time-intensive interventions based on cognitive-behavioral counseling principles achieved the best results, but that these interventions may not be feasible for primary care clinicians. With regard to counseling to prevent initiation of smoking by adolescents, a survey of physicians in New York reported that care practices such as longer office visits and time spent alone with the adolescent patient were associated with greater likelihood of providing smoking prevention counseling.7 A review of smoking prevention interventions by health care providers suggested that their effectiveness also depends greatly on the nature and quality of the effort.8 That author recommended that clinician interventions begin in early adolescence, during the period of highest susceptibility to peer influence. Content should be age- and culture-appropriate, delivered in multiple settings and repeated periodically. In a state-of-the-science conference statement, the National Institutes of Health made broad recommendations regarding this issue, placing high priority on comprehensive, statewide and school-based interventions to prevent adolescents from beginning to smoke.9
Hovell and colleagues10,11 conducted a multisite study in orthodontic offices in southern California to assess the effectiveness of a model for prevention of tobacco use among adolescents called "SMILES PLUS." In this program, the investigators instructed clinicians to give a written "prescription," a preprinted summary of one of eight topics, to each adolescent patient at a "teachable moment" during an office visit. The clinician used the prescription as the focus for a brief discussion with the patient. The investigators noted a reduction (although not statistically significant) in the percentage of adolescents initiating smoking for the group receiving the prescriptions.
The "5 As" model, proposed in 1994 and updated in 2000, is a five-step process for use by clinicians in counseling patients about tobacco use.12 A modification of the 5 As model specifically for adolescents has been published subsequently.13,14 It recommends identification of all tobacco use and exposures for adolescent patients and emphasizes anticipatory and preventive intervention. Carrying out this program reportedly requires three to five minutes per patient, and the accompanying guidelines emphasize the need for persistence.
Unfortunately, only 9 percent of adolescents in a large survey conducted in Minnesota reported that their dentist or dental hygienist had discussed smoking with them.15 However, among respondents who admitted on a health history that they smoked, 25 percent reported having had such a discussion. In the 2000 National Youth Tobacco Survey, 20 percent of adolescents reported that a dentist had provided them with preventive counseling about the dangers of tobacco use.16 Results from one survey of dentists17 showed that 32 percent provided tobacco-use prevention counseling to adolescent patients, and results from another study18 showed that 14 percent of dentists "always" or "frequently" counseled 10- to 12-year-old patients about tobacco use. A national survey of orthodontists19 found that one-half reported asking their adolescent patients if they used tobacco. Of these, 70 percent (roughly one-third of all orthodontists surveyed) reported providing advice and education on tobacco and health. In a survey of pediatric dentists, 21 percent said they believed that smoking cessation counseling by their profession would be "quite" or "very" effective, and 34 percent said they believed that smoking prevention counseling would be "quite" or "very" effective.20 Barriers to providing such counseling included perceived deficits in knowledge about smoking risk for children and adolescents, deficits in skills for providing counseling intervention, concerns about appropriateness of the counseling role, discomfort with providing counseling services and reimbursement issues.
In view of the consensus that health care professionals should undertake tobacco-use prevention efforts in primary care settings, it continues to be important for dental professionals to assess their role in this area. Since initial smoking and nicotine dependence occur at an early age, it is imperative that clinicians provide effective prevention education to children and adolescents. Our study focused on children aged 8 through 12 years, assessing the self-reported frequency of tobacco-use prevention counseling for children in a sample of dentists, orthodontists and hygienists.
|
MATERIALS AND METHODS
|
|---|
Survey population, materials and methods.
We collected data through a mailed survey of dentists, orthodontists and hygienists actively practicing in Colorado to assess practitioners’ tobacco-use prevention counseling activity with 8- through 12-year-old patients. The questionnaire was an 8.5-inch-by-11-inch paper booklet. We asked practitioners to answer questions related to their demographic characteristics, barriers to counseling and attitudes toward tobacco use and tobacco-use prevention counseling. The survey content drew on published literature related to tobacco-use prevention counseling and input from focus groups of dentists, hygienists and orthodontists. We conducted a pilot test of the questionnaire with a small random sample of dentists and hygienists before administering it to the full sample.
The Colorado Dental Association provided a member list, which we used to identify general dentists, pediatric dentists and orthodontists. Expecting a response rate of 60 percent and estimating that 400 completed surveys would provide adequate statistical power to estimate current attitudes and practices (95 percent confidence interval of ± 5 percentage points), we randomly sampled 667 of the 1,726 pediatric and general dentists on the list. We included all 162 orthodontists on the Colorado list in the sample. To select hygienists, we obtained the State of Colorado’s licensing list for dental hygienists and randomly sampled 333 of the 2,142 hygienists with the goal of receiving 200 completed questionnaires (95 percent confidence interval of ± 7 percentage points). (This sample size affords the power to detect statistically significant differences.)
We sent three mailings of the questionnaire beginning in February 2001, with the final mailing sent in April 2001. We sent a reminder postcard between the second and third mailings. In addition, we included a self-addressed, stamped postcard for respondents to return separately when they returned the questionnaire so researchers could track who had returned the questionnaire while maintaining the anonymity of responses to the survey.
Variables.
The outcome variable we assessed was the dental practitioners’ current tobacco-use prevention counseling activity with 8- through 12-year-old patients. This variable incorporates responses from two questionnaire items. These items asked respondents to estimate the percentage of patients whom they counseled not to start using tobacco in the last year who were aged 8 through 10 years and aged 11 or 12 years. The five-item response scale ranged from "0 percent (none)" to "76–100 percent." We considered respondents who provided an answer greater than "0 percent (none)" to either of the two questions as providing counseling to 8- through 12-year-olds about tobacco-use prevention. We considered those who responded "0 percent (none)" to both questions as not providing prevention counseling.
We assessed the following predictor variables for dental practitioners:
- – perceived barriers to tobacco-use prevention counseling (lack of time, lack of reimbursement, lack of training, fear of offending patient or family, and difficulty integrating counseling into practice);
- – attitudes toward conducting tobacco-use prevention counseling (perceptions of the extent of the problem of tobacco use among children, the relevancy of providing prevention counseling to children, difficulty of tobacco-use cessation, effectiveness of prevention counseling, better places for tobacco-use prevention counseling than a dental office and their role in providing prevention counseling);
- – demographic characteristics, including age, sex, percentage of 8- through 12-year-old patients, practice type (that is, solo or group), practice location (that is, metropolitan area, medium-sized city, small town or rural area) and personal use of cigarettes.
For select variables, we created additive scales, which grouped questionnaire responses of related questions into a single variable (Table 1
). To create the scales, we added the responses to questionnaire items and then divided the sum by the number of items in the scale. We assessed the appropriateness of these additive scales through reliability analysis by using Cronbach 
, which ranged from 0.71 to 0.85.
Analysis.
We used commercially available software (SAS, Version 9.1, SAS Institute, Cary, N.C.) to analyze the survey responses. We analyzed the responses of dentists and hygienists separately. We combined responses from general dentists, pediatric dentists and orthodontists because all have doctoral dentistry degrees and tend to have similar roles within their respective practices. To assess potential differences between general or pediatric dentists and orthodontists, we included specialty as a variable within the analysis. We used 
2 and t test analyses to assess bivariate relationships between the predictor variables and tobacco-use prevention counseling. P < .05 indicated statistical significance.
We used multiple logistic regression to determine which variables were associated independently with a dental practitioner’s counseling 8- through 12-year-old patients about preventing tobacco use. The initial model included all variables associated with tobacco-use prevention counseling at the P 
.20 level as determined by means of bivariate analysis. We selected the final model variables by using a manual approach in which we removed the least significant variables until all variables remaining in the model either were significant at the P .05 level or could be considered confounders. We considered a variable a confounder if its removal changed either the direction of the relationship of any remaining variables or the odds ratio of any remaining variable by 20 percent or more.
|
RESULTS
|
|---|
Study sample.
The overall response rate was 63.7 percent (740 of 1,162); the pediatric/general dentist response rate was 68.3 percent (456 of 667), the orthodontist response rate was 59.3 percent (96 of 162) and the hygienist response rate was 56.5 percent (188 of 333). Thirty-one of 740 respondents (4.2 percent) did not meet inclusion criteria because they did not treat children (n = 29) or their specialty was outside the focus of this analysis (oral and maxillofacial surgeon, n = 1; dental assistant, n = 1). We excluded questionnaires on which respondents did not answer the questions related to the outcome variable (24 of 740, 3.2 percent). In the final analysis, we used responses from 685 participants (434 dentists, 91 orthodontists and 160 hygienists).
Most dentists and hygienists estimated that more than 5 percent of their entire patient population consisted of 8- through 12-year-olds. In addition, most members of both groups were younger than 55 years and practiced in a solo practice. Most dentists were men, whereas most hygienists were women. Only a small percentage of dentists (1.3 percent, seven of 522) and hygienists (7.5 percent, 12 of 160) reported that they currently used cigarettes. One hundred one (19.3 percent) dentists and 25 (15.6 percent) hygienists reported they formerly used cigarettes (Table 2).
Tobacco-use prevention counseling.
Thirty-eight percent of dentists (198 of 525) and 44 percent of hygienists (70 of 160) indicated they counseled their 8- through 12-year-old patients about preventing tobacco use at least 1 percent of the time. Of those who counseled, most reported doing so only 1 to 25 percent of the time; counseling was more frequent for 11- to 12-year-olds than for 8- to 10-year-olds (Table 3).
View this table:
[in this window]
[in a new window]
|
TABLE 3 Frequency of tobacco-use prevention counseling among dentists and hygienists for 8- to 10- and 11- to 12-year-old patients.
| |
The questionnaire asked respondents to estimate the percentage of time they included certain topics such as "tobacco use is a bad habit" or "using tobacco is unattractive" when counseling their 8-through 12-year-old patients about tobacco use. Responses ranged from "0 percent (never)" to "76 percent-100 percent" on a five-point scale. The figure shows the percentages of hygienists and dentists (of those who responded to the question) who indicated they included a topic 76 to 100 percent of the time.
View larger version (60K):
[in this window]
[in a new window]
|
Figure. Strategies that dentists and hygienists use more than 75 percent of the time when counseling patients aged 8 through 12 years to prevent tobacco use (self-report).
| |
Barriers and attitudes regarding tobacco-use prevention counseling.
The barriers to providing prevention counseling identified by the greatest percentage of dentists were the difficulty of integrating counseling into practice (37.9 percent, 194 of 512) followed by lack of reimbursement (31.5 percent, 163 of 517). For hygienists, the greatest barriers to providing tobacco-use prevention counseling were the difficulty of integrating counseling into practice (47.1 percent, 74 of 157) followed by lack of skills (23.1 percent, 37 of 160). Dentists and hygienists who reported lack of skills, lack of time and fear of offending patients as barriers were significantly less likely to counsel (Table 4, page 473). For dentists only, those who reported the difficulty of integrating counseling into practice also were significantly less likely to counsel (Table 4).
View this table:
[in this window]
[in a new window]
|
TABLE 4 Percentage of dentists and hygienists reporting selected barriers to and attitudes toward tobacco-use prevention counseling by level of counseling activity.
| |
Only a small percentage of dentists and hygienists thought that tobacco-use prevention counseling was not relevant to children (Table 4
). In fact, most in both groups agreed it was their role to provide prevention counseling. Most hygienists (52.9 percent, 83 of 157) also agreed tobacco-use prevention counseling provided by themselves or other dental practitioners was at least moderately effective, whereas fewer dentists (42.1 percent, 219 of 520) agreed with this statement. Approximately one-half of both dentists and hygienists agreed children already know they should not use tobacco, and most in both groups estimated that less than 10 percent of their 8-through 12-year-old patients had used or experimented with tobacco. Most of these attitudes were related significantly to counseling for dentists. Among hygienists, the belief that there are better places to counsel, that it is their role to counsel and that counseling is effective were related significantly to counseling.
Multivariate analyses of factors associated with conducting tobacco-use prevention counseling.
Among dentists, four factors were associated significantly with counseling children about preventing tobacco use in the multivariate analysis. Positively associated with tobacco-use prevention counseling were the perception that tobacco use in children is a problem, the perceived effectiveness of such counseling and the perception that it is a dental practitioner’s role to counsel children. Lack of skills was associated negatively with dentists’ counseling children about tobacco-use prevention. The dentist’s specialty (general/pediatric dentist or orthodontist) did not contribute significantly to prevention counseling. Two factors were associated significantly with hygienists’ counseling children about preventing tobacco use—the perception that it is a dental practitioner’s role to counsel children was associated positively with prevention counseling and lack of time was associated negatively with prevention counseling. Lack of skills remained in the model even though it was not related significantly to tobacco-use prevention counseling, as it appeared to confound the "lack of time" factor (Table 5, page 474). Note that the responses to the factors identified in both models are in ordinal scales. Therefore, the odds reported in Table 5 are associated with a one-step movement on the scale. For example, for every one-point increase in agreement that it is the practitioner’s role to provide tobacco-use prevention counseling (for example, from "agree" to "strongly agree"), the odds of providing tobacco-use prevention counseling increase twofold for hygienists.
View this table:
[in this window]
[in a new window]
|
TABLE 5 Odds ratios and confidence intervals of separate multivariate models predicting tobacco-use prevention counseling for dentists and hygienists.
| |
|
DISCUSSION
|
|---|
Tobacco use is recognized widely as the single most preventable cause of premature death in the United States.21 Decisions to use tobacco affect a person’s oral health in addition to his or her overall health. Therefore, the ADA encourages dental practitioners to play a role in tobacco-use prevention and cessation activities,22 and the editor of The Journal of the American Dental Association has stated that conducting smoking-cessation activities no longer should be a choice.23 Yet studies have shown that few dental practitioners regularly conduct smoking-cessation activities24,25 or prevention counseling.16–18 The results of our study reflect the findings of other studies that a minority of dental practitioners conduct tobacco-use prevention counseling with 8- through 12-year-old patients and show that multiple factors are related to whether dentists and hygienists counsel children about preventing tobacco use. These factors, which are different for dentists and hygienists, lay a foundation from which to increase the frequency of tobacco-use prevention counseling in the dental office.
For hygienists, lack of time was the factor most strongly related to lack of counseling children to prevent tobacco use. Time can be viewed as a reflection of actual time spent with patients, as well as time pressures related to seeing a certain number of patients throughout the day. Crawford and colleagues26 examined the time pressures described by hygienists and found that lack of control over the day’s schedule, time per patient and number of patients per day contributed to pressures related to time. As the control over schedule often is set by dentists as the business owners, dentists could play a role in influencing time pressures faced by hygienists. In addition, the second factor related to a hygienist providing tobacco-use prevention counseling—the hygienist’s perception of his or her role with respect to prevention counseling—also could be influenced by the dentist as the business owner. We speculate that when hygienists work in an office environment supportive of tobacco-use prevention counseling, they might be more likely to view conducting prevention counseling as part of their role. These study findings suggest that the impetus to increasing the tobacco-use prevention counseling activities of hygienists is to first address the attitudes and barriers perceived by dentists to influence prevention counseling activity so that they encourage an atmosphere conducive to such counseling.
The factor most strongly related to a dentist counseling children about avoiding tobacco use is the perceived barrier of lacking the skills to do so. This barrier can be addressed readily by establishing training programs such as live and Web-based continuing education courses. In the SMILES PLUS program, Hovell and colleagues11 showed that by providing training to orthodontists by using National Cancer Institute training guidelines, orthodontists were more likely to provide tobacco-use prevention counseling than were their counterparts who did not receive training.
The content of a training program should incorporate the remaining factors identified through our analysis—the degree of tobacco use among children, the effectiveness of tobacco-use prevention counseling and the emphasis on why it is the dentist’s role to counsel children about preventing tobacco use. The dentist’s perception of tobacco use among children is the second most significant factor related to whether a dentist conducts tobacco-use prevention counseling. Children and adolescents use tobacco, and the smoking activities of children play a major role in whether they become smokers in adulthood.27 Results from the 2003 Youth Risk Behavior Survey conducted by the U.S. Centers for Disease Control and Prevention indicated that 22 percent of high school students were smokers and 10 percent were frequent smokers.28 In addition, the 2003 National Survey on Drug Use and Health, conducted by the Substance Abuse and Mental Health Services Administration, classified an estimated 35.7 million Americans aged 12 or older as nicotine dependent in the past month because of their cigarette use.29 Including information about the ages at which children and adolescents first experiment with tobacco and information about the need to prevent smoking in adolescence are key components of a tobacco-use prevention counseling training program for dentists.
Dentists’ perception of the effectiveness of tobacco-use prevention counseling also is related to counseling activity. A Cochrane Review of controlled trials found that medical practitioners increased the odds of quitting among patients when they provided smoking cessation advice compared with results if they provided no advice.30 For dental practitioners in particular, a Cochrane Review found tobacco abstinence rates increased among smokeless tobacco users when cessation interventions were conducted in the dental office.31 In addition, a randomized controlled trial involving 50 dentists and their staff members showed a significant increase in the number of patients who quit smoking after one year in the treatment arm of their study.32 Investigators in few studies, however, have examined the effectiveness of interventions to prevent tobacco use among children or adolescents.8 We identified one study that examined the effectiveness of orthodontists in preventing tobacco use among adolescents; results showed that two years after the intervention, the tobacco use incidence in adolescents seeking care from the control group orthodontists was 12.6 percent compared with 12.0 percent in adolescents seeking care from orthodontists in the intervention group (nonsignificant).10 Even though there is a lack of definitive evidence of effectiveness, a training program for dental practitioners could stress the success of tobacco-use cessation counseling provided by dental practitioners as well as successful prevention counseling protocols used in other settings.
The final factor related to a dentist’s counseling children to prevent tobacco use is the perception of whether it is the dentist’s role to provide counseling. Because tobacco use is associated with oral cancer, periodontitis and other oral morbidities,33 addressing tobacco use is integral to promoting the oral health of patients. Future training programs should include information regarding tobacco use and its effect on oral health.
One limitation of this study is the nature of self-reported data, because survey respondents tend to overestimate behaviors that are believed to be "socially desirable."34 However, although it is likely that respondents to our survey overestimated the frequency with which they counsel patients, their reported frequency of counseling relative to each other likely is accurate, and, thus, our findings regarding predictors of counseling are likely to be valid.
|
CONCLUSION
|
|---|
Most dentists and hygienists in this study did not counsel 8- through 12-year-old children to prevent tobacco use. To increase tobacco-use prevention counseling within dental practices, the profession should emphasize addressing dentists’ attitudes and barriers regarding counseling to prevent tobacco use. Enhancing and encouraging tobacco-use prevention curricula that stress the incidence and prevalence of tobacco use in children and the importance of providing counseling to younger children to prevent tobacco use during adolescence, address the effectiveness of counseling in preventing children and adolescents from starting to use tobacco and demonstrate the role of dental practitioners in promoting oral health by addressing tobacco use likely would promote tobacco-use prevention counseling activity among dentists and, in turn, among hygienists. Dental educators should adopt such programs into dental education curricula and continuing education programs.
|
FOOTNOTES
|
|---|
Ms. Kast is a project coordinator, Colorado Department of Public Health and Environment, Denver.
Dr. Berg is an associate professor, Department of Applied Dentistry, School of Dental Medicine, University of Colorado Denver.
Ms. Deas is a graduate student, Five Branches University, College of Traditional Chinese Medicine, Santa Cruz, Calif.
Dr. Lezotte is a professor, Department of Preventive Medicine and Biometrics, School of Medicine, University of Colorado Denver.
Dr. Crane is an associate professor, Department of Preventive Medicine and Biometrics, School of Medicine, University of Colorado Denver, 4200 E. 9th Ave., Box B119, Denver, Colo. 80262, e-mail "Lori.Crane{at}uchsc.edu". Address reprint requests to Dr. Crane.
Disclosure: None of the authors reported any disclosures.
The authors gratefully acknowledge the contribution of Michael Diorio, DDS, for his assistance with the survey design.
|
REFERENCES
|
|---|
- American Dental Association. Current policies. Chicago: ADA; 2007.
- Centers for Disease Control and Prevention. Racial/ethnic differences among youths in cigarette smoking and susceptibility to start smoking—United States, 2002–2004. MMWR Morb Mortal Wkly Rep 2006;55:1275–1277.[Medline]
- Johnson TP, Mott JA. The reliability of self-reported age of onset of tobacco, alcohol and illicit drug use. Addiction 2001;96(8):1187–1198.[Medline]
- Wellman RJ, DiFranza JR, Savageau JA, Dussault GF. Short term patterns of early smoking acquisition. Tob Control 2004;13(3):251–257.[Abstract/Free Full Text]
- Sussman S, Sun P, Dent CW. A meta-analysis of teen cigarette smoking cessation. Health Psychol 2006;25(5):549–557.[Medline]
- McVea KL. Evidence for clinical smoking cessation for adolescents. Health Psychol 2006;25(5):558–562.[Medline]
- Klein JD, Levine LJ, Allan MJ. Delivery of smoking prevention and cessation services to adolescents. Arch Pediatr Adolesc Med 2001;155(5):597–602.[Abstract/Free Full Text]
- Krowchuk HV. Effectiveness of adolescent smoking prevention strategies. MCN Am J Matern Child Nurs 2005;30(6):366–372.[Medline]
- National Institutes of Health State-of-the-Science conference statement: tobacco use: prevention, cessation, and control. Ann Intern Med 2006;145(11):839–844.[Free Full Text]
- Hovell MF, Slymen DJ, Jones JA, et al. An adolescent tobacco-use prevention trial in orthodontic offices. Am J Public Health 1996;86(12): 1760–1766.[Abstract/Free Full Text]
- Hovell MF, Jones JA, Adams MA. The feasibility and efficacy of tobacco use prevention in orthodontics. J Dent Educ 2001;65(4):348–353.[Abstract]
- Fiore MC, 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.
- Institute for Clinical Systems Improvement. Tobacco use, prevention, and cessation for infants, children and adolescents. Bloomington, Minn.: Institute for Clinical Systems Improvement; 2004.
- Albert DA, Severson HH, Andrews JA. Tobacco use by adolescents: the role of the oral health professional in evidence-based cessation programs. Pediatr Dent 2006;28(2):177–187.[Medline]
- Hennrikus D, Rindal DB, Boyle RG, Stafne E, Lazovich D, Lando H. How well does the health history form identify adolescent smokers? JADA 2005;136(8):1113–1120.[Abstract/Free Full Text]
- Shelley D, Cantrell J, Faulkner D, Haviland L, Healton C, Messeri P. Physician and dentist tobacco use counseling and adolescent smoking behavior: results from the 2000 National Youth Tobacco Survey. Pediatrics 2005;115(3):719–725.[Abstract/Free Full Text]
- Block DE, Hutton KH, Johnson KM. Differences in tobacco assessment and intervention practices: a regional snapshot. Prevent Med 2000;30(4):282–287.[Medline]
- Gregorio DI. Counseling adolescents for smoking prevention: a survey of primary care physicians and dentists. Am J Public Health 1994;84(7):1151–1153.[Abstract/Free Full Text]
- Sears CR, Hayes C. Examining the role of the orthodontist in preventing adolescent tobacco use: a nationwide perspective. Am J Orthod Dentofacial Orthop 2005;127(2):196–199.[Medline]
- Shenkin JD, Horowitz AM, Drury TF, Kanellis M. Attitudes of pediatric dentists towards tobacco intervention for children and adolescents: a pilot survey. Pediatr Dent 2003;25(1):53–60.[Medline]
- U.S. Department of Health and Human Services. Reducing the health consequences of smoking: 25 years of progress: a report of the surgeon general. Washington: Public Health Service, Centers for Disease Control and Prevention, Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1989. DHHS publication CDC 89–8411.
- American Dental Association. ADA positions and statements: Summary of policy and recommendations regarding tobacco. "www.ada.org/prof/resources/positions/statements/tobac.asp". Accessed Feb. 5, 2008.
- Glick M. Smoking cessation: no longer a choice. JADA 2005; 136(8):1076, 1078.[Free Full Text]
- Dolan TA, McGorray SP, Grinstead-Skigen CL, Mecklenburg R. Tobacco control activities in U.S. dental practices. JADA 1997;28(12): 1669–1679.
- Jones RB, Pomrehn PR, Mecklenburg RE, Lindsay EA, Manley M, Ockene JK. The COMMIT dental model: tobacco control practices and attitudes. JADA 1993;124(9):92–104; discussion 106–108.[Medline]
- Crawford L, Gutierrez G, Harber P. Work environment and occupational health of dental hygienists: a qualitative assessment. J Occup Environ Med 2005;47(6):623–632.[Medline]
- U.S. Department of Health and Human Services. Preventing tobacco use among young people: A report for the surgeon general. Atlanta: National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 1994.
- Centers for Disease Control and Prevention (CDC). Cigarette use among high school students: United States, 1991–2003. MMWR Morb Mortal Wkly Rep 2004;53(23):499–502.[Medline]
- Substance Abuse and Mental Health Services Administration. Results from the 2003 National Survey on Drug Use and Health: National findings. Rockville, Md.: U.S. Department of Health and Human Services, Office of Applied Studies; 2004. NSDUH Series H-25, DHHS Publication SMA 04–3964.
- Lancaster T, Stead L. Physician advice for smoking cessation. Cochrane Database Syst Rev 2004;(4):CD000165.
- Carr AB, Ebbert JO. Interventions for tobacco cessation in the dental setting: the Cochrane Database Syst Rev 2006;(1):CD005084.
- Cohen SJ, Stookey GK, Katz BP, Drook CA, Christen AG. Helping smokers quit: a randomized controlled trial with private practice dentists. JADA 1989;118(1):41–45.[Abstract]
- U.S. Department of Health and Human Services. The health consequences of smoking: A report of the surgeon general. Rockville, Md.: 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; 2004.
- Sudman S, Bradburn NM. Asking threatening questions about behavior. In: Sudman S, Bradburn NM, eds. Asking Questions: A Practical Guide to Questionnaire Design. San Francisco: Jossey-Bass; 1982:54–87.
TOP
ABSTRACT
MATERIALS AND METHODS
