Tobacco Cessation kj1

Tobacco Cessation Interventions in the Dental Office
Tobacco Cessation Interventions in the Dental Office: A Review of the Literature
By
Katherine Jones
Dental Hygiene 521: Graduate Study
A Literature Review
Submitted in Partial Fulfillment of
Master of Science in Dental Hygiene
Fones School of Dental Hygiene
University of Bridgeport
Bridgeport, CT
May 2015
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Abstract
The purpose of this study is to evaluate tobacco cessation interventions in the dental office. This
research presents the risks of tobacco use and the benefits of cessation of which dental hygienists
must be aware. The study will identify the need for and advantages of implementing tobacco
cessation in the dental office setting as well as effective, evidenced-based intervention methods
to be implemented in practice. If successful, this work will help dental hygiene practitioners
modify patient behavior, reducing the number of people who use tobacco and ultimately
improving the health of numerous people.
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Table of Contents
Chapter 1
Introduction..Page 4
Statement of the Problem....Page 6
Purpose of the Study...Page 6
Significance of the StudyPage 6
Research Questions.Page 7
Definition of Terms.....Page 7
Limitations of the Study......Page 9
Delimitations of the Study..........Page 9
Chapter 2
Abstract.....Page 10
Preface...Page 11
Review of Literature.........Page 11
Chapter Introduction.....Page 11
Recommendations for Further Research..Page 37

Summary..Page 40
ReferencesPage 43
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Chapter One
Introduction
According to the Center for Disease Control (CDC), twenty million people have died
from tobacco use in the last half century. It continues to be the number one preventable cause of
morbidity and mortality in the United States. Approximately 480,000 deaths annually are due to
tobacco-related diseases and an additional 41,000 deaths are contributable to exposure to second
hand smoke. Tobacco use is associated with four of the top five causes of mortality in the United
States: heart disease, cancer, chronic lower respiratory disease and stroke. Eliminating tobacco
use would substantially decrease expenses and improve public health. These illnesses are
expensive to treat; tobacco use increases the United States economic loss by $300 billion
annually. More than 16 million Americans are living with illness related to tobacco use. Illnesses
caused by tobacco include cancer, heart disease, stroke, lung disease, diabetes and chronic
obstructive pulmonary disease, not to mention it's effect on oral health. Tobacco use remains a
public health epidemic. Currently, 19.8% of the US population reports smoking cigarettes. The
state of tobacco in the U.S. calls for intervention through the collaboration of healthcare
providers, including dental hygiene professionals. (Dept of HHS, 2014; Studts et al, 2011;
Williams, 2011)
The medical community has placed significant value on tobacco cessation as a means of
preventing systemic disease. Systemic disease occurs when a number of organs and tissues in the
body are affected by illness. Research has illuminated effective approaches to delivering tobacco
cessation intervention. Utilizing these strategies will likely reduce morbidity and mortality
related to tobacco use. Most of the reductions in mortality resulting from tobacco use in the near
future will be achieved through helping current users quit (Shelley et al, 2011). Although people
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are often educated about the health risks of tobacco use, tobacco users have been insufficiently
motivated and/or lack the tools necessary to quit using tobacco. Evidence-based strategies have
been developed to assist healthcare providers in effectively delivering tobacco cessation services
to patients. Dental hygienists can be an important part of this delivery.
There are various reasons that the dental hygiene setting is ideal for providing dental
patients with tobacco cessation services. Many dental patients use tobacco products and visit the
dentist annually; more tobacco users visit the dental office regularly for services than any other
healthcare provider. The majority of dental appointments are often spent with the dental
hygienist and the frequency of these visits is generally 2-4 times per year. The dental hygienist
has access to a patients health history, as well as their oral cavity. Not only are they are free to
incorporate the medical information to which they are privy, but dental hygienists are also able to
evaluate and inform patients of the oral manifestations of tobacco use. Tobacco cessation
services are an integral component of a comprehensive dental hygiene treatment plan. (Albert et
al, 2012; Studts et al, 2012; Williams, 2011)
Tobacco use impacts oral health negatively and quitting will improve oral health. As
healthcare providers, it is the responsibility of dental hygienists to aid patients in achieving
optimum oral health. This cannot be sufficiently achieved without cessation of tobacco products.
Still, dental hygienists often lack the skills, confidence and motivation necessary to effectively
assist their patients with tobacco cessation. This research study is of particular interest to the
dental hygiene community, as they are the ideal health professional to implement tobacco
cessation services.
Many people struggle with tobaccos addictive nature. As healthcare providers who treat
tobacco users frequently, dental hygienists have the social responsibility to improve public health
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through the delivery of evidence-based care. The dental community is supported by various
organizations working to eradicate tobacco use through research and legislation. Given the
opportunity to become knowledgeable and effective through training, hygienist develop the
ability to successfully guide patients through tobacco cessation. It is evident that large strides
have been made in eradicating tobacco use; there is still progress to be made to improve the
status of tobacco in the United States. The goal of this study is to identify the current need for
tobacco cessation intervention in the dental office and the best strategies for putting these
services into practice.
Statement of the Problem

Tobacco use is still prevalent in todays society. Although dental hygienists have the
professional responsibility of delivering tobacco cessation services to patients, evidence has
shown that they often fail to carry out this task. This study specifically seeks to investigate
tobacco cessation interventions in the dental office.
Purpose of the Research

The purpose of this research is to gather information in order to develop and implement
effective tobacco cessation training programs for dental hygienists ultimately increasing tobacco
cessation rates and improving health of the general population.
Significance of the Research

Registered Dental Hygienists working in clinical practice with patients who use tobacco
need to be educated about the importance of delivering evidence-based tobacco cessation
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services; implementing these interventions is necessary to fulfill their responsibility as an oral
care professional.
Research Questions
Specifically this study sought to answer the following:
How did tobacco use evolve in the United States?
How does tobacco cause disease?
What is the prevalence of tobacco use in the US today?
What is Tobacco Use Disorder?
What has been done to control tobacco use by the opposition?
Why is a dental practice a good setting to implement intervention strategies?
What barriers to care exist in the dental setting?
Why do people use tobacco?
What intervention strategies can be used by dental hygienists to manage tobacco use?
What can be done to prevent and detect disease caused by tobacco use?
Definitions of Terms
For the purpose of this study the following terms were defined:
Active Listening- a communication technique used in counseling, training and conflict

resolution, which requires the listener to feed back what they hear to the speaker, by way of restating or paraphrasing what they have heard in their own words
American Dental Association (ADA)- the nation's largest dental association and is the leading
source of oral health related information
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Atherosclerosis- the build-up of fatty deposit in the lining of the artery walls
Bidis- small brown cigarettes, often flavored, consisting of tobacco hand rolled in tendu or
temburni leaf and secured with a string at one end
Chewing tobacco- a type of smokeless tobacco product consumed by placing a portion of
the tobacco between the cheek and gum or upper lip teeth and chewing
Cigar- a cylinder of fermented tobacco rolled in tobacco leaves for smoking
Cigarillo- little cigars that have filters and are filled with pipe tobacco
Dissolvable Tobacco- strips, sticks, orbs and compressed tobacco lozenges finely processed to
dissolve on the tongue or in the mouth
Homeostasis - a balanced state of health
Hookah- a pipe used to smoke Shisha, a combination of tobacco and fruit or vegetable that is
heated and the smoke is filtrated through water
Keratinization
Kreteks- clove cigarettes
Leukoplakia- white patches affecting the oral mucosa
Motivational Interviewing- a directive, patient-centered counseling intervention
Nicotinic Stomatitis- a diffuse white patch on the hard palate caused by a response of the
palatal oral mucosa to chronic heat
Peripheral Artery Disease (PAD)- a condition in which the arteries of the legs are blocked and
cannot provide enough oxygen
Pipe- a reusable device specifically made to smoke tobacco comprised of a chamber, stem and
mouthpiece
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Self-efficacy- the extent or strength of one's belief in one's own ability to complete tasks and
reach goals
Snuff (tobacco)- a smokeless tobacco made from ground tobacco leaves that is inhaled into the
nasal cavity, delivering a swift 'hit' of nicotine and a lasting flavored scent
Squamous Cell Carcinoma- cancer that develops in the thin, flat squamous cells that make up
the outer layer of the skin.
Tobacco Use Disorder (TUD)- a condition characterized by the harmful consequences of
repeated tobacco use, and physiological dependence on tobacco
Limitations of the Research

This literature review is based on current, accredited resources and classic work. The
researcher had no control over study designs, methodology, instruments used, data collection,
data analysis or results.
Delimitations of the Research

The studies accepted for this research were directly related to tobacco cessation and
intervention in the dental office. Classic work was related to the history of tobacco use in the
United States, tobaccos link to morbidity and mortality, and current data regarding tobacco use
today.
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Chapter Two
Abstract
The purpose of this review is to analyze the current literature regarding tobacco cessation
interventions in the dental office. An electronic search was conducted of EBSCO host and
Pubmed and the OneSearch Wahlstrom Library service through the University of Bridgeport for
articles published between 2008 and 2015 via health sciences. A combination of the following
terms was used: tobacco, cessation, dental, hygiene, hygienist, office. This search produced a
variety of articles pertaining to the need for effective implementation of tobacco cessation
methods by dental hygienists in the dental office. Previous research indicated that provider
perceptions about delivering tobacco cessation services and lack of education were a significant
barrier to the delivery of quality care. The literature included gives insight to the problem of
tobacco use in the United States and the need for dental hygienists to take action.
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Preface
Chapter Two provides an overview of the literature and research related to tobacco
cessation in the dental office. The chapter is divided into sections that include: the history of
tobacco use in the United States, why people use tobacco, tobacco use disorder, how tobacco
causes disease, the prevalence of tobacco use in the United States, tobacco control, intervention
in the dental practice, intervention strategies, disease prevention and detection, and barriers to
care in a dental practice.
Literature Review
Introduction
The trend of tobacco use in the United States is decreasing. Still, there are a number of
people who use tobacco. Tobacco is the leading cause of preventable illness and death, globally.
The risks of tobacco use on physical health are widely known today, but this is no revelation to
the tobacco industry. Tobacco company scientists have linked tobacco use to lung cancer since
the 1950s.
Still, the tobacco industry continues to increase spending on marketing their
deadly product. In fact, tobacco is the only commercially sold product known to cause death. It
comes in multiple forms: bidis, cigarettes, cigars, pipes, snuff, dissolvable tablets, hookahs,
chewing tobacco and in its most modern form, e-cigarettes. There are social, psychological and
physiological reasons people begin to use and continue using tobacco. It is both physically and
psychologically addictive; this is the cause of Tobacco Use Disorder (TUD). Tobaccos highly
addictive component, nicotine, is a poison that paralyzes breathing muscles. Cigarette smoke
contains over 7,000 carcinogenic chemicals; these chemicals cause cancer of the lungs, lips,
mouth, tongue, larynx, pharynx, esophagus, bladder, pancreas, cervix, kidney and stomach.
Smoking also causes coronary heart disease, stroke, chronic obstructive pulmonary disease
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including chronic bronchitis and emphysema (which destroys a persons ability to breathe),
increases the likelihood of diabetes, and periodontal disease.
Steps have been taken to minimize the amount of damage that tobacco can wreak on
society. The control of Environmental Tobacco Smoke (ETS) is a practice outlawing tobacco use
in schools, airports, public buildings, restaurants and bars. The high cost of tobacco taxes aims to
limits sales and deter potential customers from making purchases. Restrictions have been set on
advertising/marketing tobacco, and it is no longer legal to market tobacco on billboards or using
cartoon characters. Self-service displays have become obsolete, the sale of tobacco products in
pharmacies such as CVS has been banned and warning statements on product labels have been
enlarged. Yet, tobacco use is still prevalent in todays society; according to the CDC, nearly 20%
of Americans still use tobacco. Dental professionals are able to reduce the burden of oral and
overall health by influencing tobacco use (Hanioka et al, 2013). Dental hygienists can use
tobacco cessation interventions to prevent and detect tobacco related disease and death. There is
a need for oral health professionals to address the issue of tobacco use with patients who have
chosen to use despite the consequences.
The History of Tobacco Use in the United States

The health risks of tobacco use were called into question as early as the 17th century. In
colonial America, tobacco acted as a source of currency for trade with Europe. Ironically, it took
a number of years to establish the legitimacy of tobacco as a trade commodity because King
James I disapproved of its use for reasons of health. In 1604, a Counterblaste to Tobacco was
printed outlining concerns over passive smoking, the danger to lungs and its foul odor. A
custome loathsome to the eye, hatefull to the Nose, harmefull to the braine, dangerous to the
Lungs, and in the blacke stinking fume thereof, nearest resembling the horrible Stigian smoke of
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the pit that is bottomelesse (Counterblaste to Tobacco, 1604). Years before scientific studies
were completed which proved that tobacco had negative health affects, there were people who
believed it to be harmful. (Basic Skills, 2015)
The growth of tobacco plantations directly coincided with the boom of slavery in the
1700s. The process of growing tobacco was labor intensive. Having brought workers from
Africa that received no wages made America profitable as a new nation. Tobacco consumption
during this time period grew rapidly and the plantation owners profited immensely. Tobaccos
profits led directly to the rapid growth of slavery in the new nation because it was a good
business venture. (Knight, 2010)
The tobacco industry flourished in the era of industrialization in the early-mid 1800s for
various reasons. The Industrial Revolution marked the transition from hand production of
cigarettes to machines, causing manufacturing to be more efficient. Distribution was made easier
by use of the developing railway system. During this time the match was invented, making
lighting cigarettes easier. National advertising of branded goods emerged in response to the
changes of the era to find and persuade buyers: men, women and children alike. Anti-tobacco
campaigns were primarily aimed at women and children in the early part of the 20 th century.
Womens habitually smoking was viewed as dirty by society. The suffragists rebelled in their
fight for equality, and the tobacco industry took advantage of the opportunity. Through
marketing, tobacco became associated with good health, attractiveness, and independence. (Basic
Skills, 2015)
According to the Surgeon Generals Report of 2014, it was hypothesized as early as 1912
that tobacco caused lung disease. The first study was completed in 1950, associating smoking
with lung cancer and by the late 1950s, it was well known by tobacco industry scientists that
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cigarettes were a cause of lung cancer. The general public was not made aware of tobaccos
inevitable harm however, until the release of the Surgeon Generals report in 1964, which
conclusively linked tobacco use to disease. In 1965, warning labels were placed on cigarette
packages, indicating the risk in smoking cigarettes. Tobacco companies responded by
introducing filtered, slim and light cigarettes as healthier ways to smoke. There is no evidence
these choices are any healthier than a traditional cigarette. A tobacco companys success is
measured solely by sales and profits; there is little interest in the health of tobacco products.
Although significant removal of nicotine from cigarettes was technologically possible, tobacco
producers worried this would eliminate cigarettes addictive properties and erode demand
(Glantz et al. 1996). Tobacco companies want to assure that they maintained a market for their
product. (Surgeon Generals Report, 2014; Basic Skills, 2015)
Tobacco, though widely known to be harmful, has been prevalent in the United States
since colonial times. Mounting evidence in the 1950s and 60s did little to deter smokers. In the
21st century, the causal relationship between tobacco use and lung cancer is common knowledge.
Despite these facts, almost 1/5th of the population uses tobacco.
Why People Use Tobacco

There are a variety of reasons why people use tobacco. These reasons also impact why it
is so difficult to quit using tobacco. The Social Learning Theory includes classical conditioning,
operant conditioning and modeling as influences on the decision to use tobacco. Classical
conditioning occurs when environmental and cognitive cues come to be associated with
smoking. For example, drinking coffee, driving, feeling stressed or bored (mood states) or
celebrating at a party can become triggers for tobacco use. These antecedents then trigger an urge
or craving for tobacco. This is the pairing of cues and behaviors. Tobacco products become
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paired with and linked to a wide range of activities, situations and circumstances, making
quitting particularly challenging. Operant conditioning takes places when a behavior, such as
smoking, has a positive consequence. With tobacco use, the positive consequences such as
feeling relaxed, are immediate and definable. The negative consequences are delayed and
indefinite. Learning through the observation of models, also known as modeling or observational
learning, plays a role in the acquisition and maintenance of the smoking habit. This is reflected in
the social aspect of nicotine addiction. The behavioral chain of events: antecedent (cues/triggers),
behavior and consequence are difficult to break. The goal of the healthcare provider is to help
people learn skills to cope while breaking this chain of events, so that they have new ways to act
in old situations. Addressing the social, biological, and psychological factors that contribute to
the initiation and maintenance of tobacco use is essential to helping tobacco users achieve
cessation. (Basic Skills, 2015)
Types of Tobacco
In addition to tobacco cigarettes, there are other types of tobacco products. These include
bidis, cigars, cigarillos, pipes, chewing tobacco, dissolvable tobacco, kreteks (clove cigarettes),
hookahs, water pipes, snuff and electronic cigarettes. Electronic cigarettes are battery operated
devices that heat a liquid solution for vapor inhalation. They have gained increasing popularity
since 2010 as an electronic delivery system for nicotine
Other popular methods of using
tobacco among male college students and graduates under age 26 are the hookah and water pipe
using shisha. According to statistics, around 9.5-27% of college students have used a hookah in
the past month. These methods are often associated with cigarette and marijuana use. E-hookahs
are the newest product to hit the market: a tobacco free, flavored e-cigarette. In and of itself, the
e-hookah may not seem dangerous; however, its prevalence among middle and high school
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students is alarming because it is giving them the experience of inhaling warm vapors, and the
comfort of handling a cigarette. It encourages a smoke-like experience, one step away from a
nicotine filled e-cigarette. The array of tobacco products available has led to a society where
tobacco use is prevalent. (Bucklin, 2013; Rollins, 2014)
Prevalence of Tobacco Use

Adult smoking rates remained steady through the 1990s. Over the past decade these
numbers have slowly declined from 25% in 1993 to an estimated 17.8% today. Smoking rates
among youth rose in the first half on the 90s, and have significantly decrease since their peak in
the mid 90s. According to the National Center for Health Statistics 1974-2009 Interview Survey,
the overall trend has been a falling rate of youth and adult smokers in the last five years. The
majority of smokers are Caucasian females. There are a greater number of people who consider
themselves intermittent or light smokers, smoking less than 15 cigarettes per day or are not daily
smokers. In 2009, 57% were non-daily smokers. Irregular tobacco users tend to be less
concerned with dependence and negative health effects of tobacco use.
The number of adults over age 25 who use smokeless tobacco has remained steady; men
aged 25-44 have the highest prevalence of smokeless tobacco use among all age groups (Albert
et al, 2012). The greatest increase of smokeless tobacco use is by adults aged 18-25. The
majority of users are American Indians and native Alaskans. Significantly more males use
smokeless tobacco than females. The amount of middle school users has declined, but the
number of high school users has increased. According to the CDC, in 2012 an estimated 1.7% of
middle school students and 6.4% of high school students used smokeless tobacco. Tobacco is
prevalent of in the United States is prevalent in every community and exists in every age,
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gender, ethnicity, education level and state. The number of smokeless tobacco users varies
greatly by age, gender, ethnicity, education and state.
Tobacco Use Disorder

Tobacco Use Disorder (TUD) is the term used when referring to people who are tobacco
dependent. Tobacco dependence occurs in just weeks of using the drug. Experimentation with
tobacco can quickly lead to addiction. Two of 11 key features of Tobacco Use Disorder must be
present within a 12 month period for a person to be categorized as having TUD. Key features
include continuing to use increased amounts of tobacco for a greater time than intended, being
unable to decrease tobacco use or spending an increasing amount of time obtaining and using
tobacco. This may cause failure to fulfill obligations, social and interpersonal problem, and
reducing or giving up activities. People with tobacco use disorder are likely to use tobacco in
physically hazardous situations. They will have a higher tolerance for the amount of tobacco
used, or diminished effects of the drug. Finally, TUD is characterized by the presence of
withdrawal symptoms such as irritability, when abstaining from tobacco use. It is a chronic,
relapsing condition. (Basic Skills, 2015)
How Tobacco Causes Disease

Tobacco use is the United States' number one preventable public health problem. It is the
leading cause of morbidity and mortality in the United States. According to the CDC, tobacco
use is linked to the top causes of death in the United States including cardiovascular disease,
cancer, chronic lower respiratory disease, and stroke. Tobacco is responsible for 480,000 deaths
in the United States annually. This accounts for 1 in 5 deaths in the US. There is a direct
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correlation between the frequency, amount and length of time that tobacco is used and the
likelihood of damage being caused. (US Dept HHS, 2010)
Risks of Tobacco Use

Tobacco smoke is a deadly mix of more than 7,000 chemicals. Over 200 of these
chemicals are poisons and carcinogens including arsenic, benzene, carbon monoxide, cyanide,
formaldehyde, lead and acetone. The human body was not designed to ingest these toxins.
Inhalation is an effective drug delivery system as it causes drugs to enter the blood stream
rapidly. The toxic chemicals are then carried through the blood stream to tissues in all parts of
the body. These chemicals get into the bodys tissues, causing injury; tissues become inflamed
and damaged by tobacco smoke making it difficult to heal. Tissue damage eventually leads to
opportunistic disease. (US Dept HHS, 2010)
The immune system is weakened and cannot fight against DNA cellular damage. This
cellular damage perpetuates cancer throughout the body. This includes cancer of the mouth,
larynx, pharynx, esophagus, pancreas, uterine cervix, kidney, bladder and lungs. According to
statistics, 9 of 10 men who die from lung cancer are smokers.
Tobacco
smoke
changes
blood chemistry causing atherosclerosis: damage to arteries by making blood sticky and causing
deadly clots. This leads to aneurysms, heart attacks, strokes, peripheral artery disease (PAD) and
kidney disease. Tobacco smoke also increases the risk of lung infection. It inflames the lining of
the lungs causing irritation which makes it difficult to stretch the lungs and exchange air. Chronic
obstructive pulmonary disease (COPD) such as emphysema and chronic bronchitis make it
strenuous for smokers to get enough oxygen. Other respiratory illnesses associated with smoking
are pneumonia and asthma; these illnesses also make breathing difficult. Another health
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consequence of tobacco use is uncontrolled diabetes. Tobacco smoke effects blood sugar,
making it more likely for tobacco users who are diabetic to have serious health complications.
This includes: heart and kidney disease, amputation, retinopathy, and peripheral neuropathy.
Various health implications are associated with tobacco use. (US Dept HHS, 2010)
Manifestations of Tobacco Use on Oral Health

There are oral ramifications related to the use of tobacco of which patients should be
informed. The top oral health problems that are caused by tobacco use include cancer and
periodontal disease (resorption of the bone and gums supporting the teeth) resulting in tooth loss,
dental caries and poor wound healing.
Tobacco use increases the likelihood that a person will develop cancer of the mouth, lips,
tongue, throat, nose, larynx and esophagus among other vital organs because of the burning and
drying effects of smoked tobacco. Approximately 30,000 new cases of oral cancer
are
diagnosed in the United States each year, and about 9,000 people die of the disease each year
(Albert et al, 2012). This may manifest as red, white or discolored areas in the mouth. Once oral
cancer can be seen visually in the mouth it has progressed to the advanced stages; those
diagnosed only have a five-year survival rate (MacDonald, 2000). Non-cancerous oral conditions
such as leukoplakia may convert to squamous cell carcinoma. Increased keratinization of tissue
often appears as nicotinic stomatitis with chronic inflammation of the palatal salivary glands.
Keratinization of tissue will inhibit inflammation therefore, lack of bleeding upon probing is not
indication of good periodontal health. (Albert et al, 2012)
There are consequences of smoking on periodontal health. A plethora of substances are
inhaled when smoking a cigarette. These toxic substances have a multitude of biologically
plausible effects, including vasoconstriction resulting in tissue ischemia, impaired inflammatory
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vascular response, impaired oxygen metabolism, impaired polymorphonuclear leukocyte
chemotaxis, deficient phagocytosis, and cellular repair (Albert et al, 2012). The tissue cannot
fight infection and does not repair easily; wound healing is debilitated by toxic chemicals. The
alteration in pH can also lead to an altered immune response and break down mucosal
membranes making tobacco users prone to viral and fungal infections. It will inhibit the ability of
the body to heal after a dental implant has been placed. Smoking may be associated with
compromised wound healing, effect on bone architecture, width, length, density, and effect on
peri-implant tissue (Goutam, et al., 2013). In addition, smokers have been shown to have a
greater amount of pathogenic bacteria subgingivally. Higher levels of colonization by pathogenic
bacteria will cause alveolar bone loss, caries, tooth loss, and poor wound healing. This frequently
results in and a less favorable result from periodontal therapy. (Albert et al, 2012)
Aesthetic manifestations of the use of smoked and smokeless tobacco include stained
teeth, oral malodor, black hairy tongue, abrasion, recession, cervical caries, and decreased
effectiveness of whitening products. Halitosis increases the chance that a tobacco user regularly
has sweetened candies, mints and gum causing acid attacks that make teeth more susceptible to
decay. Black hairy tongue results when plaque and tobacco residue becomes trapped on the
dorsal surface of the tongue. Tobacco damages the gingiva, causes tooth decay and results in the
loss of taste and smell senses. (Albert et al, 2012)
Second hand smoke

According to the 2006 Surgeon General Report, there is no risk-free level of exposure to
second-hand smoke. The health consequences of involuntary exposure include low birth weight,
SIDS, acute respiratory infections, ear problems and severe asthma.. Cessation reduces the risk
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of these illnesses.
In adults, second-hand smoke had immediate adverse effects on the
cardiovascular system and can cause lung cancer and coronary heart disease. (Albert et al, 2012).
Benefits of Tobacco Cessation

There are short-term and long-term benefits to ceasing use of tobacco regardless of age or
health status. Immediate benefits of quitting include lowered blood pressure and increased
peripheral circulation 20 minutes after stopping, and a drop in carbon monoxide levels eight
hours after stopping. Smell and taste are enhanced one week after ceasing tobacco use. Cilia regrowth begins and viscosity of mucous decreases in one-nine months. Quitting smoking will
improve respiratory health. Lung function increases by 30% in two to three months; coughing
and wheezing will subside within months and breathing will be easier. People who quit smoking
will see fatigue diminish in one to nine months. Smokers who quit have a reduced risk for
cardiovascular disease and cancer. Quitting smoking decreases the risk of myocardial infarction
by 50% with the first year, and stopping at age 40 or 50 avoids more than 90% of the tobacco
related risks of lung cancer. (Albert et al, 2012; US Dept HHS, 2010)
Within five years of quitting the chance of developing cancer of the mouth, throat,
esophagus and bladder is cut in half. After ten years after quitting the risk of dying from lung
cancer also decreases by fifty percent. As precancerous cells are replaced, the risk of cancer of
the mouth, throat, esophagus, bladder, kidney and pancreas decrease. The risk of cardiovascular
disease also returns to that of a nonsmoker after ten years of not smoking. Progression of bone
loss and rate of tooth loss is significantly decreased in those who quit smoking. Tobacco
cessation gives the body a chance to heal and return to a state of homeostasis. (US Dept. HHS,
2010; Albert et al, 2012)
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Tobacco Control
Opponents to tobacco use have succeeded in recent years in spreading awareness of the
ramifications of tobacco use on health. Tobacco use has moved from being viewed as acceptable
harm, to become denormalized and even demonized in society today. Limitations have been set
in place to minimize tobacco use including taxation, laws and regulations. In recent years this
has resulted in decreased tobacco consumption.
A trend in parts of the world has been to minimize use of tobacco with more stringent
regulations. The Family Smoking Prevention and Tobacco Control Act of 2009 was the first time
in history that the FDA could control tobacco. In 1970, tobacco advertising on the radio and
television was banned in the United States. Regulations are set in place to limit advertising on
television, in magazines and on billboards. Cartoon characters that aim to make tobacco products
appeal to children have been eliminated. Stronger health warnings that are either photographic
and/or written must appear on advertising and tobacco packaging. Strict policies have been set in
place to limit where tobacco can be sold. In the last twenty years, self-service kiosks to buy
cigarettes have become obsolete and internet sales have been restricted. In fact, tobacco products
are non-deliverable by the United States Postal Service. Penalties for the sale of tobacco products
to minors vary by state law but include fines, criminal misdemeanor charges, and employer fines
that may result in job loss. Proliferation of smoke free air laws has influenced the use of tobacco.
Various organizations worldwide have made recommendations to implement tobacco
cessation programs including the World Health Organization (WHO), American Cancer Society
and American Dental Association. The WHO developed a guide to provide recommendations
and partake in tobacco control initiatives. The National Cancer Institute began tobacco
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intervention trials in 1980. The ADA continues to revise its policies and update its
recommendations regarding tobacco use. Currently the ADA code 1320 is used for tobacco
counseling for the control and prevention of oral disease. Increased tobacco screening and
cessation counseling in dental care settings were introduced as objectives of Healthy People
2020. Since the mid-1990s, there has been a steady decrease in the number of youth and adults
who use tobacco in the US. In 2013, approximately 17.8% of adults were current smokers.
Approximately half of smokers see a dentist at least once a year. (Huff-Shack et al, 2012; Albert
et al, 2012; Hanioka et al, 2013)
Tobacco companies have responded to these restrictions and big company lawsuits by
increasing spending on advertising, and to market their products with great precision and
planning. They have created novelty tobacco products such as snuff and dissolvable tablets, and
purchased smokeless tobacco companies. Current marketing techniques include sponsoring
entertainment and cultural events. (CDC, 2015)
They also have moved business overseas to underdeveloped countries, where no tobacco
regulations exist. Countries such as Indonesia have no limitations on advertising or sales.
Children begin smoking and are tobacco dependent at a young age. They are misinformed of the
health consequences of tobacco use and there is little that opponents can do to challenge the
influence of big tobacco companies. Statistics show that there is a rise of tobacco related illness
in these undeveloped countries; big tobacco companies stand to profit at the expense of this
population, ensuring that they will not go bankrupt.. This exemplifies why education and
regulation is crucial to eradicating tobacco use. (Hodel, 2012)
Tobacco Intervention in the Dental Practice
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Great demand for tobacco intervention in the dental office has arisen. There has been
accumulating empirical support for dental office based intervention (Studts, 2011). Tobacco
cessation is well within the scope of dental practice and has proven to be effective at increasing
quit rates. Current tobacco users are more likely to have perceived dental needs than nonsmokers (Hanioka et al, 2013). Second to mechanical plaque control, tobacco use cessation has
become the most important measure for the treatment of periodontal diseases (Williams, 2011).
Assisting tobacco users in cessation has the potential to yield a positive and significant public
health impact.
The profession of dental hygiene has been called to action in the aim of eradicating
tobacco use disorder. In 1989, the National Dental Tobacco Free Steering Committee was
created, through funding from the National Institute of Health, to encourage oral health
organization and its members to enhance their role in advocacy for a tobacco free society.
Former US Surgeon General Dr. C. Everett Koop called upon the oral health professions,
particularly dental hygiene, to take the lead in tobacco prevention and cessation activities for our
nation (Williams, 2011). Healthy People 2020 identified dental professionals as key
practitioners in the effort to meet public health goals for treatment of tobacco use and
dependence (Studts, 2011). This includes improving screening and cessation rates as key
objectives.
There are benefits to the circumstance of dental hygiene when providing tobacco
cessation services. This is a cost-effective method for reaching a large number of tobacco users.
The dental hygienist typically sees patients for multiple visits and has an opportunity to establish
a rapport with clients. They treat patients with regular frequency, with ample amount of time to
discuss tobacco use. Procedures allow an opportunity to demonstrate visibly the association
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between tobacco use and oral health, as well as its effect on the patient current health issues.
Incorporation of an oral examination component as part of behavioral interventions for tobacco
cessation conducted by oral health professionals may increase abstinence rates among tobacco
users. Brief intervention by dental professionals utilizing feedback on oral symptoms and dental
treatments relevant to smoking motivates tobacco users to stop using tobacco (Hanioka et al,
2013).
There are various modalities for tobacco interventions in the dental setting. These include
low-intensity intervention (brief) and intensive intervention. The typical dental professional
spends five minutes or less discussing tobacco use with patients (Binnie, 2008). Binnie
insinuates that this is not enough time to effectively discuss tobacco use. Other researchers
conclude that tobacco interventions should be kept brief to increase effectiveness (Ramseier,
2009). Low-intensity intervention is reported to be the first treatment option in a dental setting
because of its efficacy of achieving increased abstinence rates at 3 months (Hanioka et al, 2013).
The National Institute for Clinical Excellence recommends 5-10 minute interventions (NICE,
2006). The stigma now attached to tobacco use makes it difficult for practitioners to comfortably
broach the topic of cessation. Tobacco use should not be demonized as a personality defect; an
atmosphere of unconditional acceptance based on firm scientific knowledge of the multifactorial
nature of tobacco dependence and a firm knowledge of the most efficient methods should be
used for tobacco prevention and cessation counseling (Antal et al, 2012). It is imperative for a
provider not to villainize the tobacco user, but to be sympathetic to its addictive nature.
Developing a good rapport with patients is necessary to the success of behavioral intervention
strategies.
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Intervention Strategies
There are benefits to encouraging tobacco cessation in a dental practice. Studies have
shown that intensive tobacco intervention in the dental setting is effective (Hanioka, 2010; Carr,
1995). Dental professionals see patients regularly; the dental prophylaxis recall schedule of 2-4
visits annually provides the dental team with the opportunity to discuss tobacco cessation at
regular intervals, an opportunity that few other healthcare providers have. 50% of smokers visit
the dentist regularly, and more people visit the dentist annually than the physician. These visits
help patients and providers develop a rapport. In addition, appointments of 45-75 minutes are
lengthy compared to that of the typical physicians 15 minute visit. (Parker, 2003)
The dental team has the ability to work together to help patients achieve optimum health.
Altering a patients lifestyle begins the moment the patient enters the dental practice. Oral care
professionals can provide information and resources that patients may otherwise not be able to
access. A dentists advise to quit coupled with pharmacotherapy can double or triple success
rates (Albert et al, 2012). Brief counseling and medication increase quit rates from 3-4% to
22%. A provider's influence has the potential to reduce morbidity and mortality associated with
tobacco use. Tobacco cessation information should be available in the waiting room. Reading
these brochures while sitting in the waiting room will remind patients of why they should quit.
(Ramseier, 2009)
In a dental office it is the responsibility of oral healthcare providers to inquire about a
patients tobacco habits, to document the tobacco status of patients in charts and to discuss those
practices and to encourage patients to modify their behavior. The goal of the practitioner is to
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increase the patients self-efficacy and confidence in their ability to accomplish their goal of
become non-tobacco dependent. One suggestion is to delay a cigarette each time they feel the
urge to smoke. Talking to patients about their outcome expectancies is essential to enhance their
motivation to quit smoking. Outcome expectancies are the beliefs that if the desires task is
performed and their goal is accomplished, it will have the desired result. If the desired goal is
unrealistic, the person may not achieve the desired result and may go back to using tobacco. For
instance, if a smoker quits smoking because they want to be healthy and then they continue to
gain weight, and they view weight gain as unhealthy, they may return to smoking because they
believe it helps them keep their weight under control and thus, is healthier. They may then enter
a state of learned helplessness, where one feels consistently unable to control important events,
such as tobacco use, leading to a sense of chronic discouragement. Tobacco users may come to
believe that they will never be successful in a quit attempt.
It is important to relay the consequences of tobacco use on oral health and to evaluate a
patients willingness to quit. Although different variations of this protocol exist, most researchers
suggest that the most effective is referred to as the 5As: ask, advise assess, assist and arrange
(Binnier, 2008; Parker, 2003; Ramseier, 2009 ). When used effectively, the 5As play a large role
in patients decision to cease tobacco use. Cognitive-behavioral therapy aims to change the way
tobacco users think and act. In fact cessation quit rates increase dramatically when tobacco
users receive professional counseling. (Ramseier, 2009) Psychoeducation can educate tobacco
users about the health effects of tobacco use, the nature of addiction and inform them of the
benefits of and method of quitting. Patients may require referrals to ancillary services for
substance abuse, psychiatric care and/or nutritional support. Therapy can also be used to prevent
relapse with follow-up and after care protocol.
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Dental hygienists are constantly striving to help patients achieve optimum health by
preventing and treating disease. Ask-Advise-Refer is the American Dental Hygienists
Association (ADHA's) national Tobacco Intervention Initiative designed to promote cessation
intervention by dental hygienists. This is a public health action plan for dental hygienists that
simplifies tobacco cessation into a three step process. The approach, developed in 2003,
integrates the 5 As (Ask, Advise, Assess, Assist, Arrange) into an abbreviated intervention (3
minutes in length) that remains consistent with recommended smoking cessation guidelines.
Ask
Every patient should be queried at every visit about tobacco use and that information
should be documented. Tobacco use history forms can be utilized as a way to non-threateningly
introduce the ensuing conversation. This form will gather information regarding how many years
tobacco has been used, what type of tobacco is used ie. smoke, smokeless, if the patient uses
tobacco within five minutes of waking, the number of times during the day they use tobacco and
if they have made past quit attempts. This will help determine how dependent the patient is on
nicotine (Ramseier, 2009; HHS, 2008). After asking if a patient uses tobacco, it is important to
ask patients for permission to discuss tobacco use. The most important thing a provider can do is
to form an alliance with the one the provider is trying to help. The best way to form an alliance is
to entertain the validity of their point of view. A provider should never assume that they
understand a persons perspectives and beliefs; it is important to ask them. The next step would
be to ask open ended questions about the psychological, physiological and social benefits of
tobacco use that they find most important. These questions should actively engage the tobacco
user, and encourage them to think about their habits in a new way. (Basic Skills, 2015) For
example, some patients report that it is the only time they have to themselves. After determining
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the benefits of tobacco use, the negative aspects of tobacco use should be discussed as it directly
relates to the tobacco user.
Advise
Patients should be advised to stop using tobacco and given reasons to quit. Advice should
be clear, strong and personalized. There are risks associated with tobacco use. Oral health
professionals should inform patients about the consequences of tobacco use on their oral health.
Discussing visible oral consequences of tobacco use may encourage tobacco users to stop using
tobacco. (Binnie, 2008).
Brief Motivational Interviewing (BMI) can be used to encourage tobacco users to quit.
First, the practitioner asks the patient if they are motivated to change their behavior. The provider
then increases the patients desire to change; she reminds the patient of the benefits of stopping
tobacco use: fresh breath, better tasting food, and a healthy mouth and body. It is important to
clearly and firmly advise patients to stop using tobacco. (Ramseier, 2009)
Assess
It is important to assess the patients desire to quit or cut back on tobacco. The majority
of smokers, 70%, are interested in quitting however, only 2% are successful annually (Binnie,
2008). Most people who use tobacco want to quit but find it difficult because of its addictive
nature. A patient should be asked how they feel about tobacco use and how it fits into their life.
Every time a person is asked if they are ready to stop using tobacco, the chance that they will
quit sooner increases.
The practitioner needs to determine the extent of dependency of the tobacco user by
evaluating frequency of use, how soon upon waking the first cigarette is smoked, the number of
cigarettes smoked per day, how long a patient has been using tobacco and the number of
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previous quit attempts. Prochaska, DiClemente, and Norcross (1992) report that the average
number of times that a smoker tries to quit before achieving success is between 6 and 8 attempts.
The next step is to determine what stage of change the tobacco user is in using the Stages
of Change model. If they are in pre-contemplation stage, the tobacco user does not wish stop
and has no interest in quitting. If they are in contemplation stage, they plan to quit sometime
within the next six month and require more support, information and guidance; they want to quit
but they really like smoking. If patients commit to discussing their behavior at their next dental
visit it is imperative that the practitioner continues to encourage change. A patient who is ready
to stop is in the preparation stage and is ready to quit smoking. They will need assistance to
achieve this goal. Action is the stage of change when a person no longer smokes and the stage of
maintenance occurs when they consider themselves a non-smoker. These conversations should
be well document in the patients chart. (Ramseier, 2009)
Assist
A client-centered model should be used to assist patients with their quit attempt. The oral
healthcare provider needs to encourage the patient to set a quit date within two weeks. The
tobacco user should also inform friends, family and coworkers of his intent to live tobacco free
and ask for their support and understanding. Patients should be advised to eliminate tobacco
from their environment such as cars, home and work. This will help create tobacco free areas
where they spend a lot of time. The healthcare provider can help the patient identify possible
challenges to the quit attempt and ask the patient what alternative tasks can be done to replace
tobacco use and alleviate stress. (Treating Tobacco Use and Dependence, 2008) Examples of
tasks include walking, taking a bath, doing yoga and working out. The patient should stock up on
sugar-free chewing gum, mints and cinnamon sticks in order to curb their oral fixation (Fisher,
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1998). Studies also have shown that St. Johns Wort may help diminish tobacco cravings
(Lawvere, 2006). If the tobacco user tends to associate using tobacco with other tasks (such as
drinking) he should be advised to avoid those activities.
The person undergoing cessation should be given a journal to record how he is feeling
(Ramseier, 2009). He can log what and when he is eating, how often and when he desires to use
tobacco, and how he feels at that time ie. happy, stressed, apathetic, in order to determine what
triggers those urges. Other sources have proven that internet based resources and personalized
cessation emails have had significant results in helping tobacco users refrain from using tobacco
(Poel, 2009; Polosa, 2009). Finally, encourage patients to reward themselves for small victories:
the first day, week or month tobacco free is a huge accomplishment.
Arrange
There are resources that can be utilized to aid patients in physical and psychological
tobacco cessation. There are many public health self-management interventions for smoking
cessation that have been found to be effective; however, they are substantially underutilized
(Huff-Shack, 2012). These interventions include tobacco cessation literature, referrals to
psychologists and tobacco cessation hotlines or websites for counseling, recommending nicotine
replacement therapy (NRT), and referring to a physician for prescription cessation medication
such as Bupropian (Zyban/Wellbutrin SR) and Varenicline (Chantix). NRT options include the
patch, gum, lozenge, inhaler and nasal spray. Some patients may want to try alternative therapies
such as hypnosis, laser therapy or acupuncture. (Miller, 2009; Solloway, 2006) Adjunctive
therapies should not be the primary approach to treatment.
Research has shown that the most effective method for achieving cessation is a
combination of counseling and pharmacotherapy. There is a strong correlation between the use of
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medication when combined with a number of counseling sessions and the likelihood of success.
The most effective combination medications long term is the nicotine patch and NRT
(gum/spray), the nicotine patch and nicotine inhaler, and the nicotine patch and Bupropian.
Varenicline cannot be used in combination with NRT. Lots of people benefit from individual
therapy. Cessation support groups are also available as well as inpatient cessation programs.
(Rameier, 2009; HHS, 2008)
E-cigarettes and vapor products have not been extensively tested or approved for use as
tobacco cessation devices. Early studies indicate that quit rates using e-cigarettes are not
significantly higher than using FDA approved nicotine replacement therapy products. They
contain the chemical nicotine, which is highly addictive, toxic and unregulated. The FDA does
not currently regulate e-cigarettes and there is no oversight of the ingredients, nicotine content or
safety claims of the manufacturers. E-cigarettes are likely to be the reason for the spike in
nicotine poisonings in recent years (Rollins, 2014).
A follow-up procedure should be arranged to evaluate the patients success with tobacco
cessation. Follow-up procedures could include calling the patient around their quit date to
support their quit attempt, scheduling an office visit, and/or mailing a card or letter. Tobacco, like
other substance abuse disorders, is a chronic illness, and requires comprehensive and ongoing
treatment. (Basic Skills, 2015)
Motivational Interviewing
Motivational Interviewing (MI) strategies can be used to explore a tobacco users
feelings, beliefs, values and ideas about tobacco use when they are unwilling to quit using
tobacco products. MI is used to encourage patients to resolve their ambivalence towards tobacco
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use and take responsibility for their own health (Schoonheim et al, 2012). Motivational
Interviewing strategies include expressing empathy, developing discrepancy, rolling with
resistance, and supporting self-efficacy. The content areas that should be addressed in a
motivational counseling intervention can be captured by the 5 Rs: relevance, risks, rewards,
roadblocks, and repetition. Research suggests that the 5 Rs enhance future quit attempts.
(Treating tobacco Use and Dependence, 2008) Persuasive messages can be used to promote
cessation. Gain-framed messages place emphasis on the benefits of quitting while loss-framed
messages emphasize the consequences of continuing to use tobacco. Smokers who visited
dental clinics were more receptive to information that emphasized the benefits of quitting
(Hanioka et al, 2013). An example of a gain-framed persuasive message is the recommendation
to use nicotine gum to decrease tooth staining, a common complaint among smokers.
Disease Prevention
The best way to prevent disease related to smoking is to send a strong message to
children and adolescents urging them to totally abstain from tobacco use. Tobacco companies
rely on the inexperienced and uneducated young people to help their company profit. Todays
teenager is tomorrows potential customer (MacDonald, 2000). Because most people begin
using tobacco at a young, impressionable age, healthcare providers need to begin discussing
tobacco use and risks at a young age. In addition, parents need to be educated about the risks of
second hand smoke to children. If parents have chosen to smoke, they are putting their children
at risk by smoking in confined quarters with their children.
Numerous studies demonstrate the nutritional implications of tobacco use. A metaanalysis of nutrient intake in cigarette smokers indicates lower intakes fiber, polyunsaturated fat
of beta-carotene, Vitamin C and E, while showing higher intakes of energy, total fat, cholesterol
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and alcohol (Dallongeville et al, 1998). Similar to Dallongeville et al, other studys conclude that
current smokers lack Vitamin C, B-12 and folate compared to that of non-smokers (Piyathilake et
al, 1994; Smith, 2005; Simone, 1995). Preston suggests that an overabundance or depletion of
macro and micronutrients may play a role in the pathological conditions attributed to smoking.
Oral health professionals should recommend that patients using tobacco take supplements to
restore depleted nutrients necessary for optimum health. For instance, Vitamin C will aid in
collagen production which will help maintain bone support around teeth by reversing
vasoconstriction; tobacco users will benefit by taking twice as much vitamin C as a non-tobacco
users. (Preston, 1991)
Disease Detection
Tobacco users should undergo a standard oral cancer screening at every dental visit. They
must be educated to inform the dental professional of any swelling, tenderness or lesions of the
head or neck region. A brush biopsy may be used to confirm suspicion of precancerous areas in
the mouth and referral to an oral surgeon for a surgical biopsy. Other methods available to screen
patients for oral cancer include the Velscope, ViziLite, Microlux and Orascoptic; these tools
shine a special light which helps practitioners detect abnormal cells that are not apparent to the
naked eye. These diagnostic tests are recommended to be done once per year for low risk patients
and biannually for high risk patients beginning at age thirteen. (Patton, 2008)
Barriers to Care
The major barriers to effectively discussing tobacco cessation with patients include the
fear of losing the patient, the desire to respect the patients individual freedom, lack of time,
reimbursement, patient interest, resources, training and experience (Ramseier, 2009; Dalia,
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2007). While most dental hygienists report asking patients about tobacco use, few do more than
recommend patients stop because it is unhealthy. If one aggregates research results on the
subject, it appears dental hygienists have not widely accepted the guidelines described in the US
Public Health Services Treating Tobacco Use and Dependence: Clinical Practice Guidelines
(TTUD-CPG) (Studts et al, 2011). The majority of oral health professionals are not equipped
with the tools necessary to aid patients in tobacco cessation, particularly those patients who are
unwilling to quit (Brothwell, 2009; Binnie, 2008; Ramseier, 2009; Tremblay, 2009; Roof, 2008).
Stopping tobacco use is an essential aspect of treatment planning, especially in patients
with periodontal disease. In order to help patients stop using tobacco, all members of the dental
team should be educated in tobacco management, prevention and disease detection. Over the
last ten years little progress has been made related to dental hygienist taking the lead in tobacco
prevention and cessation activities. Literature suggests that the identical barriers, reimbursement
and lack of confidence that influence dentists hesitation to implement tobacco prevention and
cessation activities continue to discourage us from implementing this most needed patient
service (Williams, 2011). Recently, insurance companies have begun covering tobacco cessation
services in a dental practice. As third party payer coverage of tobacco cessation counseling
expands, the financial burden of providing screening and counseling will be alleviated (Giddon
et al, 2013).
Dental hygienists frequently report lack of comfort or confidence in their ability to
employ evidence-based interventions, deficiencies in areas of tobacco control knowledge and
confidence. Sub-optimal training opportunities have been linked to insufficient, limited and
inaccurate knowledge and comfort providing cessation services. A clinical decision support tool
embedded in an EDR (Electronic Dental Record) was effective at improving evidence-based
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tobacco-cessation efforts in the dental setting for patients who smoke cigarettes (Rindal et al,
2013). This tool helps providers overcome their shortcomings in providing intervention services
to patients.
A dental hygienist must be willing to provide tobacco education and cessation
interventions. Study findings suggested that nearly 95% of dental hygienists do not regularly
ask patients tobacco use status, assist patients who are willing to quit or arrange a follow-up,
despite having specific training that prepared them to do so (Studts, 2011). Even hygienists who
have received training to provide these services are failing to implement them in practice.
Attitudinal barriers act as a barrier to the delivery of care. These include perceived resistance on
the part of the patient. Providers often fear that their patients do not want to be educated
regarding tobacco use and that doing so will result in the patient seeking services elsewhere.
Patients however, report that they are open to receive counseling from their oral healthcare
provider. Often it is assumed that tobacco cessation is a low priority for patients. Hygienists have
reported being concerned about the effectiveness of intervention and have low to moderate selfefficacy about ones ability to carry out tobacco cessation: 85% of dental hygienists believe that
their patients will not quit tobacco use, even if their healthcare provider advises them to do so.
Most people who use tobacco want to quit but find it difficult because of its addictive nature but
are receptive to suggestions made by dental hygienists. There is a lack of implementation of
evidence based tobacco treatment strategies, thus the reason for ineffective counseling. If one
aggregates research results on the subject, it appears dental hygienists have not widely adopted
the guidelines described in the US Public Health Services Treating Tobacco Use and
Dependence: Clinical Practice Guidelines (Studts, 2011). One suggestion is to ask permission to
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discuss tobacco with patients who are tobacco dependent before proceeding. This proves to be a
simple way to determine if a patient will be receptive to advice from their healthcare provider.
Another barrier to the delivery of care occurs when an oral healthcare provider is tobacco
dependent themselves. Dentists who themselves smoke will shy away from the topic too,
possibly so as not to lose patients respect (Antal et al, 2012). The empathy they feel can be
used as a strength: the provider understands how difficult it is to not use tobacco. Furthermore,
the recipient of tobacco cessation services may be in a different stage of change, therefore using
the clinical practice guidelines will help determine if they are ready to move forward with
cessation. This cannot be a missed opportunity to help a patient quit using tobacco because of the
way the provider feels and how they assume the patient feels.
The literature has shown that the perception of healthcare providers is a major barrier to
the effective delivery of care. Dental clinicians often cite patient resistance, time constraints,
effectiveness of tobacco-cessation interventions, access to educational materials, and
reimbursement as barriers to incorporating tobacco cessation into dental practice (Albert &
Ward, 2012). Dental hygienists have an obligation to track tobacco status and incorporate
intervention skillfully into practice. Making assumptions about interventions lack of
effectiveness may result in a failure on the part of the practitioner to take steps that have a proven
record of success. Healthcare providers cannot fail to try to help because they are afraid of
failure.
Need for Further Research

There is still much work to be done in the field of tobacco cessation education. Tobacco
cessation needs to be included as part of the dental hygiene curriculum. More research needs to
be done regarding the development of an educational curriculum for tobacco intervention
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programs in dental hygiene schools. Effective continuing education training programs need to be
developed to prepare dental hygienists already in the field to provide patients with tobacco
cessation services. Tobacco cessation training programs for dental hygienists need to be
implemented to increase knowledge and alter attitudes about the delivery of care to patients, to
increase adoption, implementation and sustainability of these interventions (Studts, 2011).
Hygienists need to become competent in helping patients develop a tobacco cessation plan, and
be comfortable recommending pharmacotherapy. Simulation with video feedback is a strong
element of a behavioral intervention program and it provides the opportunity to put theory into
practice immediately without the risks of real-life application. (Antal et al, 2012). There is also a
need for research to help determine methods to increase adoption of the Assist and Arrange
phases of intervention.
Whether or not tobacco cessation clinics or implementing a smoke free environment for
students will reduce nicotine use and encourage cessation, and what type of influence dental
hygienists conceptions about tobacco use plays their ability to influence their patients also needs
to be investigated (OShea, 1992). Johnson (2004) also argues this line of reasoning by pointing
out that in much of Europe, healthcare professionals have a high prevalence of tobacco use and a
low rate of involvement in tobacco intervention with patients. Healthcare providers should be
advocates of good health; they should advise tobacco users to quit and not use tobacco
themselves.
More research needs to be done to evaluate electronic cigarettes as an effective tobacco
cessation tool. A number of smokers have switched over from using tobacco cigarettes to using
e-cigarettes as a tool for cessation, thinking that is it a healthier alternative. More stringent
regulations need to be placed on e-cigarettes to determine if this method is actually a useful tool
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in cessation, or a better and healthier alternative, or if in fact there are health risks of which we
are unaware at this time.
Resources are available to assist dental professionals with the delivery of tobacco
cessation services. These resources are underused. Dental hygienists need to be encouraged to
use available resources as there is low translation from guidelines into practice. Studies often did
not assess subsequent quit rates. Further research needs to assess quit rates after computer
assisted guidance for dental office tobacco cessation counseling (CATI) is used with patients
(Rindal et al, 2013). This technique will only prove successful if patients are reporting high quit
rates. It seems that this approach would be quite beneficial for dental hygienists, aiding them
through the delivery of care to patients.
All too often, practitioners are not taking responsibility for providing cessation services
to patients. More research is needed to examine systematically in dental practice whether clinical
audit and feedback increase providers adherence to tobacco-use cessation treatment guidelines
(Shelley, et al, 2011). This surmises the premise that someone needs to take responsibility for
delivering tobacco cessation services. Healthcare practitioners may be more motivated and
compliant if their services where being evaluated by others.
Lack of reimbursement is a reported barrier for delivering tobacco intervention services
to patients. Pay-for-Performance, providing financial incentives for meeting predetermined
performance goals, should be evaluated as an implementation strategy for tobacco use cessation
treatment guidelines in dental practice (Shelley, et al, 2011). This would help determine if
reimbursement/cost is a true barrier to the delivery of cessation interventions to dental patients.
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Summary
The influence of dental professionals over their patients behavioral choices should not be
underestimated. Dental hygienists are an underutilized resource for tobacco control. One would
have difficulty arguing against the negative consequences of tobacco use on health; the majority
of patients desire to stop using tobacco to better their health but so not have the resources or
motivation to do so alone. Oral health care providers are presented with a unique opportunity to
help patients improve the quality and longevity of their lives; tobacco cessation is one aspect of
health that needs to be addressed at every dental visit. Dental hygienists are best equipped to
provide there services because of the frequency of dental hygiene appointments, the length of
time that they spend with patients and the rapport they develop.
In order to help dental patients achieve tobacco cessation, dental professionals must have
the knowledge, experience and confidence in managing and preventing tobacco use and
detecting disease related to tobacco use. Collaboration with other healthcare providers increases
the efficacy of tobacco intervention. The skills most effective in the management of patients who
use tobacco include the PHS clinical practice guidelines of the 5As: ask, assess, advise, assist
and arrange. This includes motivational interviews concerning the 5 Rs (relevance, risks,
rewards, roadblocks and repetition). These strategies replace the guidelines for assisting and
arranging cessation services for patients unwilling to stop using tobacco. Knowing how to
effectively utilize the tools that will aid patients in tobacco cessation is crucial in providing them
with comprehensive oral care.
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One solution is to equip dental hygienists with a program that guides them through the
delivery of tobacco cessation care. This would use a simple algorithm, designed to be used in a
quick manner. Content would include brief advice and counseling, choosing and prescribing
pharmacotherapy, and facilitating referrals for counseling resources. A custom handout could
then be given to the patient. Electronic dental records that integrate clinical decision support
should be developed. Giving providers a program that aids clinical decision support is one of the
best ways to alter their behavior. (Montini et al, 2013) With repetition, dental professionals will
become competent and thus, competent in providing tobacco cessation intervention to patients.
According to the literature, it is hypothesized that referrals to effective public health selfmanagement interventions that are underutilized would greatly increase use. In reality, patients
often refuse to be contacted by public health programs that aim to assist in tobacco cessation.
They often need a more personalized method of counseling. Counseling often provides the
opportunity for patients to talk through how they feel and find solutions for dilemmas they may
encounter.
Alternative therapies, through not researched in depth in this study, provide an interesting
alternative to be used in conjunction with conventional methods. An alternative therapy that may
be beneficial in this regard is hypnotherapy, as part of the session may encourage tobacco users
to subconsciously create new methods for achieving their goal of cessation (Salloway, 2006).
Other successful alternative therapies are with the use of lasers or acupuncture to bring about
cessation. These therapies may be intriguing to patients who have had unsuccessful past quit
attempts. In addition, tobacco users have to actively seek out treatment and commit to it
financially. This may increase their will to be successful. Some people may argue that these
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therapies only work because of the placebo effect; the cause should not be questioned if the
therapy works
As practicing clinicians, it is the dental hygienists responsibility to help patients see the
benefits of stopping tobacco use so that they desire to stop as well as to give them the motivation
to believe they are capable of this feat. This is the biggest challenge with tobacco users. Once
they have reached the contemplation stage of change, it is important to discuss and recommend
options to achieve cessation. There are a variety of effective cessation methods to recommend; a
good patient rapport will mean patients value the providers suggestions and improve chances of
cessation.
One of the most important aspects of care , that this literature review points out , is that
providers are essentially there to educate, motivate and provide necessary resources for patients
just as for other aspects of oral health. The resources are there, providers just need to figure out
what will work best for their patients. Knowledge about tobacco use disorder is essential to
provide care to patients; knowing why people use tobacco and what makes it difficult to quit
enables providers to act empathetically towards patients with TUD. Ultimately, tobacco users
need to make the personal decision to stop using tobacco before they will be successful with their
quit attempt.
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References
Albert D, Ward A. Tobacco Cessation in the Dental Office. Dental Clinic of North America
2012, 747-770.
Antal M, Forster A, Zalai Z, Barabas K, Spangler J, Braunitzer G, Nagy K. A video feedbackbased tobacco cessation counseling course for undergraduates-preliminary results.
European Journal of Dental Education 2012, e166-e171.
Binnie, Vivian I. Addressing the topic of smoking cessation in a dental setting. Periodontology
2000, Vol. 48, 2008, 170178.
Basic Skills for Working with Smokers. Center for Tobacco Treatment Research and Training,
Division of Preventive and Behavioral Medicine, University of Massachusetts Medical
School 2015.
Cahill K, Perera R. Competitions and incentives for smoking cessation. Cochrane Database of
Systematic Reviews 2008, Issue 3.
Carr, A. , Ebbert J. Interventions for tobacco cessation in the dental setting. Cochrane Database
of Systematic Reviews 2006, Issue 1.
Centers for Disease Control and Prevention. Cigarette Smoking Among Adults and Trends in
Smoking Cessation- United States, 2008. Morbidity and Mortality Weekly Report
2009;58(44):12271232.
Centers for Disease Control and Prevention. Department of Health and Human Services.
Smoking and Tobacco Use. 2015. http://www.cdc.gov/tobacco/
JONES
Page 43

Dalia, D. Management of smoking patients by specialist periodontists and hygienists in the
United Kingdom. Journal of Clinical Periodontology May2007, Vol. 34 Issue 5, p416-422
7.
Dallongeville, Jean, Marcaux, Nadine, Fruchart, Jean-Charles, Amouyel, Philippe. Cigarette
Smoking Is Associated with Unhealthy Patterns of Nutrient Intake: a Meta-analysis. The
Journal of Nutrition Vol. 128 No. 9 September 1998, pp. 1450-1457.
Fisher, Edwin B. 7 Steps to a Smoke-Free Life. John Wiley & Sons, Inc. New York, NY; 1998.
Giddon D, Swann B, Donoff R, Hertzman-Miller. Dentists as Oral Physicians: The Overlooked
Primary Health Care Resource. The Journal of Primary Prevention 2013, 34:279-291.
Glantz Stanton
A., Slade John, Bero Lisa
A., Hanauer Peter, Barnes Deborah
E.
The
Cigarette Papers. Berkeley and Los Angeles: University of California Press 1996.
Goutam M, Singh M, Patel D. A literature review on effectsof smoking on the success of dental
implants. Journal of Dental Implants 2013, Vol 3, Issue 1, 46-49.
Hanioka, T, Ojima, M, Tanaka, H. Naito, M. Hamajima,N and Matsuse, R. Intensive
Smoking-cessation Intervention in the Dental Setting. J Dent Res 89(1):66-70, 2010.
Hanioka, T, Ojima M., Kawaguchi Y, Hiata Y, Ogawa J, Mochizuki Y. Tobacco Interventions
by Dentists and Dental Hygienists. Japanese Dental Science Review 2013, 49, 47-56.
Hodel, Kate. Indonesias Smoking Epidemic- an old problem getting younger. The Guardian
2012. http://www.theguardian.com/world/2012/mar/22/indonesias-smoking-epidemic
Huff-Shack J, Coley H, Houston T, Williams J, Hubbell A, Sadasivam R, Funkhouser E, Gilbert
G, Ray M. Dental Practice Implementation of a Point of Care Electronic Referral System
for Patients Who Smoke: A Dental PBRN Study. The Journal of Dental Hygiene 2012,
Vol. 86, No. 1, 34.
JONES
Page 44

Johnson, NW. The role of the dental team in tobacco cessation. Eur J Dent Educ . Volume: 8
Suppl 4, Date: 2004 Feb , Pages: 18-24.
Knight, Frederick. Working the Diaspora : The Impact of African Labor on the Anglo-American
World, 1650-1850. New York, NY, USA: New York University Press (NYU Press),
2010. ProQuest ebrary. Web. 21 April 2015.
Lawvere, Silvan. A Phase II study of St. John's Wort for smoking cessation. Complement Ther
Med . Volume: 14, Issue: 3, Date: 2006 Sep , Pages: 175-84
MacDonald, Joan. Tobacco and Nicotine Drug Dangers.Enslow Publishers, Inc. Berkeley
Heights, NJ; 2000.
Montini T, Schenkel A, Shelley D. Feasibility of a Computerized Clinical Decision Support
System for Treating Tobacco Use in Dental Clinics. Journal of Dental Education 2013,
Vol 77, Number 4, 458-462.
National Institute for Health and Clinical Excellence. Brief Interventions and Referral for
Smoking Cessation in Primary Care and Other Settings. London: NICE, 2006.
OShea R. Hygiene students' conceptions of the role of the dental hygienist in smoking cessation.
Health Values: The Journal of Health Behavior, Education & Promotion 1992 Mar-Apr
16 (2): 44-50 16 (2) 44-50.
Parker, DR. A dental hygienist's role in tobacco cessation. International Journal of Dental
Hygiene 2003 May 1 (2): 105-9 1 (2) 105-9.
Patton LL, Epstein JB,Kerr AR. Adjunctive techniques for oral cancer examination and lesion
diagnosis: a systematic review of the literature. J Am Dent Assoc.2008 Jul;139(7):896905; quiz 993-4.
Piyathilake,CJ, Macaluso, M, Hine,RJ, Richards, EW, Krumdieck, CL. Local and systemic
JONES
Page 45

effects of cigarette smoking on folate and vitamin B- 12. American Journal of Clinical
Nutrition, Vol 60, 559-566, 1994.
Poel, F. Efficacy of a single computer-tailored e-mail fo smoking cessation: results after 6
months. Health Education Research 2009 Dec 24 (6): 930-40 24 (6) 930-40.
Polosa,R . Feasibility of using e-mail counseling as part of a smoking-cessation program.
Respiratory Care 2009 Aug 54 (8): 1033-9 54 (8) 1033-9
Preston, AM. Cigarette smoking-nutritional implications. Prog Food Nutr Sci . Volume: 15,
Issue: 4, Date: 1991 , Pages: 183-217.
Ramseier, C.A, Fundak A. Tobacco use cessation provided by dental hygienists International
journal of dental hygiene [1601-5029] yr:2009 vol:7 iss:1 pg:39 -48.
Rice, VH. Nursing interventions for smoking cessation. Cochrane Database of Systematic
Reviews; 2008.
Rindal D, Rush W, Schleyer T, Kirshner M, Boyle R, Thoele M, Asche S, Thyvalikakath T,
Spallek H, Durand E, Enstad C, Huntley C. Computer-Assisted Guidance for Dental
Office Tobacco-Cessation Counseling. American Journal of Preventive Medicine 2013,
44(3): 260-264.
Rollins, A. E-cigarettes & Vapor Products: The Truth so For. Oklahoma Dental Association
Journal 2014, 28.
Roof, Joanna L. Tobacco Cessation Education In North Carolina Dental Hygiene Programs.
Journal of Dental Hygiene Fall2008, Vol. 82 Issue 5, p66.
Schoonheim-Klein M, Gresnigt C, van der Velden U. Influence of dental education in
motivational interviewing on the efficacy of interventions for smoking cessation.
European Journal of Dental Education 2013, e28-e33.
JONES
Page 46

Shelley D, Jannat-Khah D, Wolff M. Tobacco-use treatment in dental practice. Journal of
American Dental Association 2011, 592-595.
Simone, Charles B. Smoking and the immune system. Nutrition Health Review: The
Consumer's Medical Journal 1995, Issue 73, p18 1/4p.
Smith, Linda M. Vitamin C Restores Healthy Blood Flow in Smokers. Life Extension Mar2005,
Vol. 11 Issue 3, p18-18 1/3p.
Studts J, Burris J Kearns D, Worth C, Sorrell C. Evidence-based Tobacco Cessation Treatment
by Dental Hygienists. The Journal of Dental Hygiene 2011, Vol 85, No.1, 13-20.
Solloway, Veronika.. A hypnotherapy for smoking intervention investigates the effects of
autonomy support on motivation, perceived competence and smoking abstinence.
European Journal of Clinical Hypnosis 2006, Vol. 7 Issue 2, p26-40 15p.
Surgeon Generals Report: The Health Consequences of Smoking50 Years of Progress, US
Department of Health and Human Services 2014.
http://www.surgeongeneral.gov/library/reports/50-years-of-progress/
Tremblay, Michele. Tobacco cessation counseling among dental hygienists in Quebec Canadian
Journal of Dental Hygiene Jan/Feb2009, Vol. 43 Issue 1, p9-14 6p.
U.S. Department of Health and Human Services Clinical Practice Guideline (HHS). Treating
Tobacco Use and Dependence:Update. May 2008.
US Public Health Service Treating Tobacco Use and Dependence: Quick Reference Guide for
Clinicians 2008. http://www.healthquality.va.gov/tuc/phs_2008_quickguide.pdf
Williams, N. Tobacco and Oral Health: A Call to Action. The Journal of Dental Hygiene 2011,
Vol. 85, No.1, 2.
JONES
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Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office: A Review of the Literature

Dental Hygiene 521: Graduate Study

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Recommendations for Further Research..Page 37

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Statement of the Problem

Purpose of the Research

Significance of the Research

Tobacco Cessation Interventions in the Dental Office

Active Listening- a communication technique used in counseling, training and conflict

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Limitations of the Research

Delimitations of the Research

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Still, the tobacco industry continues to increase spending on marketing their

Tobacco Cessation Interventions in the Dental Office

The History of Tobacco Use in the United States

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Why People Use Tobacco

Tobacco Cessation Interventions in the Dental Office

Other popular methods of using

Tobacco Cessation Interventions in the Dental Office

Prevalence of Tobacco Use

Tobacco Cessation Interventions in the Dental Office

Tobacco Use Disorder

How Tobacco Causes Disease

Tobacco Cessation Interventions in the Dental Office

Risks of Tobacco Use

Tobacco Cessation Interventions in the Dental Office

Manifestations of Tobacco Use on Oral Health

Tobacco Cessation Interventions in the Dental Office

Second hand smoke

Tobacco Cessation Interventions in the Dental Office

In adults, second-hand smoke had immediate adverse effects on the

Benefits of Tobacco Cessation

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Tobacco Intervention in the Dental Practice

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office

Need for Further Research

Tobacco Cessation Interventions in the Dental Office

Tobacco Cessation Interventions in the Dental Office