Key Points
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Training on counselling techniques and motivational interviewing diminishes dental professionals' anticipated perception of the possible resistance of patients.
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Periodontal treatment and the presence of smoking-related diseases can be used as a way into smoking cessation discussions.
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Promoting the use of structured advice and counselling protocols is a good strategy to increase dental professionals' involvement in prevention of tobacco addiction.
Abstract
In a controlled study, primary care dental professionals in the intervention group were encouraged to provide smoking cessation advice and support for all smoking patients with the help of a stage-based motivational protocol. The barriers and facilitators reported by the dental professionals on two occasions for their efforts to incorporate smoking cessation advice and counselling into daily patient care are summarised here. Lack of practice time and anticipated resistance on the part of the patient were cited as barriers by over 50% of the dental professionals in the first interviews. Periodontal treatment and the presence of smoking-related diseases were mentioned as the most important stimuli. The experience-based interviews revealed key points for the implementation of smoking cessation advice and support in daily dental care. Education on the associations between smoking and oral health, vocational training on motivational interviewing and the offering of structured advice protocols were identified as promising components for an implementation strategy to promote the involvement of dental professionals in the primary and secondary prevention of tobacco addiction.
Main
J. P. Rosseel, J. E. Jacobs, S. R. Hilberink, I. M. Maassen, D. Segaar, A. J. M. Plasschaert and R. P. T. M. Grol British Dental Journal 2011; 210: E10
Editor's summary
Only a handful of years ago the notion of conducting smoking cessation advice within a dental practice was all but unthinkable. What business is it of ours? we would have asked. We don't have the time, we would have protested. No one has given us any training we would have sulked. These three main barriers have been expressed throughout the world and so this study, although based in the Netherlands, has a universality which touches us all in confronting the immediate objections and the inherent reticence to start something new.
Agreeably, the results of this research also reflect those in other parts of the world. With sufficient training, motivation and organisation, dental professionals not only embrace the concept of teaching their patients tobacco cession they can become positively evangelical about it. Logically it makes perfect sense since the oral effects, going on to relate to general health effects, provide a perfect starting point from which to engage patients in the process of quitting.
Time, or let's be blunt, money, remains as one of the barriers most often still cited as problematic even when the concept has been fully acknowledged. There are ways around this and we should never underestimate people's desire to quit smoking and to have the help, guidance and encouragement of a known and trusted health professional on that journey can be a huge added incentive to begin the process, as the positive results confirm.
As we move more and more into territory which links oral and general health and in which patient expectations are that we will view them as whole people and not merely mouths disconnected from the rest of the body we will be expected to provide increasing levels of what had previously been regarded as additional (or un-thought of) care. As I have written here before, the process is unlikely to stop here and alcohol consumption is already hovering in the wings awaiting its turn to face similar initial expressions of concern but I suspect equally similar adoption and eventual levels of success.
The full paper can be accessed from the BDJ website (www.bdj.co.uk), under 'Research' in the table of contents for Volume 210 issue 7.
Stephen Hancocks, Editor-in-Chief
Author questions and answers
1. Why did you undertake this research?
Smoking is still one of the leading causes of illness. Dental professionals can play an important role in smoking cessation advice and counselling as they see their patients frequently. In spite of their opportunities it is uncommon to advise or counsel patients who smoke. In the context of a controlled, empirical study we implemented a motivational stage-based protocol to stimulate primary care dental professionals to provide more smoking cessation advice and support for all smoking patients visiting the practice. We were interested in the barriers and facilitators they experienced in incorporating the protocol into daily dental practice and intended to evaluate the various components of the smoking cessation protocol.
2. What would you like to do next in this area to follow on from this work?
Dental professionals are not always familiar with the provision of smoking cessation advice and counselling. As mentioned in the paper professionals are not sufficiently trained to advise or counsel patients. We would like to work on:
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Building more training on motivational interviewing into undergraduate and postgraduate education to raise confidence in future dental professionals
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Dissemination of structured advice protocols and encouragement of their actual use
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Further research on the collaborative and financial conditions and methods of dentists' referring patients to specialised smoking cessation services or general practice after providing basic smoking cessation advice.
Commentary
This paper reviews the barriers to and facilitators for incorporating smoking cessation advice and a counselling protocol into primary care dental professionals' activity. A longitudinal study design was adopted that included an intervention group of practices who chose to adopt an extended counselling protocol based on the Stages of Change model of behaviour change.1 This model proposes that individuals move through a series of stages in any behaviour change journey.
One of the main findings of the study is that, whatever smoking cessation advice and support approach is adopted, the impact of perceived barriers to implementation recedes as dental teams develop expertise. Such barriers are primarily seen to be lack of time and anxiety about negative patient reactions. Successful implementation of this activity also requires a collaborative whole-practice approach. Being able to provide relevant advice by linking tobacco use to related oral disorders is additionally helpful. Finally, the stage-based protocol supported the implementation of this activity.
These findings develop the advice already proposed with respect to smoking cessation implementation in primary care.2 This states that every tobacco user should be advised to quit once a year, that patient interest in quitting should be established, that referral to intensive support and pharmacotherapy (nicotine replacement therapy) should be offered and that smoking status should be recorded, reviewed and updated regularly.
The study provides two new insights. Firstly, the perceptions and activity of members of the dental care team can be managed successfully through training and practice-based support. Secondly, it demonstrates for the first time the potential of a stage-based approach to tobacco cessation in a primary dental care setting.
Study developments should include reviewing referral practice and options to include offering patients access to a telephone counsellor, as has been successfully demonstrated in North America.3 Longer-term outcomes, for both dental practices and their patients, should be generated through a more robust study design comparing the effectiveness of the stage based approach with brief advice.4
References
Prochaska J O, Velicer W F . The transtheoretical model of health behaviour change. Am J Health Promot 1997; 12: 38–48.
National Institute for Health and Clinical Excellence. Brief interventions and referral for smoking cessation in primary care and other settings. Public Health Intervention Guidance 1. London: National Institute for Health and Clinical Excellence, 2006.
Little S J, Hollis J F, Fellows J L, Snyder J J, Dickerson J F . Implementing a tobacco assisted referral programme in dental practices. J Public Health Dent 2009; 69: 149–155.
West R. Time for a change: putting the Transtheoretical (Stages of Change) Model to rest. Addiction 2005; 100: 1036–1039.
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Croucher, R. Summary of: Experienced barriers and facilitators for integrating smoking cessation advice and support into daily dental practice. A short report. Br Dent J 210, 312–313 (2011). https://doi.org/10.1038/sj.bdj.2011.264
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DOI: https://doi.org/10.1038/sj.bdj.2011.264