Nicotine replacement therapy: products that deliver controlled nicotine doses, reduced over time.
Five A's model of smoking cessation: 1) Ask the patient about their tobacco usage; 2) Advise them to quit; 3) Assess their willingness to quit; 4) Assist them in quitting; 5) Arrange follow-ups.
Three A's model of smoking cessation: 1) and 2) as above; 3) Act to refer the patient to specialist support.
Smokeless tobacco: tobacco that is orally chewed or 'snuffed' through the nose.
Since August 2009, members of the Primary Care Dentistry Research Forum (www.dentistryresearch.org) have taken part in an online vote to identify questions in day-to-day practice that they felt most needed to be answered with conclusive research. The question that receives the most votes each month forms the subject of a critical appraisal of the relevant literature. Each month a new round of voting takes place to decide which further questions will be reviewed. Dental practitioners and dental care professionals are encouraged to take part in the voting and submit their own questions to be included in the vote by joining the website. The paper below details a summary of the findings of the eighth critical appraisal. In order to address the question raised by the primary care dentistry research forum, first any international study was included that evaluated the effectiveness smoking cessation in dental practice. The aim was to understand whether smoking cessation in dental practice is an effective treatment strategy to increase tobacco cessation and abstinence. Moreover, this rapid assessment intended to identify whether there are certain types of smoking cessation intervention (or components of an intervention) in dental settings that are more effective than the others. In order to determine the applicability of the results to the NHS, we also looked for studies evaluating the cost-effectiveness of these interventions in NHS dentistry, studies reporting the current practice in NHS dentistry and finally qualitative and quantitative studies describing and evaluating the experience and views of dentists in the UK regarding implementing smoking cessation interventions in dental settings. The latter studies would help us to identify the possible barriers and facilitators in implementing these interventions in a dental setting. In conclusion, the critical appraisal of the international literature suggests that behavioural intervention for smoking cessation involving oral health professionals is an effective method of reducing tobacco use in smokers and users of smokeless tobacco and preventing uptake in non-smokers. There is not enough evidence available to assess whether these interventions are cost-effective and the effectiveness of one intervention (or component of the intervention) over another is not clear. The evaluation of the UK-related literature shows that private dental practices deliver more smoking cessation activities than their NHS counterparts. NHS practitioners report lack of reimbursement from the NHS, lack of time and training and fears over patient response as barriers to delivering smoking cessation interventions. We did not find studies evaluating the cost-effectiveness of the intervention in the UK.
In the UK, approximately 28% of the adult population smoke. The number of smokers has declined in recent years but the prevalence is still high in some disadvantaged parts of the country.1,2 General dental practice provides an ideal opportunity to support smokers in smoking cessation, however, lack of knowledge and time of practitioners and a lack of financial reimbursement has been a barrier to implementing tobacco cessation services.3 This review evaluates whether smoking cessation is an effective and cost-effective strategy for general dental practice, what are the current practises in UK, and what are the barriers and facilitators in implementing these interventions. The original question submitted was developed into the working question 'Is smoking cessation counselling in dental practise an effective and cost-effective service? How many GDP practices implement tobacco cessation programs in UK and how are these programs implemented? What are the barriers and facilitators in implementing smoking cessation counseling in dental practise in the UK?' In order to evaluate this, firstly randomised controlled trials conducted in any country were identified and critically appraised to find out whether smoking cessation in dental practise is an effective strategy or not. In order to understand the relevance of these results to the UK setting, studies describing and evaluating the current practise of smoking cessation in the UK, studies evaluating the experiences and views of dentists (barriers and facilitators) towards implementing smoking cessation in UK and studies evaluating the cost-effectiveness of the intervention UK were included.
Search for systematic reviews
Initially, a subject search was made of two databases to identify potential updated systematic reviews that summarised and synthesised the current literature on smoking cessation in dental practice. Eight relevant studies were identified on the Database of Abstracts of Reviews of Effects (DARE) and 42 on the Cochrane Database of Systematic Reviews (CDSR).
One Cochrane review addressed the topic of the effectiveness of smoking cessation programs3 and an update of this review was found in the International Dental Journal.4 This also addressed a separate question of whether in-house counselling in the dental practice is better than referring the patient to a specialist. The last search referenced in the update was in 2008. Consequently, for the question on the effectiveness of the intervention, this rapid assessment only included clinical trials that were published after 2008 and met the criteria of the Cochrane review to evaluate whether the Cochrane review is still up to date.3
Search for trials
A search was executed in MEDLINE (OVID) on 3 November 2010 using subject-related themes. The search strategy did not include any study design filter. An additional search was carried out in Cochrane Central Register of Controlled Trials (CENTRAL) to identify relevant clinical trials along with a search of the NHS Economic Evaluation Database for cost studies. Appendix 1 provides the detailed search strategies.
MEDLINE (OVID): 849 search results were initially retrieved and 26 potentially relevant studies to the effectiveness question were identified. However, all except five5,6,7,8,9 were excluded as they were either published before 2008 or did not match the inclusion criteria. Nohlert's 20099 study was omitted as it compared two methods of smoking cessation rather than examining individual effectiveness. Finally, only four studies were included in this rapid assessment.
Two cost studies10,11 and 14 potentially relevant studies were found addressing the questions of current practise of smoking cessation in dental practices in the UK or barriers and facilitators in implementing these interventions. Both cost studies were excluded as they were not conducted in the UK. From the 14 studies, only eight of them were eventually included;12,13,14,15,16,17,18,19 the other six were excluded as they did not focus on dentists in the UK or did not evaluate smoking cessation activities.
CENTRAL: 93 studies were initially identified. When searches were refined to 2008-2010, only 14 studies remained. None of these reported an additional randomised controlled trial (RCT) or quasi-RCT that matched the inclusion criteria but was not already identified by the MEDLINE search.
NHS Economic Evaluation Database: two studies were identified, one of which was irrelevant and the other had already been identified in the MEDLINE search.
Effectiveness of the intervention
Although the latest systematic review4 is quite recent, there are a number of randomised controlled trials published after this date. The Cochrane review included six trials; Needleman's 2010 review4 identified two additional trials; and the MEDLINE and CENTRAL searches identified four new trials. The outcomes and published updates of the Cochrane review have been summarised in Table 1 and an overview of the newly identified trials can be found in Table 2.
The Needleman 2010 review4 addressed a second question (that was not addressed in the Cochrane review3) of whether in-house counselling in the dental practice is better than referring to a smoking cessation specialist. The reviewers found two RCTs conducted in private dental practices. They did not report the quality of the studies for the latter question but noted that they had problems with statistical data. Both studies did not find any differences in quit rates between the in-house counselling and referral to smoking cessation specialists.
The available evidence suggests that behavioural intervention for smoking cessation involving oral health professionals is an effective strategy to increase tobacco abstinence rates amongst smokeless tobacco users. This was also the conclusion of the Cochrane review3 that predominately identified studies including participants who were using smokeless tobacco. The trials conducted after the date of the search of the Cochrane review are principally conducted amongst smokers. It seems that smoking cessation in dental settings can have a positive effect in smokers. To provide a clearer conclusion, the current studies need to be included in the quantitative synthesis and provide a pooled estimate on the effectiveness of the intervention. This is beyond the scope of this rapid assessment. There is a need for the current systematic reviews on the topic to be updated to provide clear evidence on the effectiveness of smoking cessation in smokers.
There were a few other Cochrane reviews that addressed a more general question but included studies involving oral health professionals. One of them provided a separate analysis of smoking cessation interventions involving dental professionals20 (Table 1). Three other Cochrane reviews evaluating smoking cessation intervention included studies involving oral health professionals but did not conduct separate analyses regarding whether these interventions were more or less effective than alternatives.21,22,23
Cost-effectiveness of the intervention
There were no studies evaluating the cost-effectiveness of smoking cessation in UK.
Current practise and barriers and facilitators to implementing smoking cessation
Eight studies were identified that address this question. Details are provided in Table 3.
Private practices seem to provide more smoking cessation services. They also less frequently reported barriers than NHS or mixed practices. Although a large number of dentists asked about patients' smoking habits, they less frequently provided smoking cessation advice, nicotine replacement therapy or referral to specialist services. The most common reported barrier to these interventions was a lack of time and resources. Two other barriers often reported were lack of training and concerns about patient response.
Two factors were reported as facilitators in delivering smoking cessation in dental practice: patients with oral health problems were more motivated than other patients, and reimbursement of smoking cessation advice or nicotine replacement therapy prescribed by the dentists can increase the interest of the dentist in delivering smoking cessation activities.
In conclusion, the international literature suggests that behavioural intervention for smoking cessation involving oral health professionals is an effective method of reducing tobacco use in smokers and users of smokeless tobacco and preventing uptake in non-smokers. There is not enough evidence available to assess whether these interventions are cost-effective and the effectiveness of one intervention (or component of the intervention) over another is not clear. The evaluation of the UK-related literature shows that private dental practices deliver more smoking cessation activities than their NHS counterparts. NHS practitioners report lack of reimbursement from the NHS, lack of time and training and fears over patient response as barriers to delivering smoking cessation interventions. We did not find studies evaluating the cost-effectiveness of the intervention in the UK.
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The author declares that she did not get funding for this review and do not have any conflict of interest. The article is solely the view of the authors and does not represent the views and policies of the Institute for Quality and Efficiency in Health Care (IQWiG) or British Dental Association (BDA). The Primary Care Dentistry Research Forum is sponsored by the Shirley Glasstone Hughes Trust.
The author declares no competing financial interests.
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Nasser, M. Evidence summary: is smoking cessation an effective and cost-effective service to be introduced in NHS dentistry?. Br Dent J 210, 169–177 (2011). https://doi.org/10.1038/sj.bdj.2011.117
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