• 2/7/2006
  • San Francisco, CA
  • Steven A. Schroeder, MD
  • J Am Dent Assoc, Vol 137, No 2, 144-148

Even though all health professionals understand how injurious smoking is, many may wonder whether the tobacco epidemic is yesterday’s news. After all, adult smoking prevalence is now at an all-time low in the United States—23.4 percent among men, compared with 57 percent in 1955, and 18.5 percent among women, compared with 34 percent in 1965.1,2 Smoking among youths is at a 28-year low. In public health terms, these are spectacular improvements. Furthermore, there is widespread speculation that obesity and physical inactivity soon may overtake tobacco as the most preventable causes of death and disability.3

But, as three articles in this issue of The Journal demonstrate, it is premature to drink a toast to tobacco’s demise, and there is good reason to believe that dentists can do more to reduce the toll from this deadly habit. Dye and colleagues4 analyze the data set for the Third National Health and Nutrition Examination Survey (conducted from 1988–1994) to assess the relationship between cigarette smoking and perceived needs for dental treatment. Compared with nonsmokers, smokers felt they needed more dental care, even when controlling for oral health status (odds ratio = 1.40), though the magnitude of this difference is much smaller than the fourfold risk smokers face of developing periodontal disease. Dye and colleagues call for greater involvement by dentists and dental hygienists in helping smokers quit, while acknowledging the barriers that must be overcome if that is to occur.

Hu and colleagues5 focus precisely on those barriers in their survey of smoking cessation practices among 783 dentists in east Texas. They found that 90 percent of the respondents were unfamiliar with the comprehensive U.S. Public Health Service 2000 Guideline “Treating Tobacco Use and Dependence,” which has become the gold standard for what health professionals should do to help smokers quit.6 Although more than 50 percent of the respondents usually or always asked about smoking status, and two-thirds recommended quitting, less than 20 percent spent three or more minutes counseling patients on cessation. Helping smokers quit occurred less commonly, and only 5 percent followed up on smoking status at subsequent visits. Because only 10 percent of respondents reported ever having received cessation training, Hu and colleagues recommend mandatory education about smoking cessation counseling for dental students and practitioners.

The article by Morse and Kerr7 analyzes the National Cancer Institute’s Surveillance, Epidemiology and End Results national registry to track oral and pharyngeal cancer rates among different sex and racial groups.7 An encouraging finding is the decline of both incidence and mortality, especially during the past two decades. They also highlight marked sex differences, with rates much higher in males than in females, as well as large racial differences among males (blacks greater than whites) but not among females. Since tobacco and alcohol use are the primary risk factors for such cancers, the authors recommend greater involvement of dentists in prevention and cessation.

Taken together, these three articles tell a coherent story: smoking is a major contributor to oral disease, and dentists underperform in identifying smokers and helping them to quit. In our work at the Smoking Cessation Leadership Center at the University of California, San Francisco (UCSF), we have noted similar findings among all health professionals. First of all, clinicians are good personal role models, as attested by the 6 percent smoking rate among dentists (R. Strouse, unpublished data) and 2 to 5 percent rate among professionals in different medical specialties. Second, all health professionals encounter the barriers to cessation noted by Dye and colleagues4 and Hu and colleagues5—insufficient time, lack of expertise, pessimism about success of cessation efforts and others.8 We also have found that most clinicians would like to do more, and that toll-free telephone lines offer a way to do so that does not require much time or expertise.8 Recently, a single national number (1-800-QUIT-NOW) was created to connect every American with free, effective cessation services.

For its part, the ADA offers a comprehensive Tobacco Use Cessation Resource kit, provides additional information on its Web site (ADA.org), and lobbies for tobacco control regulation/legislation in Washington. What’s more, in August 2002, the ADA received a $1.2 million grant from the National Cancer Institute to fund a five-year oral cancer prevention program. Pfizer Consumer Health Care and our UCSF Smoking Cessation Leadership Center provided additional funding for the program.

Through the program, the Association offers a five-hour continuing education course, which is being presented in various venues across the country. Half of the course centers on oral cancer detection; the other half is on tobacco-use cessation. Though targeted to dentists, many dental hygienists also have participated in this course. At this writing, 64 of these courses have been scheduled through November 2006; 47 already have taken place, attracting nearly 4,000 participants. The plan calls for the course eventually to be offered in all 10 U.S. Public Health Service regions nationwide.

Indeed, the American Dental Hygienists Association (ADHA) has developed an alternate model for those unable or unwilling to undertake the “5 A’s” model described in the Public Health Service Guideline. This model—Ask, Advise, and Refer (“http://askadviserefer.org”) —involves ascertaining smoking status for every patient, advising about the health benefits of cessation and referring the patient to a quitline. ADHA has pledged to double the rate of smoking cessation activity among dental hygienists from the current estimate of 25 percent of all smoking patients to 50 percent within three years. We have called this approach “Take 30 Seconds to Save a Life” and recommend it as one of three acceptable approaches to the patient who smokes. The most preferred option, as described by Hu and colleagues,5 is to become a cessation expert. But sadly, too few dentists are willing or able to do that and, as a consequence, millions of opportunities to intervene are lost. The second option is to practice in a setting in which systems are in place to identify all smokers and direct them to a cessation expert for counseling and appropriate pharmacotherapy. The third option is to adopt the ADHA approach, which now is being replicated by other health professionals, including pharmacists and family physicians. Our center has developed a prototype national referral card that is available at cost (approximately 13 cents/card) for all who would like it. Orders can be placed through the Smoking Cessation Leadership Center’s Web site (“http://smokingcessationleadership.ucsf.edu”). A fourth, and unacceptable, option is to do nothing. Given the fact that smoking causes so much oral disease, and that 70 percent of all smokers want to quit, missing the opportunity to help smokers quit is incompatible with being a dental health professional.8

Taken together, these three articles tell a coherent story: smoking is a major contributor to oral disease, and dentists underperform in identifying smokers and helping them to quit.

For those dentists who would like to become more knowledgeable about smoking, I highly recommend Rx for Change, a comprehensive curriculum for all health professionals developed by pharmacists at UCSF (“http://rxforchange.ucsf.edu”). In addition, Margaret Walsh and colleagues at the UCSF School of Dentistry are studying ways to translate the clinical guideline into dental settings. Stay tuned.

There still are almost 46 million smokers in the United States. Many of them want to quit, and it is well-established that the advice of a health professional can improve the chances of successfully quitting. Even a small increase in cessation rates would bring a tremendous health benefit.8 Dentists, who see patients more frequently than do most clinicians, should do their part.

Author’s affiliation:
Dr. Schroeder is a distinguished professor of health and health care, Department of Medicine, and the director, Smoking Cessation Leadership Center, University of California, San Francisco.

References:
1. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Cigarette smoking among adults: United States, 2004. MMWR Morbid Mortal Wkly Rep 2005;54:1121–4.[Medline]

2. Schroeder SA. Tobacco control in the wake of the 1998 Master Settlement Agreement. New Engl J Med 2004;350: 293–301.[Free Full Text]

3. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291:1238–45.[Abstract/Free Full Text]

4. Dye BA, Morin NM, Robison V. The relationship between cigarette smoking and perceived dental treatment needs in the United States, 1988–1994. JADA 2006;137:224–34.

5. Hu S, Pallonen U, McAlister AL, Howard B, Kaminski R, Stevenson G, Servos T. Knowing how to help tobacco users: dentists’ familiarity and compliance with the clinical practice guideline. JADA 2006;137:170–9.

6. Fiore MC, Bailey WC, Cohen SF, et al. Treating tobacco use and dependence: Clinical practice guideline. Rockville, Md.: U.S. Department of Health and Human Services, Public Health Service; 2000.

7. Morse DE, Kerr AR. Disparities in oral and pharyngeal cancer incidence, mortality and survival among black and white Americans. JADA 2006;137:203–12.

8. Schroeder SA. What to do with a patient who smokes: grand rounds at the University of California, San Francisco, Medical Center. JAMA 2005;294:482–7.[Abstract/Free Full Text]