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Promotion of Tobacco Cessation Through Dental Hygiene Education: A Pilot Study

Key words: tobacco cessation counseling, stages of change, transtheoretical model, dental hygiene education, barriers to counseling, health promotion

Submitted for publication 03/17/05; accepted 05/18/05

	Abstract

Top Abstract Tobacco cessation counseling Review of transtheoretical model... Transtheoretical model applied... Methods Results Discussion Recommendations for dental... Recommendations for further... References

 
The purposes of this pilot study were as follows: 1) to determine the percentage and frequency of dental hygiene graduates who were providing tobacco cessation counseling (TCC) activities, after receiving TCC training during their formative years of education; 2) to identify the graduates’ stages of change using the transtheoretical model regarding TCC; and 3) to identify factors influencing the delivery of TCC. A convenience sample of fifty-one Minnesota State University, Mankato (MSU) dental hygiene graduates were surveyed in this study. Wilcoxen signed rank tests were used to analyze the relationship between counseling actions and dental hygienists’ stage of change in four TCC activities: asking, advising, assisting, and arranging follow-up. Pros and cons affecting the delivery of TCC were also examined. Findings indicate that dental hygienists who received TCC education during their training do not provide cessation counseling to a high percentage of their patients even though they believe in the value of such activity. However, dental hygienists are more likely to provide TCC to patients with periodontal disease than other dental patients. Conclusions: 1) addressing the potential frustration of the dental hygienist and coping methods when providing TCC during training may alleviate one of the barriers to TCC; 2) ready access to tobacco education materials may alleviate one of the barriers to TCC; and 3) emphasis during TCC training on providing education for all patients as part of health promotion, rather than just periodontal patients, may increase the overall counseling provided.

Based on mortality statistics from 1995 to 1999, male adult smokers, compared to male adult non-smokers, lost an average of 13.2 years of life, while female adult smokers, compared to female adult non-smokers, lost an average of 14.5 years.³ An estimated 6.4 million children, as adults, will die prematurely from a smoking-related cause, if current tobacco use patterns continue in the United States.⁴ Prochaska and Velicer concluded, "If we could make even modest gains in our science and practice of smoking cessation, we could prevent millions of premature deaths and help preserve billions of years of life."⁵

On the American Dental Hygienists’ Association (ADHA) national dental hygiene research agenda of 2001, health promotion and disease prevention is listed as one of the top three priorities. Specifically addressed within this priority is the call to assess dental hygienist effectiveness in counseling with regard to prevention and cessation of tobacco use.⁶ On the ADHA website, President Tammi O. Byrd stated, "Oral health screenings provide a unique opportunity to give patients information that could save their lives and to place dental hygiene on the front line of smoking cessation intervention. The advice of a dental hygienist can be a major motivation for a quit attempt by a patient who smokes." A recent grant from the Robert Wood Johnson Foundation has instigated a tobacco cessation initiative by the ADHA.

The U.S. Public Health Service Clinical Practice Guideline, "Treating Tobacco Use and Dependence," recognizes dental health care providers among those primary care clinicians most relevant to providing brief interventions for smokers.⁷ According to Albert et al., national surveys revealed that only 25 percent of dental hygienists provide tobacco cessation counseling (TCC).⁸

Warnakulasuriya reviewed two previous decades of tobacco cessation activities among dental care providers and concluded that the most significant barrier to TCC by providers remains the lack of tobacco cessation education during formative years of training.⁹ Similarly, Ohman and Kellerman concluded that education in dental hygiene school about tobacco cessation is necessary to motivate dental hygienists to incorporate tobacco cessation into daily practice.¹⁰

In addition to incorporating tobacco education into school curriculums, Spangler et al. indicated that long-term follow-up studies have yet to be undertaken to determine retention of tobacco cessation skills beyond school.¹¹ Health care providers’ efforts to provide TCC can be categorized into stages of change according to the Transtheoretical Model of Change that is summarized in Table 1.⁵ Health care providers have the opportunity to provide smoking cessation counseling, but do not always choose to do so. Examining the stage of change the provider is in may provide insight into what counseling actions have been taken.

	Tobacco Cessation Counseling

Top Abstract Tobacco cessation counseling Review of transtheoretical model... Transtheoretical model applied... Methods Results Discussion Recommendations for dental... Recommendations for further... References

 
The National Cancer Institute and Clinical Practice Guidelines list several primary steps for implementing TCC in a primary care setting.^7,12 Steps within the counseling strategy are asking, advising, assessing, assisting, and arranging follow-up—known as the 5 As. Health care providers should utilize the appropriate steps to identify the patient’s willingness to quit, help smokers who want to quit by providing expertise and resources, and help motivate patients unwilling to quit. Even spending a brief amount of time, three minutes or less, implementing the tobacco cessation steps is effective in reducing tobacco use.

The first step involves systematically asking all patients, at every visit, about tobacco use.^7,12 Forms, stickers, electronic medical records, or computer reminder systems can be used to help remind health care providers to ask about tobacco use.

The next step involves advising all tobacco users to quit.^7,12 Advice given should be clear and strong. In addition, it is important to personalize the advice. This may include advising patients of the benefits of quitting, using photos to demonstrate risks and deleterious oral effects. In addition, relating tobacco use to current health/illness and social and economic costs personalizes the advice given. Using scare tactics and negative approaches should be avoided, since these techniques tend to make the patient defensive.

The third step involves assessing the willingness of the tobacco user to make a quit attempt.⁷ The health care provider should tailor the counseling provided based on the tobacco user’s readiness to change. At this time, the health care provider should identify which stage of change the tobacco user is in, utilizing the transtheoretical model described in the next section. This assessment includes identifying if the tobacco user is in the precontemplation, contemplation, preparation for action, action, or maintenance stage of change.

The fourth step involves assisting all tobacco users willing to quit by formulating a quit plan.⁷ A quit plan includes setting a quit date, ideally within the following two weeks. Social support and educational materials should be embedded within the quit plan. The health care provider should encourage the tobacco user to elicit help from family, friends, and coworkers. Counseling may include discussion of withdrawal symptoms and coping tips, referral resources, and nicotine replacement therapy.

The fifth and final step involves arranging scheduled follow-up contact for the tobacco user.^7,12 The follow-up contact should ideally occur within the first week after the quit date. In addition, a second follow-up should occur within the first month. The follow-up contacts allow the health care provider opportunity to congratulate the patient and assess if any problems have arisen.

	Review of Transtheoretical Model of Change

Top Abstract Tobacco cessation counseling Review of transtheoretical model... Transtheoretical model applied... Methods Results Discussion Recommendations for dental... Recommendations for further... References

 
Prochaska and Velicer described the Transtheoretical Model of Change as using a "temporal dimension, the stages of change, to integrate processes and principles of change from different theories of intervention, hence the name transtheoretical."⁵ The model of change involves six stages reviewed in Table 1. The sixth stage, termination, is not attainable due to the high risk of relapse. Fifteen core constructs are used within the transtheoretical model to describe one human function: the intentional change of behavior. Authors derived this model by analyzing and integrating multiple leading theories of psychotherapy and behavior change. Through research of smokers, Prochaska and Velicer discovered that participants used different processes at different times during attempts to quit smoking. Studies scrutinized by authors enabled them to theorize that change unfolds through a series of stages.

The transtheoretical model has been used to investigate a wide variety of issues including physicians’ practice of preventive medicine, alcohol and substance abuse, anxiety, panic disorders, delinquency, eating disorders, obesity, high-fat diets, AIDS prevention, mammography screening, medication compliance, unplanned pregnancy prevention behaviors, pregnancy and smoking, radon testing, sedentary lifestyles, and sun exposure.⁵

	Transtheoretical Model Applied to Tobacco Cessation Counseling

Top Abstract Tobacco cessation counseling Review of transtheoretical model... Transtheoretical model applied... Methods Results Discussion Recommendations for dental... Recommendations for further... References

 
The Transtheoretical Model of Change has been applied in other research studies to assess behaviors of physicians, health care providers, and smokers.^13–16 Goldstein et al. surveyed 246 primary care physicians regarding smoking cessation counseling practices and categorized physicians according to the Transtheoretical Model of Change; their findings are summarized in Table 2.¹⁶ Their results were used as the foundation for assessing TCC of dental hygienists in this study.

The extensive number of diseases associated with smoking, including oral cancer and periodontal disease, demands the attention of the dental staff including dental hygienists. Equipped with appropriate training, dental hygienists have a unique opportunity to increase both the oral and general health of their patients. Educators can promote TCC by incorporating the Transtheoretical Model of Change and the National Cancer Institute’s strategies of asking, advising, assessing, assisting, and arranging follow-up as part of the education curriculum. Research is needed to determine if dental hygienists with TCC education actually implement the techniques of TCC after graduation.

The purposes of this study were to 1) identify the percentage and frequency of trained MSU dental hygiene graduates implementing TCC activities (asking, advising, assisting, arranging) in dental practice, 2) identify the stage, using the Transtheoretical Model of Change, for trained MSU dental hygiene graduates regarding TCC activities in dental practice, and 3) identify factors that influence TCC among trained MSU dental hygiene graduates.

	Methods

Top Abstract Tobacco cessation counseling Review of transtheoretical model... Transtheoretical model applied... Methods Results Discussion Recommendations for dental... Recommendations for further... References

 
Minnesota State University, Mankato dental hygiene graduates of 2000, 2001, and 2002 received TCC education in the fall of their senior year. Two hours of didactic education were given regarding asking, advising, assisting, and arranging follow-up. Information about assessing a patient’s readiness to quit was added in 2001 and 2002. Each student completed an intensive intervention with one patient practicing the skills learned in lecture. Self-evaluation papers were completed by each student, addressing what they learned from the intensive intervention and concerns they had. All students were required to complete brief interventions utilizing a tobacco assessment form for all tobacco users in clinic during the remainder of fall and spring semester. As a result of feedback from previous classes, the class of 2002 was given a separate folder upon graduation containing copies of the necessary forms to encourage implementation of TCC in private practice.

The population for this study was all dental hygiene graduates who received tobacco cessation training during their formal education. Tobacco cessation counseling education was not provided until the fall of 1999. In the spring of 2003, after obtaining Institutional Review Board approval, we mailed surveys and a consent form for this study to sixty graduates from the classes of 2000 (N=19), 2001 (N=19), and 2002 (N=22). While fifty-three graduates (88 percent response rate) chose to participate, two of the graduates did not complete the survey because they were not working the minimum of one day per week as a dental hygienist.

The survey used in this investigation was adapted with permission from the instrument used by Goldstein et al.¹⁶ A total of sixty-seven items, in four sections, were included in the survey. The first section contained demographic data including year of graduation, type of dental practice, amount of time per appointment, smoking status, and family members’ smoking status. The second section of the instrument contained questions about four smoking cessation activities as described by the National Cancer Institute. Assessing readiness to quit was not included in the study as the class of 2000 did not receive training on this specific activity. Questions were designed to elicit which stage of change the dental hygienist was in regarding asking, advising, assisting, and arranging follow-up. Goldstein et al. determined validity of their stages of change scale by comparing it with the scale for thorough counseling developed by Lewis et al.^16,17 The third section of the instrument contained information regarding the frequency of smoking cessation activities including asking, advising, assisting, and arranging follow-up.

The fourth section of the instrument contained information related to factors that influence delivery of TCC. Park et al. developed a decisional balance "to better understand factors that may encourage or discourage physicians from providing smoking cessation counseling to their patients."¹⁸ This decisional balance consisted of twenty pros (facilitators) and cons (barriers) related to delivering tobacco cessation counseling. The current investigation used this decisional balance instrument after slight modifications. Eight additional pros and cons were added to the decisional balance based on factors identified by previous researchers.

	Results

Top Abstract Tobacco cessation counseling Review of transtheoretical model... Transtheoretical model applied... Methods Results Discussion Recommendations for dental... Recommendations for further... References

 
Fifty-one dental hygiene graduates qualified and participated in this study. The average dental hygiene graduate participant worked in general practice, provided care for an average adult patient in fifty- to sixty-minute appointments, attended zero hours of continuing education regarding smoking cessation, had previously smoked for a brief experimental period, and had zero family members who were current smokers.

Research Question 1.
What percentage and frequency of MSU dental hygiene graduates are implementing tobacco cessation counseling activities in dental practice?

This investigation examined the current tobacco cessation activities of MSU dental hygiene graduates one to three years after training during their senior year of education. Four individual counseling actions—asking, advising, assisting, and arranging follow-up—were examined. Percentages and frequencies of each action are provided for all patients and patients with periodontal disease (Table 3).

Research Question 2.
What is the identified stage, using the Transtheoretical Model of Change, for MSU dental hygiene graduates regarding tobacco cessation counseling activities in dental practice?

This investigation examined the relationship between all TCC activities using Wilcoxon signed rank tests (Table 5). MSU dental hygiene graduates were in a significantly later stage of change for assisting patients to quit as compared to arranging follow-up (p<.05). Additionally, MSU dental hygiene graduates were found to be in a significantly later stage of change for advising patients to quit as compared to asking about tobacco use. Furthermore, these graduates were found to be in a significantly later stage of change for advising patients to quit as compared to assisting patients to quit.

Regarding pros that affect TCC, the largest percentage, 88.2 percent, of dental hygiene graduates agreed or strongly agreed that dental hygienists can be effective in helping patients stop smoking (Table 6). Regarding barriers to tobacco cessation counseling, the largest percentage, 66.6 percent, of graduates agreed or strongly agreed that they do not have enough education materials, such as brochures, regarding tobacco cessation. Only 4 percent of graduates agreed or strongly agreed that smoking cessation counseling is not an efficient use of their time.

	Discussion

Top Abstract Tobacco cessation counseling Review of transtheoretical model... Transtheoretical model applied... Methods Results Discussion Recommendations for dental... Recommendations for further... References

Findings from this study suggest that dental hygienists with TCC education during their formative years of education do not provide counseling activities to a high percentage (81–100 percent) of all patients. In particular, the activities of asking about tobacco use, assisting to quit, and arranging follow-up were being performed by 5.9 percent or less of the dental hygienists. Tobacco cessation counseling education should stress the importance and impact of asking each patient about tobacco use. Additionally, the effectiveness of assisting patients to quit and arranging follow-up should be emphasized.

Given the limits of this investigation, graduates were found to ask a significantly lower percentage of patients about smoking and advised a higher percentage to quit (p<.001). The research data does not explain how the graduates were able to advise patients to quit without first asking about tobacco use. However, one may speculate that tobacco use was identified through a comprehensive medical history; therefore the need to ask was eliminated.

The counseling action of advising patients to quit was provided more frequently than assisting to quit or arranging follow-up, which is consistent with previous research.¹⁶ The MSU dental hygiene sample suggests that, even with education during their formative years, dental hygienists do not provide as much TCC as primary care physicians without specific tobacco cessation counseling training.

This sample suggests that dental hygienists do understand and appreciate the relationship between periodontal disease and smoking and they choose to increase the amount of tobacco counseling activities given for periodontal patients. Data from this study suggest that dental hygienists employ significantly more TCC activities for patients with periodontal disease than for all patients, except for the activity of arranging follow-up. This finding suggests that the dental hygienists have the ability to implement TCC activities, but do not choose to implement them on a regular basis for all patients. It is recommended that TCC education emphasize the importance of providing counseling to all patients, not just periodontal patients. Further research is needed to identify reasons for the lack of TCC activities from trained and capable dental hygienists.

Question 2.
To expand upon the research conducted by Goldstein et al., this investigation identified the stages of change for MSU dental hygiene graduates based on four of the tobacco cessation counseling activities.¹⁶ The majority of graduates in this study were in the early stages of change (precontemplation, contemplation, preparation for action) for asking, assisting, and arranging follow-up, and in later stages of change (action and maintenance) for advising patients to quit. This study identified 9.8 percent of graduates in later stages of change for assisting patients to quit, as compared to 37.0 percent of physicians. Nine percent of physicians were in the later stages of change for arranging follow-up care, while this investigation found only 3.9 percent of dental hygiene graduates in the later stages of change for providing follow-up care.¹⁶

This sample concurs with the finding of Goldstein et al. in that graduates were in a significantly later stage of change for assisting patients to quit as compared to arranging follow-up.¹⁶ MSU dental hygiene graduates were found to be in a significantly later stage of change for advising patients to quit as compared to asking about tobacco use. Furthermore, these graduates were found to be in a significantly later stage of change for advising patients to quit as compared to assisting patients to quit.

Research has demonstrated that TCC tailored to the patient’s stage of change is more effective than nontailored counseling.^5,7,19 Tobacco cessation counseling education may also be more effective if tailored to the health care provider’s stage of change.^5,16 Dental hygienists in this study received nontailored TCC education during their formative years of education. Future research is needed to clarify if stage-specific tailored TCC education for health care providers is more effective than nontailored TCC education.

Question 3.
Using a modified version of the decisional balance developed by Park et al., we identified several pros and cons as relating to TCC activities (Table 6).¹⁸ Previous research has identified that a common factor influencing tobacco cessation activities is the lack of time.^24–29 Albert et al., for example, found that 87.5 percent of dentists indicated time was a barrier to implementing TCC.⁸ Merely 4.0 percent of dental hygienists in this study agreed or strongly agreed that TCC was not an efficient use of time. Apparently, tobacco cessation counseling education during the formative years of training in this study impressed upon the dental hygienists that TCC was an efficient use of time.

The lack of education materials such as brochures has also been noted as a barrier to TCC in previous research.^28,29 In this study, 66.6 percent of dental hygienists, similar to the findings of Block et al., agreed or strongly agreed that the lack of education materials impacted their TCC.²⁸ Effective TCC education during the formative years of education includes access to education materials, with an emphasis on how to obtain these materials after graduation.

In this study, 54.9 percent of dental hygienists agreed or strongly agreed that counseling patients about smoking is frustrating. This finding is similar to barriers identified in previous research. Although one must speculate as to why counseling is frustrating for hygienists, one can agree that negative feedback from patients would impact the frustration level. Identified frustrations from previous research include negative feedback from patients, patient resistance, and lack of patient interest.^26,27,29 Successful TCC education includes discussion of why counseling may be frustrating. Using case studies based on patients who are resistant, uninterested, or negative may provide dental hygienists with an opportunity to discuss how to counsel these types of patients.

Fifty-one percent of dental hygienists agreed or strongly agreed that the lack of prompts or tracking systems limits their ability to counsel patients regarding tobacco. This finding is similar to the findings of Gottlieb et al. where 33.9 percent of family practice residents identified the lack of tracking systems as a barrier to counseling.²⁹

While previous research has shown the lack of referral knowledge is a barrier to TCC, 71.4 percent of dental hygienists in this study agreed or strongly agreed that they were aware of at least one referral source, with 28.6 percent unaware of referral sources.^19,25 This finding is similar to the findings of Gould et al., who found 25 percent of the dental team cited the lack of knowledge regarding referrals was a barrier to counseling.²⁷

In this study, 5.9 percent or less of dental hygienists asked about tobacco use assisted to quit or arranged follow-up for more than 80 percent of all patients. This finding seems unusual considering 88.2 percent of dental hygienists agreed or strongly agreed that they can be effective in helping patients to stop smoke. The results reported here indicate that additional research is needed to explore why dental hygienists believe they can be effective in helping patients to stop smoking, but do not provide counseling for more than 80 percent of all patients.

	Recommendations for Dental Hygiene Education

Top Abstract Tobacco cessation counseling Review of transtheoretical model... Transtheoretical model applied... Methods Results Discussion Recommendations for dental... Recommendations for further... References

 
In consideration of the findings of this investigation, recommendations for tobacco cessation education within dental hygiene curriculum include:

1. Provide case study examples focusing on the potential frustration of the dental hygienist and patient. In particular, attention should be given to how counseling should proceed when the patient seems unwilling to quit.
   
2. Discuss potential pros and cons related to tobacco cessation counseling.
   
3. Provide each graduate with a packet of materials that includes the tobacco assessment form and tobacco education materials, including websites and phone numbers to access additional information. This packet can be used by the graduate to implement tobacco cessation counseling within dental practice.
   
4. Encourage all practicing dental hygienists to attend an annual continuing education refresher course about tobacco cessation counseling.
   

	Recommendations for Further Research

Top Abstract Tobacco cessation counseling Review of transtheoretical model... Transtheoretical model applied... Methods Results Discussion Recommendations for dental... Recommendations for further... References

 
In consideration of the findings of this investigation, recommendations for future studies include:

1. Replicate this study with a larger sample, including dental hygienists trained during their formative years at other colleges or universities.
   
2. Determine whether factors such as year of graduation, time scheduled for an average adult patient, number of hours of continuing education regarding smoking cessation, current smoking status, and family members’ smoking status impact the hygienists’ stage of change.
   
3. Determine why hygienists are not implementing the tobacco cessation counseling skills they learned and used during their formative years of education.
   
4. Determine why hygienists are advising a higher percentage of patients to quit versus asking about tobacco use, assisting patients to quit, or arranging follow-up.
   
5. Determine what moves the dental hygienist to more advanced stages of change regarding tobacco cessation counseling activities.
   

	Acknowledgments

 
Angela Monson would like to thank the Minnesota Dental Hygiene Association for assistance with funding this investigation. Additionally, thank you to Steve Bohnenblust, Ed.D., and Norma Krumwiede, Ed.D., for help with statistical analysis.

	Footnotes

 
Prof. Monson and Prof. Engeswick are Assistant Professors of Dental Hygiene in the College of Allied Health and Nursing, Minnesota State University, Mankato. Direct correspondence and requests for reprints to Prof. Angela L. Monson, Dental Hygiene Department, 3 Morris Hall, Mankato, MN 56001; 507-389-2214 phone; 507-389-5850 fax; angela.monson{at}mnsu.edu.

Financial assistance was received for this project from the Minnesota Dental Hygiene Association.

	REFERENCES

Top Abstract Tobacco cessation counseling Review of transtheoretical model... Transtheoretical model applied... Methods Results Discussion Recommendations for dental... Recommendations for further... References

 

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