Improving Tobacco Dependence Education Among the Loma Linda University School of Dentistry Faculty

Methods

This project was designed to establish a 2008–09 baseline of tobacco dependence education (TDE) and TDE clinical practices, knowledge, and attitudes among the faculty. Additionally, it identified the effects of faculty development, curricular didactic, and clinical changes. After receiving the results of the faculty survey, we placed a focus on improving areas of curricular deficiencies and faculty development courses to enhance faculty knowledge.

Three weeks prior to distribution of the survey, additional TDE resources and patient educational materials were prominently displayed in three areas of the school: the patient lobby, the dental hygiene common area, and the Oral Health Care Stations of the clinic. Following a curriculum review, we established a Tobacco Treatment Committee comprised of chairs and faculty members from the departments of oral diagnosis, radiology and pathology, periodontics, dental hygiene, and restorative dentistry, the Center for Dental Research, and the dental school administration. The committee was formed to continue comprehensive curriculum revisions, improve clinical practice, enhance professional care of patients, and provide a faculty development resource.

An introductory letter was sent from the dean and the associate dean of academic affairs to 126 faculty members. Dental and dental hygiene faculty members employed at >0.4 FTE were e-mailed a SurveyMonkey link to an online questionnaire, which was anonymous and voluntary. SurveyMonkey, a web-based resource center, has the ability to track and remind survey nonresponders without violating their anonymity. The initial e-mail was followed by a ten-day reminder e-mail, a twenty-one-day reminder e-mail, and a final reminder at thirty days. Signs were posted in each department and on the school’s digital signage requesting faculty members’ participation in the survey.

The survey used in this investigation was adapted with permission from the instrument used by Davis et al.³⁰ The first section covered teaching methods, formal training, and lifelong learning; the second section focused on topics covered and time devoted to such topics; the third section inquired about respondents’ evaluation of student skills; and the fourth section investigated factors related to delivery of tobacco dependence training. Of the total fifty-seven questions, ten related to their formal training and teaching methods, fourteen focused on the topics faculty covered in their courses, seventeen related to resources and the use of the resources, and sixteen focused on assessing student skills and competency. Survey results were analyzed using Statistical Package for the Social Sciences for Windows (SPSS v. 15.0, Chicago, IL). The dean shared highlights from the survey with the faculty during a quarterly Faculty Advance Seminar. These tools were used to enhance the quality of education provided to students and the quality of health care provided to patients.

Results

The response rate to the survey was 101 out of 126 (80 percent) faculty members; seventy-one males and thirty females responded. The survey results revealed that while faculty members had limited formal training, numerous resources were being used to teach students: continuing education workshops, conferences, textbooks, professional journals, government agencies, private organizations, and websites. While 39.2 percent did not provide any tobacco-related instruction, the survey results revealed that tobacco-related topics are addressed in some way in every department. When asked about current graduates, 68.4 percent said they believe that, upon graduation, dental professionals should be able to perform at least a ten-minute moderate intervention, which as defined by the survey included Ask, Advise, Assess, Assist, Arrange, brief motivational interviewing, discussion of tobacco dependence treatment medications, and the 5Rs about benefits of quitting.

When asked about the benefit of additional faculty training, 73.4 percent of respondents agreed that faculty development in tobacco dependence treatment interventions would be beneficial. With this additional training, 58.5 percent agreed they would include TDE methods in their lectures and in clinic (Figure 1⇓). Among the respondents, 59.8 percent requested training in behavioral intervention techniques, 43.5 percent in diagnosis and treatment planning, and 42.4 percent in pharmacotherapy prescribing options. The results obtained from faculty members who were concerned about their lack of training during dental school are similar to those of other studies.^19,22–24

Figure 1.

Faculty responses to tobacco dependence education (TDE) survey

The survey results were also used to determine the type of courses needed to increase respondents’ knowledge base and confidence levels. As an intervention, five tobacco-related educational courses were provided to LLUSD faculty members to increase their knowledge and confidence levels in teaching TDE to students and treating tobacco-dependent patients. Faculty members perceived their educational needs to be greater than their available resources (Figure 2⇓). This result is similar to that in the Warnakulasuriya study,¹⁹ which found the most significant barrier to effective tobacco counseling in the dental office was a lack of formal training while in dental school. As a result, calibration sessions and additional faculty development courses designed to increase faculty confidence levels have been planned (Table 1⇓) as a further effort to improve the level of student interventions.

Figure 2.

Faculty perceptions and confidence levels

Discussion

Through the use of the online survey, a baseline of the school’s curricular content, clinical practices of faculty, faculty knowledge, attitudes and perceived barriers toward counseling, and the treatment of tobacco dependent patients was established. The Tobacco Treatment Committee reviewed the curriculum and restructured courses for a comprehensive curriculum in which topics were built on each other. Through these efforts, eight and four hours of TDE were added to the dental curriculum and dental hygiene curriculum, respectively (Table 1⇑).

In results similar to those of the study by Spangler et al.,³¹ LLUSD discovered a lack of integration between didactic content and clinical practice. Additionally, there was a failure to provide and teach supportive intervention skills (such as interviewing techniques, pharmacotherapy options, and instructions for working with patients who relapse), identified as missing components in the curriculum. While LLUSD has formerly taught tobacco-related topics in the departments of periodontics, dental hygiene, oral diagnosis, radiology, and pathology, the subject was also discussed in departments such as implant dentistry, pediatric dentistry, and public health dentistry although the tobacco curriculum had not been coordinated across the four-year dental curriculum and two-year dental hygiene curriculum. The topics were left to the discretion of each course director and lecturer. Utilizing the curriculum review and the faculty survey, there was a reorganization of tobacco-dependence teaching efforts across departments. Key faculty members were contacted regarding core courses and incorporating material related to tobacco dependence education. Changes were made in axiUm (v. 4.6 Exan Academic, Port Coquitlam, BC, Canada), the school’s computerized clinical patient records system, to include the Fagerstrom test,³² a nicotine withdrawal symptoms quiz,^33,34 and a tobacco counseling code.

Since the survey indicated there were insufficient education materials in the clinic for patients, we distributed referral flyers from the closest tobacco-dependence treatment clinic. Five hundred wallet cards from the California Smoker’s Helpline were distributed in the common areas and to the departments of dental hygiene, periodontics, oral diagnosis, radiology, and pathology, and 250 more wallet cards were distributed to students (two cards each) prior to their transition onto the clinic floor. The wallet cards, flyers, and fax referral forms are introduced annually during class to both dental and dental hygiene students. Referral flyers and wallet cards were replenished every quarter for faculty, students, and patients. Within two years after the initial survey, an eye-catching educational brochure was created that includes quitting tips, health tips, nicotine replacement therapy information, contact information for counseling, and pertinent websites. While wallet cards are available to patients in the lobby, the faculty use a team approach with compliant patients. The patient’s contact information is immediately faxed to the California Quit Line while the patient is still in the clinic. The use of biochemical monitoring was also made available via a carbon monoxide breath analyzer (COmpact Smokerlyzer, Bedfont Scientific Ltd., Williamsburg, VA) to motivate patients to quit using tobacco prior to oral surgery. Previous research has shown that when patients see initial results from a CO monitor, it plays an important role in correcting their problem.^35–37 Tobacco-using patients can be tested for baseline results and counseled about the ramifications of delayed wound healing and/or implant failure. At the subsequent appointment and also on the day of the surgery, the patient can then be retested to check progress.

LLUSD does not have clinical competencies in place to specifically measure dental student communication related to tobacco cessation, students’ motivational and counseling skills during patient treatment, and the monitoring of a patient’s tobacco withdrawal symptoms and pharmacotherapy needs. The lack of such clinic competencies may be a direct reflection of the faculty time constraints of supervising students on the clinic floor, combined with lack of formal training and low confidence levels.

However, identical to California statistics,³⁸ 14 percent of the LLUSD patient population have indicated in their health history that they use tobacco products. Additionally, an internal audit showed that only 0.56 percent of these patients have expressed an interest in quitting. With few tobacco dependent patients and even fewer interested in quitting, many faculty and dental students will never have the opportunity to experience treating and counseling this population at LLUSD. The survey results that showed a lack of faculty confidence toward counseling a patient could be a direct reflection of a lack of interested patients to treat.

Conclusions

LLUSD has a good model for the acquisition of dental knowledge and clinical skills, but there are no competencies in place related to TDE for graduating dentists. Because the dental hygiene program does have TDE competencies, some dental students have utilized a team approach and referred patients to the dental hygiene students for treatment. Currently, the LLUSD dental hygiene students are more competent and confident than dental students in counseling tobacco users, due to an existing curriculum, faculty commitment, and established clinical competencies. But until there are questions on the National Dental Board Examination regarding treating tobacco dependent patients or at the state level for dental license renewal, the barriers to treating these patients will continue to be hard to overcome.

Many positive and sustainable changes have been made at LLUSD, including twelve hours of additional curriculum (eight hours in dental and four in dental hygiene), establishment of a formal committee, additions to computerized clinic patient records, CO monitors available in the clinic, and personalized education materials. More time is spent in the curriculum on strategies to counsel and support these patients. Faculty development and clinic calibration sessions were scheduled for competency at moderate interventions. We will re-evaluate the LLUSD curriculum after the changes have been implemented for two years to measure effectiveness and determine if further changes are required.