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IN BRIEF

The findings of this research confirm that dentists, hygienists and dental nurses
appreciate the importance of raising their patients awareness regarding the role of smoking in dental disease. Clinicians may be able to identify their own current barriers to providing smoking cessation advice to patients and then to consider how such barriers may be overcome. The paper will hopefully stimulate dentists to consider further training in the area of smoking cessation possibly for themselves and also for other members of their team.

Smoking cessation as a dental intervention Views of the profession

F. Stacey,1 P. A. Heasman,2 L. Heasman,3 S. Hepburn,4 G. I. McCracken5 and P. M. Preshaw6

Objective To undertake a questionnaire-based survey to determine the attitudes and activities of dental professionals in primary care in the Northern Deanery of the UK in relation to providing smoking cessation advice. Methods Questionnaires for dentists, hygienists and dental nurses were sent to hygienists to distribute to other members of the team. The information collected included: smoking status of the professionals and the practice; roles of the dental team in giving smoking cessation advice; levels of training received; and potential barriers to giving this brief intervention. Results Over 90% of practices were smoke-free environments and significantly more dental nurses (23%) were smokers compared to dentists (10%) and hygienists (7%) (p<0.01). The majority of dentists and hygienists enquired about smoking status of their patients and all three groups believed that hygienists and dentists should offer brief smoking cessation advice. Potential barriers to delivering smoking cessation advice were identified: lack of remuneration; lack of time; and lack of training. Conclusion Dental teams in primary care are aware of the importance of offering smoking cessation advice and, with further training and appropriate remuneration, could guide many of their patients who smoke to successful quit attempts.

most important risk factor for oral cancer.2 Smoking has also been shown to increase the risk of periodontal destruction, even in the presence of good plaque control.3 Therefore the role of the dental team in promoting smoking cessation advice (SCA) is relevant to both the general and specialty based dental disciplines to encourage our patients to stop smoking. This role has been investigated previously in questionnaire surveys undertaken in Scotland2 and the Oxford region.4,5 These questionnaire surveys, however, invited responses only from general dental practitioners, although all members of the dental team may promote this aspect of health care. Indeed, three North American studies have shown that dental hygienists can have a strategic input into SCA.7-9 There is also considerable evidence to indicate that aspects of smoking cessation training have been successfully incorporated into undergraduate curricula for all members of the dental team.10,11 The aim of this questionnaire study, therefore, was to determine the views and activities of dentists, dental hygienists and dental nurses with respect to the delivering of smoking cessation interventions in their own practices.

INTRODUCTION Smoking cessation advice has been suggested as a component of an overall oral health assessment in Options for change.1 In addition to the general health benefits of stopping smoking upon the increased risks of cancer, respiratory diseases and circulatory disorders, there are benefits more directly associated with the oral environment. Tobacco smoking has been identified as the

MATERIALS AND METHODS This was a questionnaire-based evaluation for which the Newcastle and North Tyneside Research Ethics Committee provided a favourable opinion. Study cohort The primary sampling frame for the study comprised dental hygienists. All dental hygienists working in the Northern Deanery of the UK were identified from the General Dental Councils Roll of dental hygienists. The questionnaires were then sent in packs of three to each hygienist with written information about the study and specific instructions to complete the hygienists questionnaire. The hygienist was also requested to distribute similar but specifically designed questionnaires to one dentist and one dental nurse in one practice. Questionnaire The questionnaires consisted of closed, 6-point, Likert-type questions. They were reviewed, revised and piloted by an independent evaluator with experience in questionnaire design.
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1,2*-6School of Dental Sciences, University of Newcastle upon Tyne, Framlington Place, University of Newcastle upon Tyne, Newcastle-upon-Tyne, NE2 4BW *Correspondence to: Professor Peter Heasman Email: p.a.heasman@newcastle.ac.uk

Refereed paper Accepted 27 September 2005 DOI: 10.1038/sj.bdj.4813829 British Dental Journal 2005; 201: 109-113
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The recipients were required to either highlight answers or make a given response numerically. Return of the questionnaires was requested within four weeks in a stamped-addressed envelope that was provided. All questionnaires had an identifier to monitor returns. After four weeks, those dental hygienists who had not returned the questionnaires were followed up once by letter. If the dental hygienist was unable to return all three completed questionnaires then they were asked to return those that had been completed. The questionnaires for each professional group were designed to collect information with respect to: Smoking status of the dental team member and the practice; Perception of their own role in giving SCA; Perception of other team members roles in giving SCA; Their own level of training in providing SCA; Perceived barriers to giving SCA. Respondents were also given an opportunity to make individual open comments in relationship to smoking cessation. Statistical analysis All data were entered numerically into a spreadsheet and a coding framework was devised to identify the questions within the output of the programme. SPSS version 10.0 statistical software package was used to analyse the data including inter-group analysis of variance. Frequencies and percentages were used to determine distributions of the responses for each of the variables. Percentages for each variable were based on the number of respondents for each question. Chi-square tests were undertaken using Minitab 13 for Windows. Ninety-two per cent of dental practices were reported to be smoke-free environments. Significantly more dental nurses (23%) were current smokers compared with dentists (10%) and dental hygienists (7%) (p< 0.01) (Table 1). Eighty-two per cent of dentists thought that they had a role to play in providing SCA but only 63% admitted to being actively involved. The respective data for hygienists were 91%, 55%; and for dental nurses 28%, 21%. More dentists (63%) and dental hygienists (55%) offered SCA compared with dental nurses (21%) (p< 0.001) (Table 1). More dental hygienists (96%), and dental nurses (92%) thought dentists should offer SCA than dentists did themselves (82%) (p = 0.002) and more dental hygienists (47%) than both dentists (39%), and dental nurses (28%), thought that dental nurses should offer SCA (p = 0.017). Around 90% of all members of the dental team believed that dental hygienists should offer SCA (dental hygienists 91%, dentists 89% and dental nurses 89%). More dentists (15%, and 11% respectively) than either dental hygienists (10% and 8%) or dental nurses (5% and 2%) thought that receptionists and practice managers should offer SCA (p = 0.042 and p = 0.031 respectively) (Table 1). More nurses (70%) than either dentists (4%) or dental hygienists (0%) never enquire about their patients smoking status (p< 0.001) (Table 1) and fewer dental nurses (26%) than either dentists (42%) or dental hygienists (47%) had knowledge of SCA support agencies and services (p = 0.005). Ninety-two per cent of dentists enquired about the smoking status of patients who presented with white lesions and 67% of those presenting with periodontal disease (data not in Tables). Dental hygienists enquired about smoking status in 74% of patients presenting with periodontal disease. Lack of training was regarded as a major potential barrier to giving SCA and it was considered very important by all respondents (Table 2). Four per cent of dentists had received SCA training prior to qualification and 26% had received training since

RESULTS One hundred and eighteen dental hygienists (70% of the total sample), 100 dentists (60%) and 106 dental nurses (63%) returned their questionnaires. The detailed responses from the questionnaires are presented in Tables 1 to 3.

Table 1 Smoking cessation views and activities of the dental team Responses of: Dentists (n = 100) Yes 10% No 75% Exsmoker 15% Dental hygienists (n = 118) Yes 7% No 82% Ex-smoker 11% Dental nurses (n = 106) Yes 23% No 63% Ex-smoker 14%

Do you smoke?

Do you enquire about your patients smoking status? Do you currently offer smoking cessation advice?

Always 34%

Sometimes 62%

Never 4%

Always 38%

Sometimes 62%

Never 0%

Always 30%

Sometimes 0%

Never 70%

Yes 63%

No 37%

Yes 55%

No 45%

Yes 21%

No 79%

Who do you think should offer advice?

Dentist Hygienist Dental nurse Receptionist Practice manager

82% 89% 39% 15% 11%

95% 91% 47% 10% 8%

92% 89% 28% 5% 2%

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Table 2 Barriers to smoking cessation advice as perceived by dentists, dental hygienists and dental nurses Likert scale Dentist Lack of training Hygienist Nurse Dentist Little chance of success Hygienist Nurse Dentist Lack of Remuneration * Hygienist Nurse Dentist Possibility of losing patients Hygienist Nurse Dentist Not perceived as their role Hygienist Nurse 0 not important 5% 0% 0% 20% 12% 11% 16% 31% 42% 44% 24% 28% 39% 41% 29% 1 0% 2% 2% 7% 7% 6% 2% 9% 2% 13% 18% 10% 10% 14% 10% 2 5% 4% 5% 15% 17% 16% 7% 10% 4% 11% 23% 15% 12% 9% 13% 3 18% 19% 19% 29% 39% 32% 14% 21% 13% 17% 19% 25% 22% 18% 23% 4 28% 12% 14% 15% 17% 19% 26% 13% 15% 7% 12% 10% 12% 9% 11% 5 very important 44% 63% 60% 14% 8% 16% 35% 16% 24% 8% 4% 11% 5% 8% 14%

Responses were measured on a Likert scale with 0 corresponding to not important and 5 to very important. *Significantly more dentists than dental hygienists and dental nurses thought that lack of remuneration was a major barrier to providing SCA in dental practice (p<0.001).

Table 3 Perception of the importance of the smoking cessation role for the dental team and general medical practitioners Responses from Dentists Yes Is it important for the dental team to offer smoking cessation advice? Is it important for doctors to offer smoking cessation advice? No Dental hygienists Yes No Dental nurses Yes No

96%

4%

94%

6%

89%

11%

100%

0%

100%

0%

99%

1%

qualification (data not in Tables). The respective data for dental hygienists and dental nurses were 17%, 28% and 8%, 5%. Lack of remuneration was also regarded a significant barrier to giving SCA but only by dentists (p < 0.001) (Table 2). Another barrier to giving SCA volunteered by respondents was lack of time. This was an issue expressed more often by dental hygienists (20%), than either dentists (10%) or dental nurses (7%) (p = 0.01). The responses in Table 3 indicate clearly that all members of the dental team believe that both they and general medical practitioners have an important role to play in the delivery of smoking cessation advice.

DISCUSSION The aim of this questionnaire-based study was to ascertain the attitudes and activities of the whole dental team in relationship
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to the provision of SCA in general dental practice. Previous UK questionnaire studies have sought information from dentists only.4-6 The favourable response rate (60-70%) suggested that the dental hygienists provided a good initial sampling frame. The questionnaires from the three professional groups show that 10% of dentists, 7% of dental hygienists and 23% of dental nurses smoke. As one in 10 dentists are current smokers this may map to the 8% of dental practices which are not smoke-free. A significantly higher number of dental nurses currently smoke compared to other members of the dental team. A majority of dental hygienists have been previously trained as dental nurses and it may be that becoming better informed of the risks of smoking, for example during dental hygiene training, has reduced smoking in this group. Dentists and dental hygienists believe that they, as professional groups, have a vital role to play in SCA but this was not necessarily reflected in their current activities. Eighty-two per cent of dentists believe that they should offer SCA but only 63% stated that they were actively involved. The same was true of dental hygienists with a perceived role expressed by 96% compared with only 55% being engaged in SCA activity. Only 28% of dental nurses feel that they had a role but, encouragingly, 21% of them reported offering some SCA. Thirty-nine per cent of dentists and 47% of dental hygienists also believe that dental nurses have a greater role to play. Studies have shown that dentists who smoke are less likely to offer SCA than those who do not smoke5,6,12 and as 23% of dental nurses in the survey were current smokers (and a further 14% of them being ex-smokers), this may be, at least in part, the reason for the low percentage of dental nurses who perceived that they have a role in SCA All groups are consistent in thinking that dental hygienists have a role to play in giving SCA and dentists, as team leaders, are regarded by virtually all PCDs as having an important role. Dentists also seem keen to involve other members of the dental team in SCA including receptionists and practice managers. This attitude
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Table 4 Comparison of responses from smoking cessation questionnaires from four UK studies2-4 and the current survey

Study Is yours a no smoking practice? Do you smoke? Do you currently offer SCA? Do you routinely enquire about patients smoking status? Do you routinely enquire about the smoking status of patients with periodontal disease? Do you think dentists have a role to play in SCA?

Scotland-19952

Oxford-19973

Oxford-20034

Current survey

Yes 96% Yes 12% Yes 86% Always 6% No 71% No 14% Sometimes *58% Never 35% Ex 17%

Yes 92% Yes 9% Yes *82% Always 18% No 62% No 18% Sometimes Never 82% Ex 28%

Yes 95% Yes 8% Yes 92% Always 48% No 62% No 8% Sometimes Never 51% Ex 28%

Yes

Yes 10% Yes 63% Always 34%

No 75% No 37% Sometimes 62%

Ex

Never 4%

Always **

Sometimes **

Never **

Always 51%

Sometimes 39%

Never 10%

Always 75%

Sometimes 21%

Never 4%

Always 67%

Sometimes

Never 33%

Yes 55%

No 45%

Yes 82%

No 18%

Yes 89%

No 11%

Yes 82%

No 18%

*The responses have been merged for comparative purposes only. **Respondents were not asked specifically about smokers with periodontal disease, although, when asked for comments, 50% thought smoking an important aetiological factor in periodontal disease.

would enhance the team approach and enable a more complete and structured programme for SCA to be established in a primary care setting. All team members could have a role, including administrative involvement.13 Approximately 30% of each professional group always enquire about the smoking status of their patients. The profile for dentists and dental hygienists is very similar, although a significantly greater number of dental nurses never enquire about smoking status of patients. These observations are consistent with the data showing that 28% of dental nurses think they should have a role and 21% who are actively involved. Nevertheless, as even brief advice does have an effect in motivating smokers to quit, this could certainly be imparted effectively by dental nurses.14 The difference between the perceived role of the dental professionals and their actual activities suggests that there are barriers to offering SCA. All respondents suggested that lack of training was a very important barrier and minimal SCA training had been undertaken either pre- or post-qualification by any of the members of the dental team who responded. Only 4% of dentists had received SCA training as an undergraduate. To some extent, dentists had recognised this lack of training as 26% had undertaken postgraduate training in SCA. Seventy per cent of respondents, however, have had no training in SCA. More dental hygienists had received training than the other groups: 45% in total; 17% during the dental hygiene course and 28% had received further training after graduation. This may reflect an increase in the availability of local courses in SCA for DCPs and, perhaps, a desire amongst dental hygienists to receive training as part of their continued professional development. This lack of training was further highlighted by the observation that less than half of respondents knew of any supporting agencies and services to which they could refer their patients for SCA. A fully integrated and successful approach to the effective delivery of SCA is only likely to be realised if the commissioners of health care and smoking cessation services are aware of
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this problem and then provide information for the dental team to allow easy and efficient referral of dental patients. Thirty-five per cent of dentists also highlighted lack of remuneration as a very important barrier to offering SCA, although this was not very important to the PCDs (16% dental hygienists, 24% dental nurses). The dentist, as the team leader, is more likely to be concerned as budget holder for the practice. In North America, there has been a poor uptake of smoking cessation programmes in primary dental care.15 Lack of time was a major obstacle for those attempting their implementation. Respondents in our study confirmed that lack of time indeed was a significant obstacle to the delivery of SCA (dentists 10%, 20% dental hygienists and 7% dental nurses). One fifth of dental hygienists highlighted time as a very important barrier to providing the service; given as additional comments by the dental hygienists. Another issue highlighted by dentists was moving into an area that they did not feel confident to handle, and that there were personal issues perpetuating a patients smoking habit. While this is undoubtedly true, many dental patients welcome being asked how they feel about their smoking habit.16 Direct comparisons can be made between the responses of the dentists in this survey and those of dentists in previous studies in Scotland4 and the Oxford region5,6 (Table 4). It should, however, be noted that the previous studies did not elicit responses from dental care professionals. The percentages of practices operating a no smoking policy in their waiting area were almost identical: 92% (Oxford), 96% (Scotland) and 92% (current survey) respectively. This had increased slightly to 95% in the more recent Oxford survey. The percentage of dentists smoking was also similar: 10% (Oxford), 12% (Scotland), and 9% (current survey) respectively. The same percentage of dentists (82%) in the Oxford and current surveys thought that they had a role to play in SCA compared to only 55% of Scottish dentists. The Scottish study is the oldest (1995) and this figure may
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now have increased and be more in line with the data of more recent surveys. Scotland also has one of the higher incidences of smoking per capita in the UK and this may make the task seem even more daunting for dentists. Enquiries about patients smoking status varies across the UK regions with 34% of dentists in the North of England always and 62% sometimes recording smoking status. In Scotland, the respective data were 6% and 58% and in Oxford, only 18% of dentists, in 1997, said they always or almost always enquired. This had, however, increased to 48% in 2003. Sixty-seven per cent of dentists in this survey always enquire about the smoking status of patients with periodontal disease. The data for the Oxford studies were 51%5 and 75%6 respectively an increase of 24% over six years. Scottish dentists were not specifically asked about their smoking enquiries to patients with periodontal disease but 50% did note that they thought that this was an important issue.4 Dentists opinions on DCPs having a role in SCA were only sought in this survey and in Scotland (not shown in Table 4). Eighty-nine per cent of dentists thought that hygienists had a role and 39% thought that dental nurses had a role. In Scotland 66% of dentists thought that DCPs collectively had a role.4 Again, this difference may be due to changing views over time and the perceived widening of the role of DCPs in particular. Geographical variation may also be contributory. With training and appropriate remuneration, the dental team can guide their smoking patients to successful quit attempts. Hygienists may already be able to devote a proportion of their time at some appointments to discuss smoking cessation. The magnitude of the effect of smoking as a risk factor for periodontal disease, however, suggests that a successful quit attempt is likely to have significant long-term benefit in maintaining a functioning dentition and dental health. The engagement of the entire dental team in delivering this brief intervention is, therefore, essential.
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