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Service Delivery Innovation Profile

Public Health Dental Practitioners Offer Cessation Support to Low-Income Smokers, Leading to Increased Quit Rates


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Snapshot

Summary

Trained dental health practitioners offered tobacco cessation assistance to smokers as part of routine dental visits in 14 public health centers serving racially and ethnically diverse, low-income populations. The smoking cessation program was based on five components administered during patient visits; "ask, advise, assess, assist, and arrange" and included culturally tailored, self-help materials and free nicotine replacement therapy. The program significantly increased quit rates, especially among African-American smokers.

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial (RCT) involving 14 federally funded dental clinics located within community health centers, with the clinics being stratified by size and race/ethnicity of the population being served. The study included 2,637 participants who were randomly assigned to a group receiving program services or usual care (i.e., smoking cessation services from their primary care provider).
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Developing Organizations

Oregon Research Institute
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Date First Implemented

2006
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Patient Population

Race and Ethnicity > Black or african americanend pp

Problem Addressed

Compared with individuals of higher socioeconomic status, low-income individuals are more likely to smoke, tend to smoke for longer periods of time, and have less success in quitting (due in large part to having limited access to smoking cessation services).1 Limited access to smoking cessation programs for low-income individuals in many states compounds the problem.
  • More likely to smoke: Approximately 31 percent of low-income adults smoke, compared with 19.4 percent of adults living at or above the poverty level. Among adults under age 65, 37 percent of Medicaid recipients and 32.9 percent of uninsured individuals smoke, well above the 17.9 percent rate among those with private insurance.1
  • Less success when trying to quit: Roughly 70 percent of current U.S. adult smokers want to quit smoking completely, and millions have attempted to do so. However, higher-income smokers tend to be more successful in their efforts. For example, smoking rates among families with the highest income level fell by 62 percent between 1965 and 1999, well above the 9-percent reduction among families with the lowest income level.1
  • Longer periods of tobacco use: Smokers living in poverty smoke for an average (median) of 40 years, well above the 22-year median among smokers with household incomes three times above the poverty threshold.1
  • Limited access to comprehensive cessation programs: Only seven states offer comprehensive cessation benefits to all Medicaid beneficiaries. (Comprehensive benefits include all Food and Drug Administration–approved cessation medications, along with group and individual counseling.) Those Medicaid beneficiaries who have coverage often face significant barriers to accessing services, including copayments that dissuade them from seeking assistance and prior authorization requirements that limit the number of times they can access treatment.1

What They Did

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Description of the Innovative Activity

Trained dental health practitioners offered tobacco cessation assistance as part of routine dental visits in 14 public health centers serving racially and ethnically diverse, low-income populations. The smoking cessation program was based on five components administered during patient visits; "ask, advise, assess, assist, and arrange," and included culturally tailored, self-help materials for White and African-American participants and free nicotine replacement therapy. Key elements are described in more detail below.
  • Integration of smoking cessation assistance into routine care: Dental practitioners offered smoking cessation assistance, based on the 5 A's, as part of routine well visits for oral health:
    • Identifying smokers ("ask"): At each visit, dental practitioners asked patients about their tobacco use. During the RCT, those indicating that they used tobacco completed a brief survey. Those who had used tobacco within the past week (as indicated on the survey) could participate in the study, with enrollment dependent on completion of an informed consent document and baseline survey.
    • Educating on smoking's impact on oral health ("advise"): For patients who used tobacco, practitioners described its effects on their oral health status and advised them to quit. Oral health effects addressed included oral cancer, gum disease, and delayed healing after surgery.
    • Assessing readiness to quit ("assess"): Using a list of brief verbal questions, practitioners assessed the patient's readiness to quit. This included questions such as, "Are you willing to give quitting a try?" "Would you be willing to quit in the next 2 weeks?"
    • Offering assistance in quitting ("assist"): For patients who wanted to quit, practitioners helped set a quit date; distributed free, culturally tailored self-help materials (see below for more details); and discussed the benefits of nicotine replacement therapy, with free medication provided to those interested (as detailed below).
      • Tailored self-help materials: Self-help materials focused on the risks associated with tobacco use and the steps that can lead to quitting, with materials tailored to the type of tobacco being used (cigarettes or smokeless tobacco). Non-Hispanic African-American and non-Hispanic White participants received materials that were tailored for their culture and ethnicity (e.g., with varying language and visuals). Hispanics received a version that was translated from the materials for non-Hispanic Whites, and was not culturally tailored. When appropriate, the team used free materials from Federal agencies, including the Centers for Disease Control and Prevention and the National Cancer Institute, along with materials from the local tobacco quitline serving each community.
      • Discussion and provision of nicotine replacement therapy: Practitioners explained how nicotine replacement therapy increases quitting success and reduces withdrawal symptoms. In the RCT, clinic staff were responsible for dispensing the medication. However, in practice, the dentist would write a prescription.
      • Arranging for follow up support ("arrange"): Practitioners made arrangements for followup at the next visit for all patients. They also encouraged patients to use the quitline, especially if they had set a quit date.
      • Clinic staff training: Dentists, dental hygienists, dental interns and residents, and administrative staff took part in a 3-hour, inservice workshop focused on how to deliver smoking cessation assistance as part of routine oral health care. The workshop provided a comprehensive explanation of how the program works, including the role of administrative staff, use of the quitline, and protocols for dispensing nicotine replacement therapy.

Context of the Innovation

The program was implemented in 14 dental clinics within public health centers in Mississippi, New York, and Oregon. These centers generally served racially and ethnically diverse, low-income populations that often have high rates of tobacco use. Judith S. Gordon, PhD, a research scientist from the Oregon Research Institute, developed and tested this program in response to a request for applications from the Division of Cancer Control and Population Sciences within the National Cancer Institute. The program was built on a pilot study in two public health dental clinics that found that the typical patient served by a community health center visits the dentist several times a year. Dr. Gordon believed that these visits represented an untapped opportunity to have the dental team provide cessation advice and counseling.

Did It Work?

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Results

The program significantly increased quit rates (including those quitting for a prolonged period of time), especially among African-American smokers.
  • Higher quit rates: An assessment conducted 7.5 months after the intervention found that 11.3 percent of participants had quit smoking, well above the 6.8 percent quit rate among individuals receiving "usual care" (i.e., smoking cessation services through their primary care provider). In addition, 5.3 percent of participants had not used tobacco for at least 6 months, nearly triple the 1.9-percent rate among those receiving usual care. (See References/Related Articles to view the journal article on the study.)
  • Especially for African-American smokers: African-American smokers appear to have disproportionately benefited from the program, with 12.2 percent of non-Hispanic African Americans not using tobacco at the 7.5-month assessment date (compared with 7.7 percent of African Americans receiving usual care) and 6.5 percent having not used tobacco for the previous 6 months (compared with 2.0 percent of African Americans receiving usual care). The quit rate for non-Hispanic Whites was 10.7 percent, as compared with the usual care group, which was 4.9 percent. For Hispanics, the quit rate was 7.4 percent, as compared with the usual care group, which was 7.6 percent. Program developers believe that these higher rates among African Americans may in part be due to the use of recruitment flyers and self-help materials tailored to African Americans that had been tested and found to be effective in other studies. (See References/Related Articles to view the journal article on the study and obtain additional information on the discrepancy in quit rates.)

Evidence Rating (What is this?)

Strong: The evidence consists of a randomized controlled trial (RCT) involving 14 federally funded dental clinics located within community health centers, with the clinics being stratified by size and race/ethnicity of the population being served. The study included 2,637 participants who were randomly assigned to a group receiving program services or usual care (i.e., smoking cessation services from their primary care provider).

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Adapting intervention from "5 A's" model: Researchers adapted the "5 A's" model of the Clinical Practice Guideline for Treating Tobacco Use and Dependence, which includes the provision of nicotine replacement therapy to the dental office setting. The adaptation included a specific discussion of the affects tobacco has on oral health, along with the provision of free nicotine patches and lozenges.
  • Developing survey and assessment materials: Researchers developed enrollment materials and surveys, which included baseline and followup surveys for participants and practitioners.
  • Developing patient education and practitioner training materials: The research team conducted an extensive review of existing tobacco cessation educational materials to identify those that could be used and/or adapted to the target population. Using a team-based design, they developed a 3-hour training program for all dental clinic staff.

Resources Used and Skills Needed

  • Staffing: The RCT required the support of 6 senior researchers and 10 research assistants. (However, it is unlikely that a health center would need additional staff to implement the program in the absence of an RCT.)
  • Costs: Program expenses for participating clinics included payment for staff time during the training session and the costs associated with closing the clinic for training.
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Funding Sources

National Cancer Institute; Oregon Research Institute
The National Cancer Institute provided a $2 million grant to fund the research study; in addition to research-related costs, this grant covered a stipend paid to each participating clinic to cover the costs of program implementation and ongoing operations.end fs

Tools and Other Resources

Clinical Practice Guideline: Treating Tobacco Use and Dependence: 2008 Update: http://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/clinicians/update
/treating_tobacco_use08.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.)

Follow the link for more information about the 5 A's model: http://www.ahrq.gov/helpsmokersquit.pdf

Adoption Considerations

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Getting Started with This Innovation

  • Identify champions: Although dental practitioners may recognize the relationship between oral health and tobacco use, introducing a smoking cessation intervention during routine visits requires procedural and administrative changes within the clinic. Dental and administrative staff can play an important role in convincing other clinic practitioners of the need for this service.
  • Research reimbursement and coverage policies: Public and private insurers within each state have different coverage and reimbursement policies for tobacco cessation services. Would-be adopters of this program need to understand these policies, as they can create the need to modify record-keeping and patient monitoring systems.
  • Emphasize team approach to training: Training will be most effective if it helps all staff members understand their role in helping patients quit. To that end, it should focus on providing all dental and administrative staff with a strong understanding of the various program elements and how they will be integrated into the provision of routine oral health care.

Sustaining This Innovation

  • Monitor patients' tobacco cessation activities: Track the activities of those patients who have agreed to quit and, to the extent possible, those who have not. For example, quitlines can provide feedback on those who call the line after being referred by the clinic. Regularly reviewing this type of information as part of the patient's dental record can identify opportunities to modify or enhance patient interactions, with the goal of increasing participation and quit rates.
  • Discuss program at staff meetings: Set aside time during regularly scheduled staff meetings to discuss the program's impact on overall operations and on patient health. During these sessions, present information on the program's impact on patients (e.g., number of patients who participate, quit rates, etc.) and be willing to address any operational issues that may arise as a result of the program.
  • Train new staff: Allocate time and resources to train new dental and administrative staff on the program.

More Information

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Contact the Innovator

Judith S. Gordon, PhD
Associate Professor and Associate Head for Research
Dept. of Family & Community Medicine
University of Arizona
1450 N. Cherry Ave.
PO Box 245052
Tucson, AZ 85719
Phone: (520) 626-6452
Fax: (520) 626-6134

Innovator Disclosures

Dr. Gordon has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Gordon JS, Andrews JA, Albert DA, et al. Tobacco cessation via public dental clinics: results of a randomized trial. Am J Public Health. 2010;100(7):1307-12. [PubMed] Available at: http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2009.181214

Footnotes

1 Riordan M. Fact Sheet: Tobacco and Socioeconomic Status, Campaign for Tobacco-Free Kids. September 10, 2010. Available at: http://www.tobaccofreekids.org/research/factsheets/pdf/0260.pdf
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: January 19, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 11, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

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