Patterns and correlates of tobacco control behavior among american association of pediatric dentistry members: a cross-sectional national study

Tobacco use, the single most preventable cause of premature disease and death in the United States [1], almost always begins during adolescence[2]. Every day in the U.S. more than 3000 youth under age 18 try their first cigarette[2]. It is estimated that half of these youths will become regular addicted smokers, and one-third will succumb to smoking related diseases[2]. Overall, 22% of high school students in the US currently smoke cigarettes and 11% of high school males use smokeless tobacco (i.e., oral snuff or chewing tobacco)[3].

The National Cancer Institute (NCI) recommends all health professionals help patients be tobacco-free by applying the following brief clinical intervention known as the "Five A's Approach" [4]:

▪ Ask all patients about tobacco use;

▪ Advise tobacco users to stop using tobacco and non-tobacco users to remain tobacco-free;

▪ Assess willingness of tobacco users to stop in the next month;

▪ Assist all tobacco users to stop based on their willingness to quit;

▪ Arrange appropriate follow-up.

Many pediatric dentists' patients are adolescents. This frequent contact provides an opportunity to provide a brief tobacco prevention or cessation intervention and reinforcement over an extended period of time enhancing an individual's ability to stop tobacco use [4–6]. The purpose of this study was to evaluate the tobacco control knowledge, attitudes, and behaviors of pediatric dentists and to identify predictors of recommended tobacco intervention behaviors. Although this study was conducted in 1998, a current review of the literature revealed that the most recent published national data on pediatric dentists are from 1994. There is an ongoing need to update the literature to provide benchmarks to monitor trends of compliance with tobacco treatment guidelines over time. This paper presents important new information because it not only reports prevalences of tobacco control behaviors, but also characteristics of providers and their settings related to those behaviors.

We surveyed members of the AAPD to assess their knowledge, attitudes and behaviors related to tobacco control activities in their dental practices.

Although findings indicate low knowledge levels about general adolescent tobacco use, pediatric dentists held positive attitudes about intervening with their adolescent patients. For example, over half of respondents believed pediatric dentists should encourage, advise, and assist tobacco users to quit using tobacco. In addition, 80% reported that trying to reduce adolescent tobacco use was worth the time. Despite these positive attitudes about intervening with tobacco-using adolescent patients, less than one-quarter of respondents (24%) reported always asking adolescents if they used tobacco. This finding, however, reveals an increase in the behavior of asking patients about tobacco use status compared to the finding of a 1994 survey that reported only 2% of pediatric dentists asked most patients about smoking[9]. The discrepancy might be due to the latter study not differentiating between adolescent and younger patients.

In our study, nearly three-fourths (73%) of respondents reported always or often advising known tobacco users to stop using tobacco, which is consistent with a previously published report on pediatric dentists (80%)[7]. These findings fall just short of the US Department of Health and Human Services Healthy People 2010 objective to increase to at least 85% the proportion of dentists who advise cessation[10].

Only 37%, however, reported always or often offering cessation assistance to known tobacco-using patients, similar to other reports[7, 9], but significantly less than the 85% Healthy People 2010 goal[10]. Perhaps low assisting involvement may have been from feeling unprepared to do so. Interventions are needed to address this void. In fact, over 70% of untrained responding pediatric dentists indicated a desire for training and 55% agreed, "It is a pediatric dentist's responsibility to help patients who wish to stop using tobacco to accomplish this." These findings agree with a 2001 pilot study of 173 pediatric dentists in which 56% felt it was part of pediatric dentists' role to help their adolescent patients stop smoking[6].

In a 1994 study including 586 pediatric dentists as a subgroup, Dolan and colleagues[7] reported, consistent with our findings, that only 12% of pediatric dentists had prior training in tobacco cessation counseling. However, the 2001 pilot study found the percentage increased to 18%, with a third of trained respondents indicating training in the past year[6]. Comparisons of our 1998 data with the 1994 data [7] indicated significant increases in positive attitudes and behaviors related to tobacco control among dentists who have a pediatric interest. For example, feeling very well or well prepared to assist users with quitting significantly increased from 12% in 1994 to 17% in our 1998 study (p < 0.001). In addition, asking patients always or often about smoking and smokeless tobacco use significantly increased from 2% for each in 1994[7] to 8% and 7%, respectively in the current study (p < 0.001). Assisting tobacco users with quitting significantly increased from 9% in the Dolan study[7] to 37% in the current study (both p < 0.001). Comparisons between our study and the 2001 study[6] were not possible due to differences between the two study designs.

Feeling prepared to ask and to advise were significantly predictive of asking, advising, and assisting. Moreover, a moderate association was noted between feeling prepared to ask with asking, and between feeling prepared to advise with assisting. These findings suggest the importance of preparing dentists who see a large number of adolescents on a fairly frequent basis to address tobacco use in their practices. Such training in tobacco cessation could greatly increase the quantity and quality of cessation services to pediatric dental patients.

In addition, the UC attitude score was consistently predictive of all 3 behaviors. This scale could be used to tailor different training program components based on prospective trainee attitude scores since such scores include barriers that could be targeted as educational activities. Female gender was predictive only of asking. Women may have been more likely to ask than men since female health care providers have been reported to be generally more empathetic based on an empathy scale used in a recent study training healthcare providers[11]. Even stratifying by year of graduation to adjust for potential confounding yielded significant gender effects for asking.

Lacking time has consistently been identified as a major barrier to delivering tobacco prevention services[12–14]. Almost half of respondents identified lacking time as a barrier (somewhat of a barrier or a strong barrier). Similarly, nearly half identified feeling most adolescent patients do not use tobacco. One-third of respondents identified lacking adequate reimbursement as a barrier, whereas previous studies reported 39% and 45%[7, 9]. The American Dental Association has a tobacco cessation services reimbursement insurance code, but many individual insurance contracts restrict coverage for tobacco prevention and cessation. Dental health policy makers and insurance providers need to address tobacco cessation benefits for patients in oral healthcare settings.

Importantly, 70% of respondents felt patients would resist cessation services. This perception contradicts the literature indicating that most adolescents who smoke want to quit[15, 16]. In addition, studies report that patients prefer smoking cessation counseling from a health professional over support groups, self-help, and telephone counseling[17]. A survey of 3,088 dental patients in 53 dental practices revealed that 58.5% believed that dental offices should provide tobacco cessation treatment services. There was equal support among tobacco users and nonusers[17]. Moreover, a survey of patients in independent dental practices and HMO clinics revealed that 40–67% of ST users reported interest in receiving cessation from their dentists. Patients not only expected oral health professionals to advise them on smoking related matters, but welcomed such involvement[18]. Educating pediatric dentists to these patient perceptions may help them overcome their perceived "patient resistance" barrier to helping adolescent patients stop tobacco use. Perceived patient resistance was reported in other studies at 56–94% [14, 19].

Respondent dentists in states with higher smoking prevalence were more likely to ask, advise, and assist. Perhaps respondents in these states with high smoking prevalence were more sensitized to the tobacco use problem, and more likely to have received tobacco cessation training, and therefore were more involved in tobacco prevention and cessation activities. In addition, respondents in the Pacific region were less likely to advise about tobacco use compared to those in the Atlantic or Central regions, which may be related to lower state tobacco use prevalence in Pacific region states.

Pediatric dentists can play an important role in preventing initiation or promoting cessation of tobacco use among adolescents to whom they provide care. Adolescents are a unique population. Studies report adolescents consistently rank physical attractiveness, dental concerns, and oral health as greatly important[20, 21]. Such findings are highly relevant to pediatric dental practice. They suggest relating smoking to short-term adverse effects associated with attractiveness and oral health may be more relevant and meaningful to an adolescent smoker than relating smoking to long-term health effects such as cardiovascular or lung diseases. Pediatric dentists are well positioned to identify tobacco-related oral health and hygiene problems in the mouths of adolescents who use tobacco. Incorporating this feedback in a brief tobacco cessation intervention in the pediatric dental care setting may encourage adolescents to try to stop smoking. Several studies have demonstrated brief cessation interventions by dental professionals who identify spit (smokeless) tobacco-related lesions in a client's own mouth and who provide brief cessation counseling are effective in helping patients stop their tobacco use[22–25].

Adolescence is the primary time for cigarette smoking initiation with transition from experimentation to some level of dependence[26]. About 65% to 70% of adolescents will try smoking before completing high school, more than one-third will become daily smokers, and almost one quarter will become nicotine dependent[27]. Most adult smokers began smoking by the age of 18[28]. Since adolescent smoking results in increased adult health problems, initiation and maintenance of smoking during adolescence represent a genuine public health concern. The need for effective interventions to prevent the transition from youthful smoking to adult smoking is clearly indicated[28].

Compared with adult smokers, adolescent smokers are more likely to be sporadic or non-daily smokers, and to have more variable smoking patterns on days they do smoke[29]. Nevertheless, many adolescent smokers begin to experience nicotine addiction early in their smoking careers and when smoking only sporadically or occasionally[30–33]. Adolescents may have greater vulnerability to nicotine dependence[34]. Animal studies suggest that processes involved in central nervous system maturation may play critical roles in the development of nicotine dependence[35, 36]. Even adolescents who smoke infrequently (e.g., only a few cigarettes a month) have a high probability of becoming regular adult smokers. In a large adolescent sample, Chassin et al. [37] found that the probability of adult smoking varied by smoking level in adolescence. Findings indicated that adolescents who had smoked more were more likely to be adult smokers, yet 25% of adolescents who had only smoked one or two cigarettes also became adult smokers (defined as smoking in the past week). Given that adolescents are so vulnerable to long term tobacco use, access to them becomes important for early intervention to prevent smoking initiation and to promote smoking cessation. Pediatric dentists are more likely to see teenagers than other health professionals on a regular basis[19].

A limitation of this study was that it was performed in 1998. Publication of the 2000 Clinical Guideline for the Treatment of Tobacco Use and Dependence[4] may have increased training of dentists in the area of tobacco prevention and cessation in dental schools and residency training programs, and in dental practices through dental continuing education. In addition, dental professional associations have actively advertised and supported the dentist's role in tobacco prevention and cessation. A review of scientific sessions sponsored by the AAPD from 2000 to 2006 and of AAPD articles published during the same time period revealed tobacco cessation programs in 2002 and 8 tobacco-related papers (3 on AAPD policy statements in 2000, 2003, and 2006; 3 on the negative health effects of tobacco use on oral health, 2 in 2003 and 1 in 2004; and 2 literature reviews on evidence-based tobacco interventions, 1 in 2000 and 1 in 2006). While these strategies may have increased tobacco-control knowledge among pediatric and general dentists, they appear not to have changed tobacco-control behavior dramatically in general dentists. In the past 15 years, prevalences of general dentists asking patients about tobacco use have not changed radically: ranging from 24% in 1992[38] to 33% in 1994[7] to <60% in 1997[39] to 26% in 2001[40] to 28% in 2005[41]. It is likely that changes in the prevalences of tobacco-control behavior among pediatric dentists over time have paralleled those of general dentists. Nevertheless, no national data on pediatric dentists are available since 1994[7]. Furthermore, factors related to tobacco control activities of pediatric dentists previously have not been reported.

Another caveat of this survey was its reliance on self-reports. Respondents may have overestimated their actual performance when reporting their tobacco cessation counseling behavior. Moreover, because the study sample was drawn from the membership of the AAPD, membership bias may be present in the sample. Dentists likely to join the AAPD may be more likely to perform tobacco cessation behaviors than those who are not members. Additionally, AAPD members include dentists who have pediatric dentistry specialty certificates from accredited programs as well as general dentists interested in treating pediatric patients but who are not certified as pediatric dentistry specialists. Another limitation of our study is that our survey did not distinguish between these two groups. We should therefore be cautious about completely accepting these self-reported values. However, these study results still provide useful information for comparison to other self-reports and for developing and targeting educational programs.

The Public Health Service Guidelines for brief clinical interventions[4] recommend all individuals seeking oral healthcare be asked if they use tobacco. Tobacco users should be advised to quit, assessed for willingness to quit, assisted appropriately based on willingness to quit, and follow-up arranged. Pediatric dentists could not only deter experimental smoking among adolescents by discussing the addiction's dangers, but also could provide referral for treatment for highly dependent smokers. Training programs to enhance knowledge and skills related to the treatment of tobacco use and dependence in pediatric dental settings may be needed and evidence indicates that such programs would be well received by pediatric dentists.

Respondents who felt prepared to intervene with patients about their tobacco use were much more likely to do so than those who did not feel prepared. Moreover, respondents with training in tobacco cessation counseling were more likely to assist tobacco users with quitting. These and other findings make a strong case for the need to better prepare dentists who treat pediatric patients to address tobacco use in their practices.