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Examining the role of the orthodontist in preventing adolescent tobacco use: A nationwide perspective
ORIGINAL ARTICLE
Examining the role of the orthodontist in preventing adolescent tobacco use: A nationwide perspective Chad R. Searsa and Catherine Hayesb San Francisco, Calif, and Boston, Mass Purpose: The purpose of this study was to determine the level of antitobacco practices currently in place in orthodontic offices across the United States, so that an antitobacco standard of care might be derived. Methods: A 23-item survey was constructed and mailed to 200 orthodontists practicing in the United States, asking about antitobacco counseling and record keeping, concern for the matter, level of preparedness in helping a patient quit smoking, and potential barriers to effective antitobacco practices. Results: A corrected response rate of 59.5% (n ⫽ 119) was obtained. Whereas 89.9% of respondents were concerned about tobacco use by their adolescent patients, only 50% reported actually asking their patients whether they use tobacco. Most orthodontists (67.5%) reported that they are either “not sure” or “not ready” to provide effective cessation counseling to patients who use tobacco, but 61.1% would be willing to integrate a tobacco control program into their practices. No orthodontists were familiar with the National Cancer Institute’s strategy for doctors to help their patients stop tobacco habits, called the “Five A’s” (formerly the “Four A’s”). Conclusion: Because of the unique and often positive interactions orthodontists have with their adolescent patients, members of the specialty can play significant roles in educating patients about the health effects of tobacco use. Because of the lack of adequate training, this education is not taking place in orthodontic practices in the United States. (Am J Orthod Dentofacial Orthop 2005;127:196-9)
T
he role of the dental team in educating and counseling patients who use tobacco has increased in importance in recent years. The National Cancer Institute (NCI) has outlined a minimum tobacco use intervention for the dental professional in a simple format: the “Four A’s.”1 These 4 steps included asking questions about tobacco use, advising patients to stop using tobacco, assisting patients in stopping, and arranging for appropriate follow-up with those trying to quit. Recently, an additional step has been added, forming a newly revised “Five A’s” (Table).2 The additional step includes assessing patients’ willingness to make a quit attempt. Orthodontists and pediatric dentists are in a unique position to play an important role in educating their adolescent patients about abstaining from smoking during these very formative years, when they are a
Orthodontic resident, Department of Growth and Development, University of California, San Francisco, Calif (project completed while a dental student at Harvard School of Dental Medicine, Boston, Mass). b Associate professor of oral health policy and epidemiology, director of predoctoral research, Harvard School of Dental Medicine, Boston, Mass. Reprint requests to: Dr Catherine Hayes, Harvard School of Dental Medicine, 188 Longwood Avene, Boston, MA 02115; e-mail, catherine_hayes@ hms.harvard.edu Submitted, July 2003; revised and accepted, August 2004. 0889-5406/$30.00 Copyright © 2005 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2004.08.013
196
plagued by endless peer pressure and influence from the media. A recent study found that only 2% of pediatric dentists asked “most or nearly all” of their patients whether they smoke, whereas 33% of general dentists and 71% of periodontists asked.3 Compared with pediatricians and physicians, dentists could least accurately estimate smoking prevalence in their adolescent patients and usually underestimated these numbers.4 Although it has been shown that 89% of adult smokers began smoking before they turned 18 years of age,5 orthodontics has not used this statistic in developing tobacco abuse prevention guidelines. Previous studies found low compliance with the Four A’s by practitioners, despite training and incentives.6,7 The purpose of this study was to determine the current level of routine tobacco control efforts in US orthodontic practices by surveying a random sample of practicing orthodontists. Additionally, the overall level of readiness of orthodontists to help a patient stop smoking and the willingness to infuse daily practice with more extensive antitobacco measures were assessed. MATERIAL AND METHODS
A total of 200 orthodontists, 4 from each of the 50 states, who are members of the American Association
American Journal of Orthodontics and Dentofacial Orthopedics Volume 127, Number 2
Sears and Hayes 197
Table. The Five A’s: National Cancer Institute’s recommendations for routine, minimum clinical tobaccouse interventions by the dental team2 ● ● ● ● ●
Ask questions about tobacco use Advise patient to stop using tobacco Assess patients’ willingness to make a quit attempt Assist patient in stopping Arrange for appropriate follow-up
of Orthodontists, were randomly selected to participate in this survey. Each participant received a 4-page survey along with a cover letter and a prepaid, addressed return envelope. Two weeks later, a reminder postcard was sent, followed by a second mailing of the initial survey after another 2-week period. The survey was based on a similar questionnaire developed by the National Dental Tobacco-Free Steering Committee.8 The survey contained 23 numbered items plus additional demographic information, including age, practice location, gender, ethnicity, number of years practicing orthodontics, and questions regarding current daily routine of antitobacco practices based on the Four A’s: ask, advise, assist, arrange. Secondary questions to these 4 main concepts were then presented to obtain a more detailed picture of approximate amounts of time spent questioning, keeping records, and providing follow-up. Data were coded and entered into an Excel (Microsoft, Redmond, Wash) database. Statistical analysis of the acquired data was performed with SPSS/PC 11.1 (SPSS, Chicago, Ill). Frequencies and distributions were prepared, and chi-square analysis was conducted to compare survey responses by gender, age, ethnicity, and geographic region. RESULTS
Of the original 200 surveys mailed, 119 were collected, giving a corrected response rate of 59.5%. Most respondents were male (87.5%) and white (93.2%). The distribution of respondents by region (according to the breakdown by the U. S. Bureau of the Census9) was 20.2% western, 27.7% north central, 32.8% southern, and 19.3% northeastern. Among the practitioners who responded, there was a fairly even distribution between the ages of 30 and 75 years. The orthodontists surveyed were nonsmokers by a large majority (96.6%), which is consistent with published data on smoking prevalence among dental health professionals.10 Orthodontists were asked to estimate what percentage of patients seen in their offices were adolescents (defined as aged 12-18 years): 83.3% of respondents
Fig 1. Percentage of practitioners using “4 A’s” in daily practice.
reported that at least 50% of their patient population was in this age group, with 40.8% of these doctors having more than 71% of their patients in this group. When asked to estimate the percentage of adolescents in their practices who are tobacco users, 59.1% of orthodontists guessed that fewer than 10% of their adolescent patients use tobacco. The remaining 40.9% of orthodontists guessed that up to 25% of their adolescent patients are tobacco users (with most of these respondents guessing that 10% to 25% of their adolescent patients use tobacco). Because dentists have been shown to underestimate tobacco use in adolescent patients, the possibility of a higher prevalence is likely.4 Recent findings have shown that more than one third of high school students have recently used some form of tobacco,11 and it is estimated that 6000 American adolescents per day try tobacco for the first time, and 3000 of them will become regular smokers.12 Ninety percent of responding orthodontists were concerned about their patients using tobacco products, but only 50% of them ask their patients whether they use cigarettes, cigars, or smokeless tobacco. Of the 50% who ask about tobacco use, almost 70% provide advice and educate tobacco-abusing patients about the hazards of tobacco use. The vast majority, 92.3%, reported that they do not provide any active assistance in tobacco cessation for patients who are tobacco abusers. Of the less than 8% who do offer assistance, 80% reported using 1 method of counseling, which is usually verbal counseling. These findings are summarized in Figure 1. Orthodontists’ current level of preparedness in
198 Sears and Hayes
Fig 2. Orthodontists’ current level of preparedness in practicing tobacco cessation techniques.
practicing tobacco cessation techniques is detailed in Figure 2. More than half of the respondents stated that time and patient acceptance of counseling are the 2 most significant barriers to full incorporation of tobacco abuse prevention into daily practice, whereas such factors as lack of comfort with the topic, lack of support from auxiliary staff, and concerns about parental consent were not considered to be significant barriers. None of the orthodontists responding could name all 4 components of the Four A’s, the NCI’s method of tobacco control education. This suggests that the Four A’s concept has not permeated all specialties of dentistry. Despite not knowing the concept of the Four A’s when asked directly about it, some orthodontists use various aspects of this antitobacco measure (summarized in Fig 1), when the 4 main components were questioned individually in the survey. Adjusting for years in practice, location, gender, and ethnicity did not significantly affect the results. Each of the 4 predetermined geographic regions showed fairly homogeneous ranges of response, resulting in a lack of regional differences. Gender and ethnicity did not affect our results to any great degree, because of the exceptionally high number of white men who were randomly chosen. DISCUSSION
Given our response rate of 59.5%, coupled with the fact that all states except 3 are represented in this survey, we believe that these results represent a fairly good cross-section of practicing orthodontists. Likewise, we had a diverse age range of respondents. Most responding orthodontists were white men; this might be an accurate reflection of the profession’s demographics. Perhaps the most surprising of our results is that nearly 90% of orthodontists are concerned about
American Journal of Orthodontics and Dentofacial Orthopedics February 2005
whether their patients use tobacco products, but only half of them routinely ask their patients whether they use such products. Because orthodontic treatment typically involves seeing a patient regularly (eg, monthly), one might view this finding as a lost opportunity to discuss potential problems with, and reinforce resolutions for, tobacco use. As a minimum measure of screening for tobacco use, orthodontists might consider making this question part of their health history form and routinely updating this information along with other health information. Lack of questioning might be a result of inadequate training in how to deal with or treat a tobacco user who wishes to quit. As we found, most orthodontists (93%) do not offer cessation services in the office. A paucity of cessation services is most likely because orthodontists feel ill-equipped to handle such situations and also have time constraints, since most orthodontic practices function by seeing many patients daily. These time constraints underscore the importance of having not only the orthodontist but also the auxiliary staff trained in tobacco cessation practices. When orthodontists responded to items on the survey that allowed open-ended responses, statements frequently read as such: “[tobacco prevention is] not worth the time,” “it’s their life,” “it’s not our job,” “may not be appropriate,” and “lack of need.” Because current standards in dentistry aim to have dentists realize that they are treating a “whole patient” and not just a mouth, is it the dentist’s or the orthodontist’s responsibility to be concerned about a patient’s tobacco use history? For the orthodontist, will patient management and sensitivity be issues of concern when he or she asks adolescents about tobacco use? One possible means of maximizing the potential of each orthodontic appointment with an adolescent patient for antitobacco purposes might be to require an NCI training program in prevention and cessation techniques, called “How to Help Your Patients Be Tobacco-Free.” If offered during the orthodontic residency, the training could potentially be geared toward the orthodontic practitioner specifically and how he or she can obtain the most positive results from patient contact. Gould et al13 showed not only that dentists asked about tobacco use and assisted their patients in quitting after completing this course but also that dentists felt more confident and prepared in helping their patients do so. The American Association of Orthodontists or the American Dental Association might consider endorsing such a program as an initiative. Tobacco use is a clinical, social, and public health problem that must be addressed by all health profes-
Sears and Hayes 199
American Journal of Orthodontics and Dentofacial Orthopedics Volume 127, Number 2
sionals. By not giving our patients any quitting assistance, we, as professionals in the health care system, are effectively overlooking a major aspect of their current health status, an aspect that has far-reaching consequences for the patients and those around them. Orthodontists in particular are in an opportune position to deliver effective, frequent antitobacco messages to their patients. CONCLUSIONS
1. Adolescent tobacco-control measures in orthodontic offices are being severely underused. 2 Orthodontists should ask about tobacco use on the patient health history form as a minimum measure of screening for this health concern. 3 Orthodontists are concerned about adolescent tobacco use but often do not feel obligated or qualified to counsel their patients. 4 Practicing orthodontists do not feel prepared to educate their patients in tobacco control. 5 Graduate orthodontic programs or dental schools might consider brief mandatory training courses in tobacco abuse prevention, with special consideration for adolescents. REFERENCES 1. Mecklenburg RE, Christen AG, Gerbert B, Gift MC, Glynn TJ, Jones RB, et al. How to help your patients stop using tobacco: a National Cancer Institute manual for the oral health team. NIH publication no. 91-3191. Bethesda, Md: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute; 1991.
2. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence. Clinical practice guideline. Rockville, Md: U.S. Department of Health and Human Services, Public Health Service; 2000. 3. Dolan TA, McGorray SP, Grinstead-Skigen CL, Mecklenburg R. Tobacco control activities in U.S. dental practices. J Am Dent Assoc 1997;128:1669-79. 4. Gregorio DI. Counseling adolescents for smoking prevention: a survey of primary care physicians and dentists. Am J Public Health 1994;84:1151-3. 5. Office of Smoking and Health. Preventing tobacco use among young people: a report for the Surgeon General. Atlanta: National Center for Chronic Disease Prevention and Health Promotion; 1994. 6. Hovell MF, Slymen DJ, Jones JA, Hofstetter CR, Burkham-Kreitner S, Conway TL, et al. An adolescent tobacco-use prevention trial in orthodontic offices. Am J Public Health 1996;86:1760-6. 7. Hovell MF, Jones JA, Adams MA. The feasibility and efficacy of tobacco use prevention in orthodontics. J Dent Ed 2001;65:348-53. 8. Hayes C, Kressin N, Garcia R, Mecklenberg R, Dolan T. Tobacco control practices: how do Massachusetts dentists compare with dentists nationwide? J Mass Dent Soc 1997;46:9-14. 9. National Institutes of Health. Plan and operation of the second national health and nutrition examination survey 1976-1980. Available at: http://archive.nlm.nih.gov/proj/dxpnet/nhanes/ docs/doc/nhanes2/plan.pdf. Accessed June 2002. 10. Dolan T, McGorray SP, Grindstead CL. Dentist’s tobacco cessation activities by specialty status and geographic region. J Dent Res 1996;75:19. 11. Centers for Disease Control and Prevention. Tobacco use among high school students—United States. Morbid Mortal Wkly Rep 1998;47:229-33. 12. Giovino GA. Epidemiology of tobacco use among US adolescents. Nicotine Tob Res 1999;Suppl 1:S31-40. 13. Gould KA, Eickhoff-Shemek JM, Stacy RD, Mecklenburg RE. The impact of national cancer institute training on clinical tobacco use cessation services by oral health teams. J Am Dent Assoc 1998;129:1442-9.
AVAILABILITY OF JOURNAL BACK ISSUES As a service to our subscribers, copies of back issues of the American Journal of Orthodontics and Dentofacial Orthopedics for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted. Please write to Elsevier Inc. Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL 32887, or call 800-6542452 or 407-345-4000 for information on availability of particular issues and prices.
Examining the role of the orthodontist in preventing adolescent tobacco use: A nationwide perspective Chad R. Searsa and Catherine Hayesb San Francisco, Calif, and Boston, Mass Purpose: The purpose of this study was to determine the level of antitobacco practices currently in place in orthodontic offices across the United States, so that an antitobacco standard of care might be derived. Methods: A 23-item survey was constructed and mailed to 200 orthodontists practicing in the United States, asking about antitobacco counseling and record keeping, concern for the matter, level of preparedness in helping a patient quit smoking, and potential barriers to effective antitobacco practices. Results: A corrected response rate of 59.5% (n ⫽ 119) was obtained. Whereas 89.9% of respondents were concerned about tobacco use by their adolescent patients, only 50% reported actually asking their patients whether they use tobacco. Most orthodontists (67.5%) reported that they are either “not sure” or “not ready” to provide effective cessation counseling to patients who use tobacco, but 61.1% would be willing to integrate a tobacco control program into their practices. No orthodontists were familiar with the National Cancer Institute’s strategy for doctors to help their patients stop tobacco habits, called the “Five A’s” (formerly the “Four A’s”). Conclusion: Because of the unique and often positive interactions orthodontists have with their adolescent patients, members of the specialty can play significant roles in educating patients about the health effects of tobacco use. Because of the lack of adequate training, this education is not taking place in orthodontic practices in the United States. (Am J Orthod Dentofacial Orthop 2005;127:196-9)
T
he role of the dental team in educating and counseling patients who use tobacco has increased in importance in recent years. The National Cancer Institute (NCI) has outlined a minimum tobacco use intervention for the dental professional in a simple format: the “Four A’s.”1 These 4 steps included asking questions about tobacco use, advising patients to stop using tobacco, assisting patients in stopping, and arranging for appropriate follow-up with those trying to quit. Recently, an additional step has been added, forming a newly revised “Five A’s” (Table).2 The additional step includes assessing patients’ willingness to make a quit attempt. Orthodontists and pediatric dentists are in a unique position to play an important role in educating their adolescent patients about abstaining from smoking during these very formative years, when they are a
Orthodontic resident, Department of Growth and Development, University of California, San Francisco, Calif (project completed while a dental student at Harvard School of Dental Medicine, Boston, Mass). b Associate professor of oral health policy and epidemiology, director of predoctoral research, Harvard School of Dental Medicine, Boston, Mass. Reprint requests to: Dr Catherine Hayes, Harvard School of Dental Medicine, 188 Longwood Avene, Boston, MA 02115; e-mail, catherine_hayes@ hms.harvard.edu Submitted, July 2003; revised and accepted, August 2004. 0889-5406/$30.00 Copyright © 2005 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2004.08.013
196
plagued by endless peer pressure and influence from the media. A recent study found that only 2% of pediatric dentists asked “most or nearly all” of their patients whether they smoke, whereas 33% of general dentists and 71% of periodontists asked.3 Compared with pediatricians and physicians, dentists could least accurately estimate smoking prevalence in their adolescent patients and usually underestimated these numbers.4 Although it has been shown that 89% of adult smokers began smoking before they turned 18 years of age,5 orthodontics has not used this statistic in developing tobacco abuse prevention guidelines. Previous studies found low compliance with the Four A’s by practitioners, despite training and incentives.6,7 The purpose of this study was to determine the current level of routine tobacco control efforts in US orthodontic practices by surveying a random sample of practicing orthodontists. Additionally, the overall level of readiness of orthodontists to help a patient stop smoking and the willingness to infuse daily practice with more extensive antitobacco measures were assessed. MATERIAL AND METHODS
A total of 200 orthodontists, 4 from each of the 50 states, who are members of the American Association
American Journal of Orthodontics and Dentofacial Orthopedics Volume 127, Number 2
Sears and Hayes 197
Table. The Five A’s: National Cancer Institute’s recommendations for routine, minimum clinical tobaccouse interventions by the dental team2 ● ● ● ● ●
Ask questions about tobacco use Advise patient to stop using tobacco Assess patients’ willingness to make a quit attempt Assist patient in stopping Arrange for appropriate follow-up
of Orthodontists, were randomly selected to participate in this survey. Each participant received a 4-page survey along with a cover letter and a prepaid, addressed return envelope. Two weeks later, a reminder postcard was sent, followed by a second mailing of the initial survey after another 2-week period. The survey was based on a similar questionnaire developed by the National Dental Tobacco-Free Steering Committee.8 The survey contained 23 numbered items plus additional demographic information, including age, practice location, gender, ethnicity, number of years practicing orthodontics, and questions regarding current daily routine of antitobacco practices based on the Four A’s: ask, advise, assist, arrange. Secondary questions to these 4 main concepts were then presented to obtain a more detailed picture of approximate amounts of time spent questioning, keeping records, and providing follow-up. Data were coded and entered into an Excel (Microsoft, Redmond, Wash) database. Statistical analysis of the acquired data was performed with SPSS/PC 11.1 (SPSS, Chicago, Ill). Frequencies and distributions were prepared, and chi-square analysis was conducted to compare survey responses by gender, age, ethnicity, and geographic region. RESULTS
Of the original 200 surveys mailed, 119 were collected, giving a corrected response rate of 59.5%. Most respondents were male (87.5%) and white (93.2%). The distribution of respondents by region (according to the breakdown by the U. S. Bureau of the Census9) was 20.2% western, 27.7% north central, 32.8% southern, and 19.3% northeastern. Among the practitioners who responded, there was a fairly even distribution between the ages of 30 and 75 years. The orthodontists surveyed were nonsmokers by a large majority (96.6%), which is consistent with published data on smoking prevalence among dental health professionals.10 Orthodontists were asked to estimate what percentage of patients seen in their offices were adolescents (defined as aged 12-18 years): 83.3% of respondents
Fig 1. Percentage of practitioners using “4 A’s” in daily practice.
reported that at least 50% of their patient population was in this age group, with 40.8% of these doctors having more than 71% of their patients in this group. When asked to estimate the percentage of adolescents in their practices who are tobacco users, 59.1% of orthodontists guessed that fewer than 10% of their adolescent patients use tobacco. The remaining 40.9% of orthodontists guessed that up to 25% of their adolescent patients are tobacco users (with most of these respondents guessing that 10% to 25% of their adolescent patients use tobacco). Because dentists have been shown to underestimate tobacco use in adolescent patients, the possibility of a higher prevalence is likely.4 Recent findings have shown that more than one third of high school students have recently used some form of tobacco,11 and it is estimated that 6000 American adolescents per day try tobacco for the first time, and 3000 of them will become regular smokers.12 Ninety percent of responding orthodontists were concerned about their patients using tobacco products, but only 50% of them ask their patients whether they use cigarettes, cigars, or smokeless tobacco. Of the 50% who ask about tobacco use, almost 70% provide advice and educate tobacco-abusing patients about the hazards of tobacco use. The vast majority, 92.3%, reported that they do not provide any active assistance in tobacco cessation for patients who are tobacco abusers. Of the less than 8% who do offer assistance, 80% reported using 1 method of counseling, which is usually verbal counseling. These findings are summarized in Figure 1. Orthodontists’ current level of preparedness in
198 Sears and Hayes
Fig 2. Orthodontists’ current level of preparedness in practicing tobacco cessation techniques.
practicing tobacco cessation techniques is detailed in Figure 2. More than half of the respondents stated that time and patient acceptance of counseling are the 2 most significant barriers to full incorporation of tobacco abuse prevention into daily practice, whereas such factors as lack of comfort with the topic, lack of support from auxiliary staff, and concerns about parental consent were not considered to be significant barriers. None of the orthodontists responding could name all 4 components of the Four A’s, the NCI’s method of tobacco control education. This suggests that the Four A’s concept has not permeated all specialties of dentistry. Despite not knowing the concept of the Four A’s when asked directly about it, some orthodontists use various aspects of this antitobacco measure (summarized in Fig 1), when the 4 main components were questioned individually in the survey. Adjusting for years in practice, location, gender, and ethnicity did not significantly affect the results. Each of the 4 predetermined geographic regions showed fairly homogeneous ranges of response, resulting in a lack of regional differences. Gender and ethnicity did not affect our results to any great degree, because of the exceptionally high number of white men who were randomly chosen. DISCUSSION
Given our response rate of 59.5%, coupled with the fact that all states except 3 are represented in this survey, we believe that these results represent a fairly good cross-section of practicing orthodontists. Likewise, we had a diverse age range of respondents. Most responding orthodontists were white men; this might be an accurate reflection of the profession’s demographics. Perhaps the most surprising of our results is that nearly 90% of orthodontists are concerned about
American Journal of Orthodontics and Dentofacial Orthopedics February 2005
whether their patients use tobacco products, but only half of them routinely ask their patients whether they use such products. Because orthodontic treatment typically involves seeing a patient regularly (eg, monthly), one might view this finding as a lost opportunity to discuss potential problems with, and reinforce resolutions for, tobacco use. As a minimum measure of screening for tobacco use, orthodontists might consider making this question part of their health history form and routinely updating this information along with other health information. Lack of questioning might be a result of inadequate training in how to deal with or treat a tobacco user who wishes to quit. As we found, most orthodontists (93%) do not offer cessation services in the office. A paucity of cessation services is most likely because orthodontists feel ill-equipped to handle such situations and also have time constraints, since most orthodontic practices function by seeing many patients daily. These time constraints underscore the importance of having not only the orthodontist but also the auxiliary staff trained in tobacco cessation practices. When orthodontists responded to items on the survey that allowed open-ended responses, statements frequently read as such: “[tobacco prevention is] not worth the time,” “it’s their life,” “it’s not our job,” “may not be appropriate,” and “lack of need.” Because current standards in dentistry aim to have dentists realize that they are treating a “whole patient” and not just a mouth, is it the dentist’s or the orthodontist’s responsibility to be concerned about a patient’s tobacco use history? For the orthodontist, will patient management and sensitivity be issues of concern when he or she asks adolescents about tobacco use? One possible means of maximizing the potential of each orthodontic appointment with an adolescent patient for antitobacco purposes might be to require an NCI training program in prevention and cessation techniques, called “How to Help Your Patients Be Tobacco-Free.” If offered during the orthodontic residency, the training could potentially be geared toward the orthodontic practitioner specifically and how he or she can obtain the most positive results from patient contact. Gould et al13 showed not only that dentists asked about tobacco use and assisted their patients in quitting after completing this course but also that dentists felt more confident and prepared in helping their patients do so. The American Association of Orthodontists or the American Dental Association might consider endorsing such a program as an initiative. Tobacco use is a clinical, social, and public health problem that must be addressed by all health profes-
Sears and Hayes 199
American Journal of Orthodontics and Dentofacial Orthopedics Volume 127, Number 2
sionals. By not giving our patients any quitting assistance, we, as professionals in the health care system, are effectively overlooking a major aspect of their current health status, an aspect that has far-reaching consequences for the patients and those around them. Orthodontists in particular are in an opportune position to deliver effective, frequent antitobacco messages to their patients. CONCLUSIONS
1. Adolescent tobacco-control measures in orthodontic offices are being severely underused. 2 Orthodontists should ask about tobacco use on the patient health history form as a minimum measure of screening for this health concern. 3 Orthodontists are concerned about adolescent tobacco use but often do not feel obligated or qualified to counsel their patients. 4 Practicing orthodontists do not feel prepared to educate their patients in tobacco control. 5 Graduate orthodontic programs or dental schools might consider brief mandatory training courses in tobacco abuse prevention, with special consideration for adolescents. REFERENCES 1. Mecklenburg RE, Christen AG, Gerbert B, Gift MC, Glynn TJ, Jones RB, et al. How to help your patients stop using tobacco: a National Cancer Institute manual for the oral health team. NIH publication no. 91-3191. Bethesda, Md: U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute; 1991.
2. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence. Clinical practice guideline. Rockville, Md: U.S. Department of Health and Human Services, Public Health Service; 2000. 3. Dolan TA, McGorray SP, Grinstead-Skigen CL, Mecklenburg R. Tobacco control activities in U.S. dental practices. J Am Dent Assoc 1997;128:1669-79. 4. Gregorio DI. Counseling adolescents for smoking prevention: a survey of primary care physicians and dentists. Am J Public Health 1994;84:1151-3. 5. Office of Smoking and Health. Preventing tobacco use among young people: a report for the Surgeon General. Atlanta: National Center for Chronic Disease Prevention and Health Promotion; 1994. 6. Hovell MF, Slymen DJ, Jones JA, Hofstetter CR, Burkham-Kreitner S, Conway TL, et al. An adolescent tobacco-use prevention trial in orthodontic offices. Am J Public Health 1996;86:1760-6. 7. Hovell MF, Jones JA, Adams MA. The feasibility and efficacy of tobacco use prevention in orthodontics. J Dent Ed 2001;65:348-53. 8. Hayes C, Kressin N, Garcia R, Mecklenberg R, Dolan T. Tobacco control practices: how do Massachusetts dentists compare with dentists nationwide? J Mass Dent Soc 1997;46:9-14. 9. National Institutes of Health. Plan and operation of the second national health and nutrition examination survey 1976-1980. Available at: http://archive.nlm.nih.gov/proj/dxpnet/nhanes/ docs/doc/nhanes2/plan.pdf. Accessed June 2002. 10. Dolan T, McGorray SP, Grindstead CL. Dentist’s tobacco cessation activities by specialty status and geographic region. J Dent Res 1996;75:19. 11. Centers for Disease Control and Prevention. Tobacco use among high school students—United States. Morbid Mortal Wkly Rep 1998;47:229-33. 12. Giovino GA. Epidemiology of tobacco use among US adolescents. Nicotine Tob Res 1999;Suppl 1:S31-40. 13. Gould KA, Eickhoff-Shemek JM, Stacy RD, Mecklenburg RE. The impact of national cancer institute training on clinical tobacco use cessation services by oral health teams. J Am Dent Assoc 1998;129:1442-9.
AVAILABILITY OF JOURNAL BACK ISSUES As a service to our subscribers, copies of back issues of the American Journal of Orthodontics and Dentofacial Orthopedics for the preceding 5 years are maintained and are available for purchase from Mosby until inventory is depleted. Please write to Elsevier Inc. Subscription Customer Service, 6277 Sea Harbor Dr, Orlando, FL 32887, or call 800-6542452 or 407-345-4000 for information on availability of particular issues and prices.