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Helping smokers quit: a randomized controlled trial with private practice dentists
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m m ÊÊ ÊÊÊÊÊÊÊK ÊÊÊH ÊÊÊÊÊÊÊÊtm A R T I C L E S
Fifty priva te practitioners a n d their office s ta ff m em bers were random ly assigned to one o f fo u r groups: participants received a protocol fo r sm o kin g m a n a g em en t and a lecture o n the consequences a nd m a n a g em en t o f sm o kin g , or in addition, h a d n ico tin e g u m freely available to patients, h ad stickers attached to their charts, or h a d g u m a n d reminders. T h e percentage o f p a tien ts in each gro u p w h o h a d q u it sm o kin g a year later w as 7.7, 16.3, 8.6, a n d 16.9, respectively, indicating a sig n ific a n t m a in effect fo r the g u m conditions. T h e availability o f nicotine g u m also sig n ifica n tly increased the a m o u n t o f tim e th a t p a tie n ts reported they received sm o k in g cessation co unseling fro m th e dentists a n d office staff.
Helping smokers quit: a randomized controlled trial with private practice dentists Stuart J. Cohen, E d D George K. Stookey, P h D Barry P. Katz, P h D Catherine A. Drook Arden G. Christen, D D S
igarette sm oking is the leading preventable cause of illness and p rem a tu re d eath in the U nited States.1’2 In spite of the fact th a t sm oking is linked to more than 300,000 prem ature d e a th s a year, m o re th a n 50 m illio n A m e ric a n s s till c o n tin u e to sm oke cigarettes.3,4 A lthough m ost smokers have expressed a desire to q u it sm oking, m ost ap p e ar unable or u n w illin g to enroll in organized sto p -sm o k in g p ro g ra m s.5,6 W hereas rel atively few smokers w ill go to a sm oking cessation clinic, m ost of them will visit a d e n tis t w ith in a year. In 1978, 54% of A m erican s visited a d e n tis t.7 T h u s, dentists are in c o n tin u in g contact w ith m illio n s of sm okers a n d can have an im p act on the sm oking h ab its of their patients. M ost of the literatu re o n the im pact of the advice of health professionals on the b e h a v io r of sm okers h as in v o lv ed physicians. In review ing this evidence, P e d e rso n 8 co n c lu d e d th a t the p a tie n ts m ost likely to com ply w ith th e ir p h y s ic ia n s ’ ad v ice are th o se w ith severe, sm o k in g -re la te d diseases a n d those in im m inent danger from co ntinued sm ok
C
ing. Furtherm ore, the greater the intensity of the e d u c a tio n a n d ad v ice g iv en by the physician, the higher the percentage of sm oking cessation.9 13 H o w ev er, m a n y p e o p le w h o sm oke cig arettes re p o rt th a t th e ir p h y sic ia n s have never advised them to stop smoking.
Table 1 ■ The sociodemographic char acteristics, office visits, and nicotine dependence of the dental patients (N = 1,027).____________ M ean age M edian no. o f years of sch o o lin g com pleted M edian incom e ($) Race W hite Black O ther G ender M ale Fem ale M ean no. of dental visits p er year M ean degree of nicotine dependence
37.1 (10.4)*
I year of college 40,000 95.1% 4.1%
0.8%
43.2% 56.8%
1.2 (1.2)* 5.5
•S ta n d a rd dev iatio n is s h o w n in parentheses.
(1.9)*
O ne survey14 indicated th at w hereas 75% of smokers believed th a t their physicians’ advice w o u ld be “ so m e w h a t” to “ very effective” in g ettin g them to reduce or stop sm oking, tw o-thirds of those q u es tioned stated th a t they h ad never been advised to q u it by th eir p h y sic ia n .14 A re c e n t s ta te w id e su rv ey o f a d u lts in M ichigan found th at only 44% of smokers seen by a physician in the previous year rep o rted ever b ein g to ld to q u it smok15 ing. T h e p a ra lle l resu lts fo r d e n tists are n ot know n. However, in 1964, the H ouse of D ele g ates o f th e A m e ric a n D e n ta l A sso c ia tio n re so lv e d th a t A m e ric a n D ental A ssociation m em bers sh o u ld be encouraged to discuss the h ealth hazards involved in the use of tobacco w ith their p atien ts.16 A random ized controlled trial of p rac tic a l in te r v e n tio n s w as d e s ig n e d to im prove the effectiveness of dentists in h e lp in g th e ir p a tie n ts q u i t s m o k in g . O n the basis of exit interview s of patients, the extent to w h ich these in terv en tio n s a lte re d the freq u en cy a n d th e a m o u n t of counseling ab o u t sm oking th at patients received was also exam ined. JADA, Vol. 118, January 1989 ■ 41
ARTICLES
M ethods
Dentists F ifty -fo u r d e n tis ts in p riv a te p rac tice in th e I n d ia n a p o lis a re a ag re ed to p articipate in this study. Before attending th e o r ie n t a tio n le c tu re , fo u r d e n tis ts decided not to participate. T h e rem aining 50 d e n tis ts a n d th e ir e n tire p a n e l of eligible patients were random ly assigned to on e of four experim ental conditions as described in the follow ing study design. B efore r e c r u itin g an y p a tie n ts , fo u r d e n tis ts decid ed n o t to p a r tic ip a te in the study. After recruiting a few patients, tw o d e n tis ts d ec id e d a g a in s t f u rth e r p a rtic ip a tio n . T h u s, analyses are based o n th e resu lts of 44 den tists an d their patien ts w ho smoke.
Procedures and study design T h e procedures have been described in d e ta il else w h e re .17 Briefly, all d en tists either attended a 1-hour lecture or received personalized in struction on the medical co n seq u en ces of sm o k in g , the benefits of q u ittin g , and the evidence that p hy s ic ia n s ’ advice o r n ic o tin e -c o n ta in in g chew ing gum , or both, can be effective in h elp in g some patients q u it sm oking. A fo u r-step p rotocol was suggested for c o u n s e lin g p a tie n ts: S tep 1. Ask y o u r p atients about sm oking. Step 2. Deliver a firm q u it-s m o k in g m essage. S tep 3. M utually agree on a q u it date. Step 4. Check on each p a tie n t’s progress at each regularly scheduled visit.18 Before the lecture, dentists and their e n tir e p a n e l of p a tie n ts w h o sm o k ed c ig a re tte s w ere r a n d o m ly a ssig n e d to one of four study groups: control, gum , rem inder, an d both gum and rem inder (control = 13, gum = 9, rem inder = 10, b oth = 12). D entists in the control group were given a copy of a booklet containing th e fo u r- s te p c a re p ro to c o l a n d w ere encouraged to counsel their patients who smoke. D entists in the other three groups rec eiv e d th e sam e in s tr u c tio n as the control gro u p plus additional instruction b ased o n th e ir a s sig n e d e x p e rim e n ta l intervention. For the nicotine gum group, dentists were to ld th a t th e ir p a tie n ts w ho h ad a fluorescent red sticker attached to their c h a r t w o u ld be e lig ib le to receive u p to a ten-box supply of a nicotine chew ing g u m at no cost. If the dentists w anted a p atien t to receive the gum , he or she h a d to c o m p le te a lo g b o o k re c o rd to in d ic a te th a t n ic o tin e g um was b ein g 42 ■ JADA, Vol. 118, January 1989
T ab le 2 ■ Confirmed success rates (%) in quitting smoking at the 6-month
visit for each dentist intervention. G ro u p C ontrol R em inder G um Both
R eturnees only (N = 428) 7.1 7.4 18.2 9.4
All enrollees (N = 1,027) 3.1 3.2 9.0 3.0
G eneralized linear m odel significant P-values R em inders G um
> .1 0 .072
given and in w hat am ounts. In the rem inder condition, two flu o rescent stickers were placed on the charts to help dentists an d their staff members to re m e m b e r to fo llo w th e ste p -c a re protocol. T h e green sticker asked “ Did you ta lk to th e p a tie n t to d a y a b o u t sm oking? Yes or N o.” T h e orange sticker stated, “T h e p atien t has agreed to the follow ing q u it d a t e __________ ” In the both (gum an d rem inder) condition, all in te rv e n tio n m ethods an d stickers p e r ta in e d . T h e d e n tis ts a n d th e ir staff m e m b ers w ere in s tru c te d in b o th th e use of rem inders and of the nicotine gum .
Patients P atien ts were eligible for p a rtic ip a tio n if they w ere betw een 18 a n d 64 years, reported sm oking one or m ore cigarettes daily, and had an alveolar breath carbon m o n o x id e d eterm in a tio n of m ore th a n 8 p p m . P a tie n ts were ex clu d ed if an y of the c o n tra in d ic a tio n s for the use of nicotine gum pertained. Smokers were identified in each dental office. W h en c a llin g to re c o n firm an a p p o in tm e n t, the re c e p tio n ist in each dental office determ ined w hether a patien t w as c u rren tly a cig arette sm oker. T h e list of sm okers served as the basis for p a tie n t co n tact by the p ro ject research assistants w ho determ ined their eligibility fo r p a r ti c ip a tio n . P a tie n ts s ig n e d an inform ed consent form, in d ic atin g that their sm oking habit w ould be m onitored at each regularly scheduled office visit, reg ard less of th e ir d ecisio n to q u it or contin u e sm oking. Patients were notified th a t they w o u ld be asked to provide a breath sam ple at each regularly scheduled ap p o in tm e n t for carbon m onoxide a n a l ysis a n d to an sw e r som e q u e s tio n s im m e d ia te ly a fte r se e in g th e d o c to r. D u rin g th is ex it in terv iew , a research assistant asked the patients w hether the
.051 .061
dentist or other staff m em ber had talked to them ab o u t sm oking. If they answered affirm atively, they were asked to estim ate how m any m inutes that person had spent talk in g to them ab o u t sm oking. O f the sm okers contacted, the refusal rate was less than 10%, resu ltin g in 1,027 patients w ho agreed to participate. Because cigarette sm okers often q u it sm oking an d later relapse, the prevalence of sm o k in g was estim ated at two s u b se q u e n t tim e w indow s. T h e first e s ti m a te — 6 m o n th s —w as d e fin e d as th e sm o k in g status determ ined at any visit th a t occurred at least 3 m onths after the in itia l a p p o in tm e n t b u t n o t m ore th a n 9 m o n th s a fte r it. T h e seco n d estim ate was at 1 year, w hich was defined as any visit th at occurred at least 9 m onths and 1 day after the in itial visit an d up to 15 m o n th s after the in itia l visit. If there were m ore th an one visit d u rin g a tim e interval, the sm oking status was determ ined by the status of the last visit d u rin g th a t interval. For p atien ts w ho h ad a regularly scheduled a p p o in tm e n t d u rin g the critical period, their sm oking s ta tu s w as co n firm e d th ro u g h ca rb o n m onoxide assessment, u sin g procedures described elsew here.19 Patients n o t having a visit d u rin g the 6- or 12-m onth periods were assumed to be smokers. T h u s, the resu lts are rep o rted b o th for retu rn ees for w h o m b io ch em ical v a lid a tio n was possible and for all enrollees on the basis that a p atien t was a smoker unless there was biochem ical evidence to the contrary. In the study design, the dentists were th e u n its of ra n d o m iz a tio n . F or each d e n tis t, th e p e rc e n ta g e of h is or h e r p a tie n ts w h o h a d q u it s m o k in g a t a p articu la r tim e interval was calculated. T h e resulting q u it rate was assum ed to follow a b in o m ial d istrib u tio n w ith an u n d e rly in g m e an th a t w as d e p e n d e n t on the study condition. However, w hen data from different dentists in the same
co n d itio n were com bined, the b inom ial v a ria n c e w as e x p e c te d to be in f la te d because of the betw een-dentist variability. T h e re fo re , a g en e raliz ed lin e a r m odel w as u sed a n d a sc a le -fa c to r w as used to reflect the extra variance.20 If the scale factor was greater than one, it was used to adjust the variance estim ates and the te st s ta tistic s . A x 2 s ta tis tic b ased on c h a n g e s in th e d e v ia n c e f u n c tio n for a series of nested m odels w as used to test for m a in effects a n d in te ra c tio n s. T h e statistical m odeling was perform ed u sin g the generalized lin e ar interactive m odeling (GLIM ) software package.21 Results
G ro u p
R eturnees o nly (N = 374)
All enrollees (N = 1,027)
7.7 8.6 16.3 16.9
3.1 2.8 7.7 4.7
C ontrol R em inder G um Both
G eneralized lin e a r model sig n ific a n t / ’-values G um .012
.038
Table 4 ■ Patients’ report of the number of minutes their dentists and dental staff spent talking to them about smoking. Experim ental g ro u p
SD
R ange
1.7 2.7 5.6 6.7
7.3 6.9 6.8 8.9
0 .0 - 8.0
1.4 2.3 2.3 2.9
5.6 8.5 4.1 7.3
4.1 - 9.5 4 .5 - 9.5 0 .0 - 4.9 0.1 - 11.0 1.3- 5.0 00 <£>
altered the frequency and am o u n t of time th a t w as sp e n t in c o u n s e lin g p a tie n ts a b o u t sm o k in g , w e in te rv ie w e d th e patients im m ediately after the office visit. We exam ined the p atien ts’ reports from b o th th e firs t a n d se co n d o ffic e ex it interv iew s afte r th e p a tie n ts h ad been recruited. In m any of the dental offices, the responsibility of counseling smokers was shared between the dentists an d other o ffice sta ff m em b ers. T h e re fo re , th e c o u n s e lin g d a ta re fle c t th e c o m b in e d efforts of dentists a n d th e ir office staff m em bers. F or each d e n tist a n d h is or her staff members, we o btained an average n u m b e r of m in u te s s p e n t c o u n s e lin g p a tie n ts a b o u t c ig a re tte s m o k in g by d iv id in g the to ta l n u m b e r of m in u te s counseled by the n um ber of their patients enrolled in the study. Because some dental offices m ay h av e o n ly th re e p a tie n ts in v o lv e d a n d o th e rs 40 o r m o re, we w eighted the average n um ber of m inutes c o u n s e le d by th e n u m b e r of p a tie n ts in v o lv e d . T h is w e ig h tin g system is inversely p r o p o rtio n a l to the v arian ce of the observations and, thus, is necessary to sa tisfy th e a s s u m p tio n o f e q u a l variance needed for analysis of variance. Patients w ho reported th at they did not receive counselin g ab o u t sm o k in g were included in the analysis w ith the num ber
0 01
M ean
©
V isit one C ontrol R em inder G um Both V isit tw o C ontrol R em inder G um Both
cn ©
T h e characteristics of the dental patients w ho were enrolled in the study are show n in T able 1. As a whole, they were m ore affluent and better educated th an w ould be found am ong a n ational sam ple. T he degree of n icotine dependence was cal c u la te d u s in g a system d e v e lo p e d by F ag erstro m ,22 w here 0 = low est an d 11 = h ig h e s t degree of d ep e n d en c e. T h is sco re is b ased o n re sp o n se s to su c h questions as H ow soon after you wake u p do you sm oke y o u r first cigarette? and, H ow m any cigarettes a day do you sm o k e ?22 In g e n e ra l, p a tie n ts h a d a m oderate degree of nicotine dependence. A generalized lin ear m odel was used to analyze the results of the quit-sm oking rates. T h e 6 -m o n th re su lts are show n in T able 2. T h e generalized linear model fo r a ll e n ro lle e s p ro d u c e d b o r d e rlin e s ig n ific a n t m a in effects fo r g u m a n d for rem inders. H ow ever, the coefficient fo r th e re m in d e r effect w as n e g a tiv e . Statistically, this result is caused by the h ig h cessation rates in the gu m g ro u p coupled w ith the low er rate in the gum a n d rem inder group. T hese rates for all returnees may n o t reflect the effectiveness of th e in te rv e n tio n , b u t may, in p a rt, be a rtifa c ts of the n u m b e r of p a tie n ts w ho returned d u rin g the tim e window . Whereas those patients w ho did n ot return were classified as smokers, the cessation rate in b oth gum an d rem inder groups was depressed by a lower 6-m onth return ra te (32.3%) th a n in th e o th e r g ro u p s (control 43.8%, rem inder 43.3%, a n d gum 49.5%). T h e results at 1 year are show n in T able 3. At 1 year, there was a significant effect of the g um for both those patients who retu rn ed d u rin g th a t tim e interval an d for all p a tie n ts. No o th e r effects were significant. T o determ ine w hether the interventions
Table 3 ■ Confirmed success rates (% ) in quitting smoking at the 12-month visit for each dentist intervention.
of m inutes of co u nseling eq u a lin g zero. T h e w eig h ted m ean s of th e n u m b e r of m inutes spent co u nseling by dentists an d their staff mem bers at the first and second p atien t visit after the intervention are show n in T ab le 4. T w o-w ay analyses of v a ria n c e w ere c a lc u la te d o n th e w e ig h te d d a ta s e p a ra te ly fo r th e firs t a n d seco n d p a tie n t v isit to d e te rm in e w hether the ex p e rim en tal in terv en tio n s had a sig n ifican t effect on the a m o u n t of tim e spent in co u nseling p atien ts ab o u t th eir sm oking. For the first visit, there was a s ig n ific a n t m a in effect o n ly for the g um groups (P < .0001). T h ere were n o s ta tis tic a lly s ig n ific a n t d ifferen ces a t th e second v isit. T h u s , for d e n tists an d their staff m em bers, only access to the n icotine gum produced a significant in c re ase in th e a m o u n t of tim e sp e n t in counseling their p atients ab o u t sm ok in g . T h a t effect w as su sta in e d for th e first post-intervention visit alone. Discussion D entists could have a m ajo r im p act on the sm oking status of m illio n s of A m er icans. T h e ir low prevalence of sm oking suggests that dentists can serve as good ro le m o d e ls fo r c o u n s e lin g th e ir patien ts.23 T h e extent to w hich they can
Cohen - Others : H ELPING SMOKERS QUIT: RANDOMIZED C O NTR O LLED TRIAL ■ 43
ARTICLES
be effec tiv e w ill d e p e n d on w h e th e r d e n tis ts take th e tim e to id e n tify th e sm okers in their practices, counsel them ab o u t the dangers of sm o k in g an d the benefits of q u ittin g , offer them help in q u ittin g , and fo llo w -u p th e ir sm oking status at regularly scheduled office visits. A recen t m e ta-an a ly sis of 108 in te r ventions used in 39 controlled trials of sm oking cessation found that the greatest success w as achieved w hen there w ere
in com binatio n w ith g ro u p counseling, can be efficacious for h elp in g physicians’ patients w ho are trying to stop sm oking.25 Sim ilar findings have been show n w ith d e n ta l p a tie n ts w h o v o lu n te e re d to p a r tic ip a te to q u it s m o k in g .26,27 T h e confirm atory results of the current study are im p o r ta n t b ecau se they are based on a p o p u la tio n of general dental patients a n d n o t ju st on a g ro u p of volunteers interested in q u ittin g sm oking.
The results of this study suggest that changing the way clinicians practice requires altering their routine practice environment. m u ltip le interventions given by m ultiple h ealth care providers on m ultiple occa sions.24 T h u s, for h elp in g smokers quit, th e g re a te r th e k in d a n d n u m b e r of co n tac ts, the g rea ter the lik e lih o o d of success. T h e results of ou r study suggest th a t the add itio n of specific m echanism s (for exam ple, ch art rem inders an d n ic o tin e gum ) can increase the likelihood th a t p a tie n ts w h o sm oke w ill receive co u nseling by their health professionals. For dentists, counseling patients about sm oking was m ore likely to occur if the d en tists co u ld offer a free p resc rip tio n of n ic o tin e gu m to th eir patien ts w ho smoke. In response to a pre-intervention q u estio n n aire about their approach to c o u n s e lin g th e ir p a tie n ts w ho sm oke, less th a n h a lf of the d en tists rep o rted th ey h a d o ffered p e rs o n a l c o u n s e lin g to p a tie n ts a b o u t q u i t t i n g sm o k in g . P erhaps the availability of a new therapy (th a t is, n ic o tin e gum ) was h elp fu l in a c tiv a tin g d e n tis ts to c o u n s e l th e ir p atients w ho smoke. T h e m a jo rity of c o n tro lle d tria ls in th e lite r a tu r e o n s m o k in g c e ssa tio n in volved v o lunteers interested in q u it ti n g .24 In c o n tra s t, o u r r e c ru itm e n t e m p h asized an in te re st in m o n ito rin g the habits of all eligible smokers, regard less of their interest in quitting. Conclusions M e th o d s th a t a p p e a r to be su ccessful w ith smokers volunteering to participate in a sm o k in g ce ssa tio n p ro g ra m m ay n o t be transferable to smokers in a private practice dental setting. A recently p u b lished article show ed that nicotine gum , \4 m
JADA, Vol. 118, January 1989
E d ito ria ls c o n tin u e to e x h o rt h ea lth care professionals to take a m ore active role in counseling sm okers.28 T h e results of this study suggest th at ch an g in g the way clinicians practice requires altering th e ir ro u tin e practice en v iro n m en t (for exam ple, flagging charts an d p roviding n ic o tin e g u m ). T h e se a lte r a tio n s n o t o n ly b rin g th e p rac tice of c o u n s e lin g smokers closer to w hat is being preached, b u t also ap p e ar to h elp m any p atien ts q u it smoking.
-------------------- JA D A --------------------T h is re s e a rc h w as s u p p o rte d by a g r a n t fro m th e N a tio n a l C a n c e r I n s titu te , g r a n t no. P H S 1 R O l CA38337. T h e a u th o rs th a n k research assistants Ms. C athy A rm an tro u t, Ms. A ndra Eason, Ms. C indy G orm an, Ms. J ill H elm en, Ms. Sue Kelly, and Ms. D rusilla K rieck ; Dr. Ja m e s M cD o n a ld , D r. B y ro n O ls o n , Ms. Barbara Davis, a n d Ms. M onica H am m o n d for la b o ra to ry a n d d a ta m a n a g e m e n t s u p p o r t; a n d L a k e sid e P h a rm a c e u tic a ls for p ro v id in g n ic o tin e gum . Dr. C ohen is professor, d e p a rtm e n t of m edicine a n d R egenstrief In stitu te for H e alth Care, In d ia n a U n iv e rs ity S ch o o l of M ed icin e, a n d is p ro fesso r, p a r t- tim e , O ra l H e a lth R e s e a rc h I n s titu te a n d d e p a rtm e n t of p re v e n tiv e d e n tistry , In d ia n a U n i versity School of D entistry. Dr. Stookey is director, O ra l H e a lth R ese a rc h I n s titu te a n d d e p a r tm e n t of p reventive dentistry, In d ia n a U niversity School of D entistry. Dr. Katz is assistant professor, dep art m en t of m edicine and R egenstrief In stitute for H ealth C are, In d ia n a U niversity School of M edicine. Ms. D rook is assistant director of clinical research, O ral H e a lth R e s e a rc h I n s titu te a n d d e p a r tm e n t of p re v e n tiv e d e n tis try , I n d ia n a U n iv e rs ity S c h o o l of D entistry. Dr. C hristen is professor, O ral H ealth R ese arch In s titu te a n d d e p a rtm e n t of p re v e n tiv e d e n tistry , In d ia n a U niversity School of D entistry. A ddress re q u e sts for re p rin ts to Dr. C o h en a t the
In d ia n a U niversity D epartm ent of M edicine, R egen s trie f H e a lth C en ter, F ifth F lo o r, 1001 W T e n th St, In d ia n a p o lis 46202.
1. DHEW . H ealthy people: the surgeon g e n eral’s re p o rt on health pro m o tio n and disease prevention. W ashington, DC: G overnm ent P rin tin g Office, 1979; D H EW p u b lication no (PH S) 79-55071. 2. D H H S . N ic o tin e a d d ic tio n : a re p o rt o f the s u rg e o n g e n e ra l. W a s h in g to n , DC: G o v e rn m e n t P rin tin g Office, 1988; D H H S p u b lic a tio n n o (CDC) 88-8406. 3. S m o k in g —a ttrib u ta b le m o rtality a n d years of p o te n tia l life lo s t— U n ite d S tates, 1986. M M W R 1987; 36:581-5. 4. U S P re v e n tiv e S erv ices T a s k F o rce . R e c o m m en d atio n s for sm o k in g cessation co u n selin g . JAD A 1988; 259:2882. 5. A llen WA, Fackler WA. A n exploratory survey a n d sm o k in g c o n tro l p ro g ra m a m o n g p a re n ts of P h ila d e lp h ia school c h ild re n . In: Z agona SV, ed. S tudies an d issues in sm o k in g beh av io r. T u c so n : U niversity of A rizona Press; 1967. 6. G a llu p O p in io n Index. P u b lic puffs o n after ten years of w a rn in g s. R e p o rt n o 108. P rin c e to n , N J: G a llu p Poll, 1974. 7. Graves RC. D ental health needs and dem ands in A m erican society: cu rren t trends. H ealth V alues 1984; 8:13-20. 8. Pederson LL. C om pliance w ith physician advice to q u i t sm o k in g : a review of the lite ra tu re . P rev Med 1982; 11:71-84. 9. R ose G, H a m ilto n P J, Colw ell L, Shipley MJ. A random ized controlled trial of a n ti-sm o k in g advice: 10-year re su lts. J E p id e m io l C o m m u n ity H e a lth 1982; 36:102-8. 10. B u rt A, T h o r n e y P, I ll in g w o r th D, e t a l. S to p p in g sm oking after m yocardial infarction. L ancet 1974; 1:304-6. 11. R u sse ll M A H , W ilso n C , T a y lo r C, B aker C. Effect of g e n eral p ra c titio n e r s ’ a d v ice a g a in s t sm oking. Br Med J 1979; 2:231-5. 12. A m erican C ollege of P hysicians, H e alth and P olicy C om m ittee. M ethods for s to p p in g cigarette sm oking. A nn Intern Med 1986; 105:281-91. 13. D H H S . C lin ic a l o p p o rtu n itie s for s m o k in g in te r v e n tio n : a g u id e fo r th e b u s y p h y s ic ia n . W ashington, DC: G overnm ent P rin tin g Office, 1986; D H H S p u b lication no (N IH ) 86-2178. 14. 1978 H e a lth M a in te n a n c e S u rv ey . (C o m m is s io n e d by P a c ific M u tu a l L ife I n s u ra n c e , N ew port Beach, CA, a n d conducted by L ouis H arris a n d Associates), 1978. 15. A nda RF, R em ington PL , Sienko D G , et al. A re p h y s ic ia n s a d v is in g s m o k e rs to q u it? T h e p a tie n t’s perspective. JADA 1987; 257:1916-9. 16. A m erican D ental A ssociation. R eso lu tio n on c ig a re tte s m o k in g . N ew s o f d e n tis try . JA D A 1964;69:776. 17. C o h e n S J, C h ris te n A G , K atz B P, e t al. C o u n s e lin g m e d ic a l a n d d e n ta l p a tie n ts a b o u t cigarette sm oking: the im pact of n ico tin e g u m and c h art rem inders. Am J P ublic H e alth 1987; 77:313-
6. 18. N a tio n a l H ig h B lo o d P r e s s u re E d u c a tio n Program . T h e physician’s guide: how to help your h y p erten siv e p a tie n ts sto p sm o k in g . W ash in g to n , DC: G o v e rn m e n t P r i n tin g O ffice , 1983; N IH p u b lic a tio n no 83-1271. 19. Stookey GK, Katz BP, O lson BL, D rook CA, C o h e n SJ. E v a lu a tio n of b io c h e m ic a l v a lid a tio n m e a su re s in d e te rm in a tio n o f s m o k in g s ta tu s. J D ent Res 1987; 66:1597-601. 20. M cC ullagh P, N elder JA. G eneralized lin e a r models. L ondon: C hapm an an d H all, 1983.
21. Baker R J, N elder JA. T h e G L IM system, release 3, generalized lin e a r interactive m o d e lin g . O xford: N um erical A lgorithm s G ro u p , 1978. 22. F ag erstro m KO. T o le ra n c e , w ith d ra w a l a n d dependence on tobacco a n d sm o k in g te rm in a tio n . In t Rev A ppl Psychol 1983; 32:29-52. 23. C h ris te n AG. S urvey o f s m o k in g b e h a v io r and attitudes of 630 A m erican dentists: c u rren t trends. JAD A 1984; 109:271-2. 24. K ottke T E , B attista R N , DeFriese G H , et al.
A ttrib u tes o f successful c essatio n in te rv e n tio n s in m ed ical p ractice: a m eta-an aly sis of 39 c o n tro lle d trials. JA M A 1988; 259:2882-9. 25. T o n n e sen P, Fryd V, H ansen M, et al. Effect of n ic o tin e chew ing gu m in com b in atio n w ith group c o u n s e lin g o n th e cessatio n of sm o k in g . N E n g l J Med 1988; 318:15-8. 26. C h risten AG, M cD onald J L , O lson BL, D rook CA, Stookey GK. Efficacy of n ico tin e chew ing gum in fa c ilita tin g sm o k in g cessation. JAD A 1984; 108:594-
7. 27. C h r is te n A G , O ls o n B L , S a m p s o n V M , M c D o n a ld J L . In te n s iv e q u i t s m o k in g p ro g r a m in a d e n ta l s e ttin g u s in g n ic o tin e g u m : o n e year results. CDA J 1986; 14:28-34. 28. D av is R M . U n i t i n g p h y s ic ia n s a g a in s t sm oking: the need for a c oordinated n a tio n a l strategy. JAM A 1988; 259:2900-1.
Self-Assessment Questions 1. C igarette sm o k in g is th e le ad in g preventable cause of illness an d p re m ature death in the U nited States. a) true b) false 2. T h e m a jo rity o f sm okers w ill be
seen by a dentist w ith in a year. a) true b) false 3. W hich of the fo llo w in g was n o t
p a r t o f th e p ro to c o l re c o m m e n d e d to a ll d e n tists fo r c o u n s e lin g th e ir patients w ho smoke?
a) label the charts of patients who smoke b) ask your patients ab o u t sm oking c) d e liv e r a firm q u it- s m o k in g message d) m u tu a lly agree o n a q u it date e) check on each p a tie n t’s progress a t each regularly scheduled visit 4. E ducating dentists ab o u t the im p o r
tance of counseling their p atients w ho sm oke resulted in a significant increase in tim e s p e n t by th e d e n tis ts in counseling smokers an d a significant increase in the n u m b er of their patients
w ho q u it sm oking. a) true b) false 5. T h e av a ilab ility of n ic o tin e g um
resu lted in a sig n ific a n t increase in tim e sp e n t by th e d en tists in c o u n s e lin g sm o k e rs a n d a s ig n if ic a n t increase in the n um ber of their patients w ho q u it sm oking. a) true b) false A nsw ers are fo u n d in th e P eo p le & M eetings section.
Cohen - Others : H ELPING SMOKERS QUIT: RANDOMIZED CO NTR O LLED TRIAL ■ 45
a
_
m m ÊÊ ÊÊÊÊÊÊÊK ÊÊÊH ÊÊÊÊÊÊÊÊtm A R T I C L E S
Fifty priva te practitioners a n d their office s ta ff m em bers were random ly assigned to one o f fo u r groups: participants received a protocol fo r sm o kin g m a n a g em en t and a lecture o n the consequences a nd m a n a g em en t o f sm o kin g , or in addition, h a d n ico tin e g u m freely available to patients, h ad stickers attached to their charts, or h a d g u m a n d reminders. T h e percentage o f p a tien ts in each gro u p w h o h a d q u it sm o kin g a year later w as 7.7, 16.3, 8.6, a n d 16.9, respectively, indicating a sig n ific a n t m a in effect fo r the g u m conditions. T h e availability o f nicotine g u m also sig n ifica n tly increased the a m o u n t o f tim e th a t p a tie n ts reported they received sm o k in g cessation co unseling fro m th e dentists a n d office staff.
Helping smokers quit: a randomized controlled trial with private practice dentists Stuart J. Cohen, E d D George K. Stookey, P h D Barry P. Katz, P h D Catherine A. Drook Arden G. Christen, D D S
igarette sm oking is the leading preventable cause of illness and p rem a tu re d eath in the U nited States.1’2 In spite of the fact th a t sm oking is linked to more than 300,000 prem ature d e a th s a year, m o re th a n 50 m illio n A m e ric a n s s till c o n tin u e to sm oke cigarettes.3,4 A lthough m ost smokers have expressed a desire to q u it sm oking, m ost ap p e ar unable or u n w illin g to enroll in organized sto p -sm o k in g p ro g ra m s.5,6 W hereas rel atively few smokers w ill go to a sm oking cessation clinic, m ost of them will visit a d e n tis t w ith in a year. In 1978, 54% of A m erican s visited a d e n tis t.7 T h u s, dentists are in c o n tin u in g contact w ith m illio n s of sm okers a n d can have an im p act on the sm oking h ab its of their patients. M ost of the literatu re o n the im pact of the advice of health professionals on the b e h a v io r of sm okers h as in v o lv ed physicians. In review ing this evidence, P e d e rso n 8 co n c lu d e d th a t the p a tie n ts m ost likely to com ply w ith th e ir p h y s ic ia n s ’ ad v ice are th o se w ith severe, sm o k in g -re la te d diseases a n d those in im m inent danger from co ntinued sm ok
C
ing. Furtherm ore, the greater the intensity of the e d u c a tio n a n d ad v ice g iv en by the physician, the higher the percentage of sm oking cessation.9 13 H o w ev er, m a n y p e o p le w h o sm oke cig arettes re p o rt th a t th e ir p h y sic ia n s have never advised them to stop smoking.
Table 1 ■ The sociodemographic char acteristics, office visits, and nicotine dependence of the dental patients (N = 1,027).____________ M ean age M edian no. o f years of sch o o lin g com pleted M edian incom e ($) Race W hite Black O ther G ender M ale Fem ale M ean no. of dental visits p er year M ean degree of nicotine dependence
37.1 (10.4)*
I year of college 40,000 95.1% 4.1%
0.8%
43.2% 56.8%
1.2 (1.2)* 5.5
•S ta n d a rd dev iatio n is s h o w n in parentheses.
(1.9)*
O ne survey14 indicated th at w hereas 75% of smokers believed th a t their physicians’ advice w o u ld be “ so m e w h a t” to “ very effective” in g ettin g them to reduce or stop sm oking, tw o-thirds of those q u es tioned stated th a t they h ad never been advised to q u it by th eir p h y sic ia n .14 A re c e n t s ta te w id e su rv ey o f a d u lts in M ichigan found th at only 44% of smokers seen by a physician in the previous year rep o rted ever b ein g to ld to q u it smok15 ing. T h e p a ra lle l resu lts fo r d e n tists are n ot know n. However, in 1964, the H ouse of D ele g ates o f th e A m e ric a n D e n ta l A sso c ia tio n re so lv e d th a t A m e ric a n D ental A ssociation m em bers sh o u ld be encouraged to discuss the h ealth hazards involved in the use of tobacco w ith their p atien ts.16 A random ized controlled trial of p rac tic a l in te r v e n tio n s w as d e s ig n e d to im prove the effectiveness of dentists in h e lp in g th e ir p a tie n ts q u i t s m o k in g . O n the basis of exit interview s of patients, the extent to w h ich these in terv en tio n s a lte re d the freq u en cy a n d th e a m o u n t of counseling ab o u t sm oking th at patients received was also exam ined. JADA, Vol. 118, January 1989 ■ 41
ARTICLES
M ethods
Dentists F ifty -fo u r d e n tis ts in p riv a te p rac tice in th e I n d ia n a p o lis a re a ag re ed to p articipate in this study. Before attending th e o r ie n t a tio n le c tu re , fo u r d e n tis ts decided not to participate. T h e rem aining 50 d e n tis ts a n d th e ir e n tire p a n e l of eligible patients were random ly assigned to on e of four experim ental conditions as described in the follow ing study design. B efore r e c r u itin g an y p a tie n ts , fo u r d e n tis ts decid ed n o t to p a r tic ip a te in the study. After recruiting a few patients, tw o d e n tis ts d ec id e d a g a in s t f u rth e r p a rtic ip a tio n . T h u s, analyses are based o n th e resu lts of 44 den tists an d their patien ts w ho smoke.
Procedures and study design T h e procedures have been described in d e ta il else w h e re .17 Briefly, all d en tists either attended a 1-hour lecture or received personalized in struction on the medical co n seq u en ces of sm o k in g , the benefits of q u ittin g , and the evidence that p hy s ic ia n s ’ advice o r n ic o tin e -c o n ta in in g chew ing gum , or both, can be effective in h elp in g some patients q u it sm oking. A fo u r-step p rotocol was suggested for c o u n s e lin g p a tie n ts: S tep 1. Ask y o u r p atients about sm oking. Step 2. Deliver a firm q u it-s m o k in g m essage. S tep 3. M utually agree on a q u it date. Step 4. Check on each p a tie n t’s progress at each regularly scheduled visit.18 Before the lecture, dentists and their e n tir e p a n e l of p a tie n ts w h o sm o k ed c ig a re tte s w ere r a n d o m ly a ssig n e d to one of four study groups: control, gum , rem inder, an d both gum and rem inder (control = 13, gum = 9, rem inder = 10, b oth = 12). D entists in the control group were given a copy of a booklet containing th e fo u r- s te p c a re p ro to c o l a n d w ere encouraged to counsel their patients who smoke. D entists in the other three groups rec eiv e d th e sam e in s tr u c tio n as the control gro u p plus additional instruction b ased o n th e ir a s sig n e d e x p e rim e n ta l intervention. For the nicotine gum group, dentists were to ld th a t th e ir p a tie n ts w ho h ad a fluorescent red sticker attached to their c h a r t w o u ld be e lig ib le to receive u p to a ten-box supply of a nicotine chew ing g u m at no cost. If the dentists w anted a p atien t to receive the gum , he or she h a d to c o m p le te a lo g b o o k re c o rd to in d ic a te th a t n ic o tin e g um was b ein g 42 ■ JADA, Vol. 118, January 1989
T ab le 2 ■ Confirmed success rates (%) in quitting smoking at the 6-month
visit for each dentist intervention. G ro u p C ontrol R em inder G um Both
R eturnees only (N = 428) 7.1 7.4 18.2 9.4
All enrollees (N = 1,027) 3.1 3.2 9.0 3.0
G eneralized linear m odel significant P-values R em inders G um
> .1 0 .072
given and in w hat am ounts. In the rem inder condition, two flu o rescent stickers were placed on the charts to help dentists an d their staff members to re m e m b e r to fo llo w th e ste p -c a re protocol. T h e green sticker asked “ Did you ta lk to th e p a tie n t to d a y a b o u t sm oking? Yes or N o.” T h e orange sticker stated, “T h e p atien t has agreed to the follow ing q u it d a t e __________ ” In the both (gum an d rem inder) condition, all in te rv e n tio n m ethods an d stickers p e r ta in e d . T h e d e n tis ts a n d th e ir staff m e m b ers w ere in s tru c te d in b o th th e use of rem inders and of the nicotine gum .
Patients P atien ts were eligible for p a rtic ip a tio n if they w ere betw een 18 a n d 64 years, reported sm oking one or m ore cigarettes daily, and had an alveolar breath carbon m o n o x id e d eterm in a tio n of m ore th a n 8 p p m . P a tie n ts were ex clu d ed if an y of the c o n tra in d ic a tio n s for the use of nicotine gum pertained. Smokers were identified in each dental office. W h en c a llin g to re c o n firm an a p p o in tm e n t, the re c e p tio n ist in each dental office determ ined w hether a patien t w as c u rren tly a cig arette sm oker. T h e list of sm okers served as the basis for p a tie n t co n tact by the p ro ject research assistants w ho determ ined their eligibility fo r p a r ti c ip a tio n . P a tie n ts s ig n e d an inform ed consent form, in d ic atin g that their sm oking habit w ould be m onitored at each regularly scheduled office visit, reg ard less of th e ir d ecisio n to q u it or contin u e sm oking. Patients were notified th a t they w o u ld be asked to provide a breath sam ple at each regularly scheduled ap p o in tm e n t for carbon m onoxide a n a l ysis a n d to an sw e r som e q u e s tio n s im m e d ia te ly a fte r se e in g th e d o c to r. D u rin g th is ex it in terv iew , a research assistant asked the patients w hether the
.051 .061
dentist or other staff m em ber had talked to them ab o u t sm oking. If they answered affirm atively, they were asked to estim ate how m any m inutes that person had spent talk in g to them ab o u t sm oking. O f the sm okers contacted, the refusal rate was less than 10%, resu ltin g in 1,027 patients w ho agreed to participate. Because cigarette sm okers often q u it sm oking an d later relapse, the prevalence of sm o k in g was estim ated at two s u b se q u e n t tim e w indow s. T h e first e s ti m a te — 6 m o n th s —w as d e fin e d as th e sm o k in g status determ ined at any visit th a t occurred at least 3 m onths after the in itia l a p p o in tm e n t b u t n o t m ore th a n 9 m o n th s a fte r it. T h e seco n d estim ate was at 1 year, w hich was defined as any visit th at occurred at least 9 m onths and 1 day after the in itial visit an d up to 15 m o n th s after the in itia l visit. If there were m ore th an one visit d u rin g a tim e interval, the sm oking status was determ ined by the status of the last visit d u rin g th a t interval. For p atien ts w ho h ad a regularly scheduled a p p o in tm e n t d u rin g the critical period, their sm oking s ta tu s w as co n firm e d th ro u g h ca rb o n m onoxide assessment, u sin g procedures described elsew here.19 Patients n o t having a visit d u rin g the 6- or 12-m onth periods were assumed to be smokers. T h u s, the resu lts are rep o rted b o th for retu rn ees for w h o m b io ch em ical v a lid a tio n was possible and for all enrollees on the basis that a p atien t was a smoker unless there was biochem ical evidence to the contrary. In the study design, the dentists were th e u n its of ra n d o m iz a tio n . F or each d e n tis t, th e p e rc e n ta g e of h is or h e r p a tie n ts w h o h a d q u it s m o k in g a t a p articu la r tim e interval was calculated. T h e resulting q u it rate was assum ed to follow a b in o m ial d istrib u tio n w ith an u n d e rly in g m e an th a t w as d e p e n d e n t on the study condition. However, w hen data from different dentists in the same
co n d itio n were com bined, the b inom ial v a ria n c e w as e x p e c te d to be in f la te d because of the betw een-dentist variability. T h e re fo re , a g en e raliz ed lin e a r m odel w as u sed a n d a sc a le -fa c to r w as used to reflect the extra variance.20 If the scale factor was greater than one, it was used to adjust the variance estim ates and the te st s ta tistic s . A x 2 s ta tis tic b ased on c h a n g e s in th e d e v ia n c e f u n c tio n for a series of nested m odels w as used to test for m a in effects a n d in te ra c tio n s. T h e statistical m odeling was perform ed u sin g the generalized lin e ar interactive m odeling (GLIM ) software package.21 Results
G ro u p
R eturnees o nly (N = 374)
All enrollees (N = 1,027)
7.7 8.6 16.3 16.9
3.1 2.8 7.7 4.7
C ontrol R em inder G um Both
G eneralized lin e a r model sig n ific a n t / ’-values G um .012
.038
Table 4 ■ Patients’ report of the number of minutes their dentists and dental staff spent talking to them about smoking. Experim ental g ro u p
SD
R ange
1.7 2.7 5.6 6.7
7.3 6.9 6.8 8.9
0 .0 - 8.0
1.4 2.3 2.3 2.9
5.6 8.5 4.1 7.3
4.1 - 9.5 4 .5 - 9.5 0 .0 - 4.9 0.1 - 11.0 1.3- 5.0 00 <£>
altered the frequency and am o u n t of time th a t w as sp e n t in c o u n s e lin g p a tie n ts a b o u t sm o k in g , w e in te rv ie w e d th e patients im m ediately after the office visit. We exam ined the p atien ts’ reports from b o th th e firs t a n d se co n d o ffic e ex it interv iew s afte r th e p a tie n ts h ad been recruited. In m any of the dental offices, the responsibility of counseling smokers was shared between the dentists an d other o ffice sta ff m em b ers. T h e re fo re , th e c o u n s e lin g d a ta re fle c t th e c o m b in e d efforts of dentists a n d th e ir office staff m em bers. F or each d e n tist a n d h is or her staff members, we o btained an average n u m b e r of m in u te s s p e n t c o u n s e lin g p a tie n ts a b o u t c ig a re tte s m o k in g by d iv id in g the to ta l n u m b e r of m in u te s counseled by the n um ber of their patients enrolled in the study. Because some dental offices m ay h av e o n ly th re e p a tie n ts in v o lv e d a n d o th e rs 40 o r m o re, we w eighted the average n um ber of m inutes c o u n s e le d by th e n u m b e r of p a tie n ts in v o lv e d . T h is w e ig h tin g system is inversely p r o p o rtio n a l to the v arian ce of the observations and, thus, is necessary to sa tisfy th e a s s u m p tio n o f e q u a l variance needed for analysis of variance. Patients w ho reported th at they did not receive counselin g ab o u t sm o k in g were included in the analysis w ith the num ber
0 01
M ean
©
V isit one C ontrol R em inder G um Both V isit tw o C ontrol R em inder G um Both
cn ©
T h e characteristics of the dental patients w ho were enrolled in the study are show n in T able 1. As a whole, they were m ore affluent and better educated th an w ould be found am ong a n ational sam ple. T he degree of n icotine dependence was cal c u la te d u s in g a system d e v e lo p e d by F ag erstro m ,22 w here 0 = low est an d 11 = h ig h e s t degree of d ep e n d en c e. T h is sco re is b ased o n re sp o n se s to su c h questions as H ow soon after you wake u p do you sm oke y o u r first cigarette? and, H ow m any cigarettes a day do you sm o k e ?22 In g e n e ra l, p a tie n ts h a d a m oderate degree of nicotine dependence. A generalized lin ear m odel was used to analyze the results of the quit-sm oking rates. T h e 6 -m o n th re su lts are show n in T able 2. T h e generalized linear model fo r a ll e n ro lle e s p ro d u c e d b o r d e rlin e s ig n ific a n t m a in effects fo r g u m a n d for rem inders. H ow ever, the coefficient fo r th e re m in d e r effect w as n e g a tiv e . Statistically, this result is caused by the h ig h cessation rates in the gu m g ro u p coupled w ith the low er rate in the gum a n d rem inder group. T hese rates for all returnees may n o t reflect the effectiveness of th e in te rv e n tio n , b u t may, in p a rt, be a rtifa c ts of the n u m b e r of p a tie n ts w ho returned d u rin g the tim e window . Whereas those patients w ho did n ot return were classified as smokers, the cessation rate in b oth gum an d rem inder groups was depressed by a lower 6-m onth return ra te (32.3%) th a n in th e o th e r g ro u p s (control 43.8%, rem inder 43.3%, a n d gum 49.5%). T h e results at 1 year are show n in T able 3. At 1 year, there was a significant effect of the g um for both those patients who retu rn ed d u rin g th a t tim e interval an d for all p a tie n ts. No o th e r effects were significant. T o determ ine w hether the interventions
Table 3 ■ Confirmed success rates (% ) in quitting smoking at the 12-month visit for each dentist intervention.
of m inutes of co u nseling eq u a lin g zero. T h e w eig h ted m ean s of th e n u m b e r of m inutes spent co u nseling by dentists an d their staff mem bers at the first and second p atien t visit after the intervention are show n in T ab le 4. T w o-w ay analyses of v a ria n c e w ere c a lc u la te d o n th e w e ig h te d d a ta s e p a ra te ly fo r th e firs t a n d seco n d p a tie n t v isit to d e te rm in e w hether the ex p e rim en tal in terv en tio n s had a sig n ifican t effect on the a m o u n t of tim e spent in co u nseling p atien ts ab o u t th eir sm oking. For the first visit, there was a s ig n ific a n t m a in effect o n ly for the g um groups (P < .0001). T h ere were n o s ta tis tic a lly s ig n ific a n t d ifferen ces a t th e second v isit. T h u s , for d e n tists an d their staff m em bers, only access to the n icotine gum produced a significant in c re ase in th e a m o u n t of tim e sp e n t in counseling their p atients ab o u t sm ok in g . T h a t effect w as su sta in e d for th e first post-intervention visit alone. Discussion D entists could have a m ajo r im p act on the sm oking status of m illio n s of A m er icans. T h e ir low prevalence of sm oking suggests that dentists can serve as good ro le m o d e ls fo r c o u n s e lin g th e ir patien ts.23 T h e extent to w hich they can
Cohen - Others : H ELPING SMOKERS QUIT: RANDOMIZED C O NTR O LLED TRIAL ■ 43
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be effec tiv e w ill d e p e n d on w h e th e r d e n tis ts take th e tim e to id e n tify th e sm okers in their practices, counsel them ab o u t the dangers of sm o k in g an d the benefits of q u ittin g , offer them help in q u ittin g , and fo llo w -u p th e ir sm oking status at regularly scheduled office visits. A recen t m e ta-an a ly sis of 108 in te r ventions used in 39 controlled trials of sm oking cessation found that the greatest success w as achieved w hen there w ere
in com binatio n w ith g ro u p counseling, can be efficacious for h elp in g physicians’ patients w ho are trying to stop sm oking.25 Sim ilar findings have been show n w ith d e n ta l p a tie n ts w h o v o lu n te e re d to p a r tic ip a te to q u it s m o k in g .26,27 T h e confirm atory results of the current study are im p o r ta n t b ecau se they are based on a p o p u la tio n of general dental patients a n d n o t ju st on a g ro u p of volunteers interested in q u ittin g sm oking.
The results of this study suggest that changing the way clinicians practice requires altering their routine practice environment. m u ltip le interventions given by m ultiple h ealth care providers on m ultiple occa sions.24 T h u s, for h elp in g smokers quit, th e g re a te r th e k in d a n d n u m b e r of co n tac ts, the g rea ter the lik e lih o o d of success. T h e results of ou r study suggest th a t the add itio n of specific m echanism s (for exam ple, ch art rem inders an d n ic o tin e gum ) can increase the likelihood th a t p a tie n ts w h o sm oke w ill receive co u nseling by their health professionals. For dentists, counseling patients about sm oking was m ore likely to occur if the d en tists co u ld offer a free p resc rip tio n of n ic o tin e gu m to th eir patien ts w ho smoke. In response to a pre-intervention q u estio n n aire about their approach to c o u n s e lin g th e ir p a tie n ts w ho sm oke, less th a n h a lf of the d en tists rep o rted th ey h a d o ffered p e rs o n a l c o u n s e lin g to p a tie n ts a b o u t q u i t t i n g sm o k in g . P erhaps the availability of a new therapy (th a t is, n ic o tin e gum ) was h elp fu l in a c tiv a tin g d e n tis ts to c o u n s e l th e ir p atients w ho smoke. T h e m a jo rity of c o n tro lle d tria ls in th e lite r a tu r e o n s m o k in g c e ssa tio n in volved v o lunteers interested in q u it ti n g .24 In c o n tra s t, o u r r e c ru itm e n t e m p h asized an in te re st in m o n ito rin g the habits of all eligible smokers, regard less of their interest in quitting. Conclusions M e th o d s th a t a p p e a r to be su ccessful w ith smokers volunteering to participate in a sm o k in g ce ssa tio n p ro g ra m m ay n o t be transferable to smokers in a private practice dental setting. A recently p u b lished article show ed that nicotine gum , \4 m
JADA, Vol. 118, January 1989
E d ito ria ls c o n tin u e to e x h o rt h ea lth care professionals to take a m ore active role in counseling sm okers.28 T h e results of this study suggest th at ch an g in g the way clinicians practice requires altering th e ir ro u tin e practice en v iro n m en t (for exam ple, flagging charts an d p roviding n ic o tin e g u m ). T h e se a lte r a tio n s n o t o n ly b rin g th e p rac tice of c o u n s e lin g smokers closer to w hat is being preached, b u t also ap p e ar to h elp m any p atien ts q u it smoking.
-------------------- JA D A --------------------T h is re s e a rc h w as s u p p o rte d by a g r a n t fro m th e N a tio n a l C a n c e r I n s titu te , g r a n t no. P H S 1 R O l CA38337. T h e a u th o rs th a n k research assistants Ms. C athy A rm an tro u t, Ms. A ndra Eason, Ms. C indy G orm an, Ms. J ill H elm en, Ms. Sue Kelly, and Ms. D rusilla K rieck ; Dr. Ja m e s M cD o n a ld , D r. B y ro n O ls o n , Ms. Barbara Davis, a n d Ms. M onica H am m o n d for la b o ra to ry a n d d a ta m a n a g e m e n t s u p p o r t; a n d L a k e sid e P h a rm a c e u tic a ls for p ro v id in g n ic o tin e gum . Dr. C ohen is professor, d e p a rtm e n t of m edicine a n d R egenstrief In stitu te for H e alth Care, In d ia n a U n iv e rs ity S ch o o l of M ed icin e, a n d is p ro fesso r, p a r t- tim e , O ra l H e a lth R e s e a rc h I n s titu te a n d d e p a rtm e n t of p re v e n tiv e d e n tistry , In d ia n a U n i versity School of D entistry. Dr. Stookey is director, O ra l H e a lth R ese a rc h I n s titu te a n d d e p a r tm e n t of p reventive dentistry, In d ia n a U niversity School of D entistry. Dr. Katz is assistant professor, dep art m en t of m edicine and R egenstrief In stitute for H ealth C are, In d ia n a U niversity School of M edicine. Ms. D rook is assistant director of clinical research, O ral H e a lth R e s e a rc h I n s titu te a n d d e p a r tm e n t of p re v e n tiv e d e n tis try , I n d ia n a U n iv e rs ity S c h o o l of D entistry. Dr. C hristen is professor, O ral H ealth R ese arch In s titu te a n d d e p a rtm e n t of p re v e n tiv e d e n tistry , In d ia n a U niversity School of D entistry. A ddress re q u e sts for re p rin ts to Dr. C o h en a t the
In d ia n a U niversity D epartm ent of M edicine, R egen s trie f H e a lth C en ter, F ifth F lo o r, 1001 W T e n th St, In d ia n a p o lis 46202.
1. DHEW . H ealthy people: the surgeon g e n eral’s re p o rt on health pro m o tio n and disease prevention. W ashington, DC: G overnm ent P rin tin g Office, 1979; D H EW p u b lication no (PH S) 79-55071. 2. D H H S . N ic o tin e a d d ic tio n : a re p o rt o f the s u rg e o n g e n e ra l. W a s h in g to n , DC: G o v e rn m e n t P rin tin g Office, 1988; D H H S p u b lic a tio n n o (CDC) 88-8406. 3. S m o k in g —a ttrib u ta b le m o rtality a n d years of p o te n tia l life lo s t— U n ite d S tates, 1986. M M W R 1987; 36:581-5. 4. U S P re v e n tiv e S erv ices T a s k F o rce . R e c o m m en d atio n s for sm o k in g cessation co u n selin g . JAD A 1988; 259:2882. 5. A llen WA, Fackler WA. A n exploratory survey a n d sm o k in g c o n tro l p ro g ra m a m o n g p a re n ts of P h ila d e lp h ia school c h ild re n . In: Z agona SV, ed. S tudies an d issues in sm o k in g beh av io r. T u c so n : U niversity of A rizona Press; 1967. 6. G a llu p O p in io n Index. P u b lic puffs o n after ten years of w a rn in g s. R e p o rt n o 108. P rin c e to n , N J: G a llu p Poll, 1974. 7. Graves RC. D ental health needs and dem ands in A m erican society: cu rren t trends. H ealth V alues 1984; 8:13-20. 8. Pederson LL. C om pliance w ith physician advice to q u i t sm o k in g : a review of the lite ra tu re . P rev Med 1982; 11:71-84. 9. R ose G, H a m ilto n P J, Colw ell L, Shipley MJ. A random ized controlled trial of a n ti-sm o k in g advice: 10-year re su lts. J E p id e m io l C o m m u n ity H e a lth 1982; 36:102-8. 10. B u rt A, T h o r n e y P, I ll in g w o r th D, e t a l. S to p p in g sm oking after m yocardial infarction. L ancet 1974; 1:304-6. 11. R u sse ll M A H , W ilso n C , T a y lo r C, B aker C. Effect of g e n eral p ra c titio n e r s ’ a d v ice a g a in s t sm oking. Br Med J 1979; 2:231-5. 12. A m erican C ollege of P hysicians, H e alth and P olicy C om m ittee. M ethods for s to p p in g cigarette sm oking. A nn Intern Med 1986; 105:281-91. 13. D H H S . C lin ic a l o p p o rtu n itie s for s m o k in g in te r v e n tio n : a g u id e fo r th e b u s y p h y s ic ia n . W ashington, DC: G overnm ent P rin tin g Office, 1986; D H H S p u b lication no (N IH ) 86-2178. 14. 1978 H e a lth M a in te n a n c e S u rv ey . (C o m m is s io n e d by P a c ific M u tu a l L ife I n s u ra n c e , N ew port Beach, CA, a n d conducted by L ouis H arris a n d Associates), 1978. 15. A nda RF, R em ington PL , Sienko D G , et al. A re p h y s ic ia n s a d v is in g s m o k e rs to q u it? T h e p a tie n t’s perspective. JADA 1987; 257:1916-9. 16. A m erican D ental A ssociation. R eso lu tio n on c ig a re tte s m o k in g . N ew s o f d e n tis try . JA D A 1964;69:776. 17. C o h e n S J, C h ris te n A G , K atz B P, e t al. C o u n s e lin g m e d ic a l a n d d e n ta l p a tie n ts a b o u t cigarette sm oking: the im pact of n ico tin e g u m and c h art rem inders. Am J P ublic H e alth 1987; 77:313-
6. 18. N a tio n a l H ig h B lo o d P r e s s u re E d u c a tio n Program . T h e physician’s guide: how to help your h y p erten siv e p a tie n ts sto p sm o k in g . W ash in g to n , DC: G o v e rn m e n t P r i n tin g O ffice , 1983; N IH p u b lic a tio n no 83-1271. 19. Stookey GK, Katz BP, O lson BL, D rook CA, C o h e n SJ. E v a lu a tio n of b io c h e m ic a l v a lid a tio n m e a su re s in d e te rm in a tio n o f s m o k in g s ta tu s. J D ent Res 1987; 66:1597-601. 20. M cC ullagh P, N elder JA. G eneralized lin e a r models. L ondon: C hapm an an d H all, 1983.
21. Baker R J, N elder JA. T h e G L IM system, release 3, generalized lin e a r interactive m o d e lin g . O xford: N um erical A lgorithm s G ro u p , 1978. 22. F ag erstro m KO. T o le ra n c e , w ith d ra w a l a n d dependence on tobacco a n d sm o k in g te rm in a tio n . In t Rev A ppl Psychol 1983; 32:29-52. 23. C h ris te n AG. S urvey o f s m o k in g b e h a v io r and attitudes of 630 A m erican dentists: c u rren t trends. JAD A 1984; 109:271-2. 24. K ottke T E , B attista R N , DeFriese G H , et al.
A ttrib u tes o f successful c essatio n in te rv e n tio n s in m ed ical p ractice: a m eta-an aly sis of 39 c o n tro lle d trials. JA M A 1988; 259:2882-9. 25. T o n n e sen P, Fryd V, H ansen M, et al. Effect of n ic o tin e chew ing gu m in com b in atio n w ith group c o u n s e lin g o n th e cessatio n of sm o k in g . N E n g l J Med 1988; 318:15-8. 26. C h risten AG, M cD onald J L , O lson BL, D rook CA, Stookey GK. Efficacy of n ico tin e chew ing gum in fa c ilita tin g sm o k in g cessation. JAD A 1984; 108:594-
7. 27. C h r is te n A G , O ls o n B L , S a m p s o n V M , M c D o n a ld J L . In te n s iv e q u i t s m o k in g p ro g r a m in a d e n ta l s e ttin g u s in g n ic o tin e g u m : o n e year results. CDA J 1986; 14:28-34. 28. D av is R M . U n i t i n g p h y s ic ia n s a g a in s t sm oking: the need for a c oordinated n a tio n a l strategy. JAM A 1988; 259:2900-1.
Self-Assessment Questions 1. C igarette sm o k in g is th e le ad in g preventable cause of illness an d p re m ature death in the U nited States. a) true b) false 2. T h e m a jo rity o f sm okers w ill be
seen by a dentist w ith in a year. a) true b) false 3. W hich of the fo llo w in g was n o t
p a r t o f th e p ro to c o l re c o m m e n d e d to a ll d e n tists fo r c o u n s e lin g th e ir patients w ho smoke?
a) label the charts of patients who smoke b) ask your patients ab o u t sm oking c) d e liv e r a firm q u it- s m o k in g message d) m u tu a lly agree o n a q u it date e) check on each p a tie n t’s progress a t each regularly scheduled visit 4. E ducating dentists ab o u t the im p o r
tance of counseling their p atients w ho sm oke resulted in a significant increase in tim e s p e n t by th e d e n tis ts in counseling smokers an d a significant increase in the n u m b er of their patients
w ho q u it sm oking. a) true b) false 5. T h e av a ilab ility of n ic o tin e g um
resu lted in a sig n ific a n t increase in tim e sp e n t by th e d en tists in c o u n s e lin g sm o k e rs a n d a s ig n if ic a n t increase in the n um ber of their patients w ho q u it sm oking. a) true b) false A nsw ers are fo u n d in th e P eo p le & M eetings section.
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