Tobacco-Use Cessation Programs and Policies at the University of Manitoba’s Faculty of Dentistry

Based on this evidence, the faculty of dentistry of the University of Manitoba initiated a number of integrated tobacco-use cessation interventions in the fall of 1998. These interventions included:

1. incorporation of formal tobacco-use cessation training into the dental and dental hygiene curricula;

2. establishment of a systematic tobacco-use cessation clinic protocol for the general teaching clinic;

3. implementation of a referral program to the faculty’s Freedom From Smoking Clinics;

4. creation of a resource centre to provide educational self-help cessation materials for dental practices and consultation on how to implement a tobacco-use cessation program in the dental office;

5. delivery of a continuing education course entitled “How to Help Your Patients Be Tobacco Free”; and

6. evaluation of the effectiveness of these combined interventions and their impact on the extent of student tobacco-use cessation counselling in the clinic.

Undergraduate Curriculum

The committee on curriculum in dentistry approved the incorporation of tobacco-use cessation training in the dental curriculum in 1998. Within the second-year course “Introduction to Comprehensive Care,” dental students participate in a 3-hour training workshop as do the first-year dental hygiene students. The goal of the workshop is to ensure that all clinicians are knowledgeable, skilled and committed to providing scientifically sound clinical tobacco-use cessation intervention. (In the first year of the program, we trained all second-, third- and fourth-year dental students and both first- and second-year dental hygiene students.)

Workshop Objectives

At the completion of the training session, the student will:

• understand general and oral health consequences of tobacco use;

• have a basic understanding of the biological mechanisms of action of tobacco use on oral health;

• be aware of the physical, psychological and social factors involved in tobacco use;

• be able to describe the role of the dental professional in tobacco-use cessation;

• understand the “stages of change” model and apply it in patient counselling;

• understand the role of pharmacologic interventions including nicotine replacement therapy (NRT) (patch and gum) as well as bupropion HCl (Zyban);

• be aware of referral mechanisms to community smoking cessation resources which offer intensive individual and group tobacco cessation counselling services;

• be prepared to carry out the faculty’s tobacco-use cessation clinic protocol;

• be prepared to design and implement a tobacco-use cessation program in their future dental practices.

Workshop Content

The workshop covers the following topics:

• the prevalence of tobacco use, direct and indirect public health costs;

• general health consequences of tobacco use;

• oral health consequences of tobacco use;

• why people smoke and why they quit;

• nicotine addiction, what it is, what are its physical effects, withdrawal;

• stages of change model and the readiness to quit process;

• counselling (ask, advise, assist, arrange), self-help material, referral concepts;

• pharmacological interventions, NRT, non-NRT, indications/ contraindications;

• faculty clinic protocol — tobacco-use cessation program;

• practical cessation program for the dental practice.

Workshop Evaluation

The students were tested before and after the workshop. The results indicated that their understanding of tobacco and its effects on general and oral health increased as a result of the workshop, as did their knowledge of the addictive nature of nicotine, the physical, psychological and social impediments to quitting, the stages of change involved in quitting, and their role in advising and assisting patients to quit smoking.

Faculty Teaching Clinic Protocol

Smoking cessation counselling is considered a standard of practice for clinical health disciplines.¹⁴ The Smoking Cessation: Clinical Practice Guidelines, prepared by the Agency for Health Policy and Research and the Centers for Disease Control and Prevention in the United States¹⁵ recommend that health care administrators devise policies, provide resources and display leadership in fostering smoking cessation efforts within every health care facility. As a community health centre providing oral health care to the public, the faculty implemented these recommendations by initiating a tobacco-use cessation program for its general teaching clinic.

Clinic administrators began by revising the faculty’s medical history form to include specific questions designed to record patients’ tobacco-use status. When patients are screened in the oral diagnosis clinic, their tobacco-use status is identified on their chart using coloured stickers to indicate either non-tobacco use (white sticker) or tobacco use (black sticker). The stickers alert all providers to give appropriate advice and counselling to tobacco users. Because of the role of tobacco use on the progression of periodontal diseases and its negative influence on the outcome of periodontal therapy, the clinical forms used by undergraduate periodontics students were also revised to gather more specific tobacco-use information, including frequency and duration of tobacco exposure and readiness to quit. These forms prompt students to recognize tobacco use as a contributing factor in a patient’s periodontal condition and to incorporate cessation counselling in the periodontal treatment plan. The form also provides a record of the patient’s level of readiness to quit, the specific advice and self-help materials given by the student and whether referral to more intensive tobacco counselling was recommended. Within the general clinic there is a designated centre which contains a wide range of individualized tobacco-use cessation self-help materials and information about NRT and non-NRT as well as videos that patients can borrow.

Referral Program

Patients attending the faculty’s general teaching clinic who indicate they are ready to quit are given individualized tobacco-use cessation self-help educational materials along with directed counselling by a student. For patients who wish to have more intensive counselling, students may make referrals to the faculty’s Freedom From Smoking Clinics. These clinics offer a group approach using behaviour modification to help individuals stop tobacco use. Through a series of 8 evening sessions lasting 2 hours each, participants develop an individual plan of action to quit smoking. Information is provided about NRT and non-NRT. The program also emphasizes stress management, relaxation techniques, healthy eating practices and other positive lifestyle changes. It establishes a “buddy system” for participants. The cost of the program is approximately $130 and includes the cost of the materials, help from a facilitator, and tobacco-use cessation counselling by a nurse who is contracted by the faculty and trained by the Manitoba Lung Association. The sessions are held in a seminar room at the faculty throughout the year. Practising dentists in the province may also refer their patients to the faculty’s Freedom From Smoking Clinics. Many internal and external referrals have been made to the program over the past 2 years.

Dr. Gelskey providing tobacco-use cessation materials at the January 2001 Manitoba Dental Association annual meeting.

Resource Centre

The faculty acts as a resource centre for oral health professionals in the province who request tobacco-use cessation self-help educational materials for patients or for scientific literature related to tobacco and oral health. The faculty also provides direct consultation to practitioners about how to implement a tobacco-use cessation program in a dental practice.

Continuing Education

The faculty launched its tobacco-use cessation programs in August 1998 with a 2-day conference titled “How to Help Your Patients Be Tobacco Free.” Dr. Robert Mecklenberg of the U.S. National Cancer Institute was the speaker. Over 350 health care practitioners attended the session including physicians, dentists, nurses, dental hygienists and assistants, pharmacists and respiratory therapists. The faculty is planning a tobacco-use cessation continuing education course in the spring of 2001.

Evaluation of the Faculty Interventions

Prior to initiating the tobacco-use cessation interventions at the faculty, a baseline assessment was completed to determine the extent to which tobacco-use cessation counselling was being done by students and staff. Charts for all adults seen in the dental clinic during the 1997-1998 academic year were reviewed and patient smoking status determined. Those who reported tobacco use were contacted and asked in a structured telephone interview whether, while attending the faculty’s clinic, they had been advised of the potential oral health consequences of smoking and whether they were informed of the need to quit smoking. In the fall of 1998, following this baseline assessment, the faculty introduced its tobacco initiatives. To determine whether tobacco-use counselling activity increased as a result of the faculty’s interventions, the charts of all adult patients seen during 1999-2000 were reviewed and patient tobacco status determined. The same structured telephone interviews were once more completed. The data are currently under analysis and will be reported with the baseline results in a future publication.

Policy Considerations

In 1999, the faculty submitted a proposal to the Manitoba Dental Association (MDA) requesting the initiation of a dental service fee code for tobacco-use cessation services. The proposal was approved by the MDA and submitted to the Canadian Dental Association for consideration. CDA recently initiated the fee code and it is now in the MDA fee guide.

The faculty was also successful in receiving approval from the MDA in conjunction with the College of Physicians and Surgeons of Manitoba and the Manitoba Pharmaceutical Association to allow dentists who have completed an approved course in tobacco-use cessation training to prescribe bupropion HCl (Zyban) to help their patients quit tobacco use. Dentists who prescribe Zyban will do so in consultation with the patient’s physician who is most aware of the patient’s general health status.

Dr. Gelskey is associate professor and head of the department of dental diagnostic and surgical sciences, faculty of dentistry, University of Manitoba.

Correspondence to: Dr. Shirley C. Gelskey, Department of Dental Diagnostic and Surgical Sciences, Faculty of Dentistry, University of Manitoba, 780 Bannatyne Ave., Winnipeg, MB R3E 0W2. E-mail: shirley_gelskey@umanitoba.ca

The author has no declared financial interest. The views expressed are those of the author and do not necessarily reflect the opinion or official policies of the Canadian Dental Association.

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