Tobacco and Oral Health: Integrating Interventions - PDF

Part III Integrating brief tobacco interventions into oral health programmes in primary care: policy recommendations 1. Introduction The systematic review presented in the previous chapter demonstrated that there are adverse associations...

Part III Integrating brief tobacco interventions into oral health programmes in primary care: policy recommendations 1. Introduction The systematic review presented in the previous chapter demonstrated that there are adverse associations between tobacco use and oral disease, in that direct tobacco use and exposure to second-hand smoke are associated with oral cancer, periodontal diseases, dental caries and tooth loss. The recognition of associations between tobacco use and oral health makes it imperative for national oral health programmes to actively support tobacco control efforts at both the clinical and community levels. This chapter explores the possibilities and advantages of integrating brief tobacco interventions (brief advice) into oral health programmes in primary care. Its objectives are: to describe what oral health professionals can do to identify and support tobacco users to quit in primary care, and to propose the effective system changes needed for integrating tobacco cessation services into oral health programmes as part of oral health professionals’ routine practice in primary care 1.1. WHO ORAL HEALTH PROGRAMME TOBACCO CONTROL POLICY The objectives of the WHO Global Oral Health Programme, one of the technical programmes within the Department of Prevention of Noncommunicable diseases (PND), have been reoriented according to the new strategy of disease prevention and health promotion. There is greater emphasis on developing global policies in oral health promotion and oral disease prevention, coordinated more effectively with other priority programmes of PND and other clusters, and with external partners (1). WHO recommends that oral health programmes should embrace what is termed “the common risk factor approach” to integrate oral health promotion into broader health promotion (2). Tobacco use, as a common risk factor between oral diseases and major chronic non-communicable diseases (NCDs), provides the rationale for national oral health programmes to support tobacco control. PART III: INTEGRATING BRIEF TOBACCO INTERVENTIONS INTO ORAL HEALTH PROGRAMMES IN PRIMARY CARE: POLICY RECOMMENDATIONS W H O MON OG RA P H O N TO BA CCO CE SSAT IO N AN D O R AL H EAL TH IN T EG R A TIO N 35  The tobacco-related goal of the WHO Oral Health Programme is to ensure that oral health professionals and oral health organizations are directly, appropriately and routinely involved in influencing patients and the public to increase their awareness of the risks of tobacco use, and to avoid and discontinue the use of all forms of tobacco (3). The WHO Oral Health Programme aims to control tobacco-related oral diseases and adverse conditions through several strategies. Within WHO, the Programme enjoys a strong collaboration with the WHO Tobacco Free Initiative (TFI), and has always participated fully in oral health-related programmes. Externally, the Programme works in partnership with international and national oral health organizations to encourage the ratification and implementation of WHO Framework Convention on Tobacco Control (WHO FCTC). Promoting the effective involvement of oral health professionals in tobacco cessation is one of the priority areas in relation to tobacco control recommended by the WHO Global Oral Health Programme (4). Therefore, national oral health programmes should routinely identify and treat patients who use tobacco, and all oral health professionals should be urged to integrate tobacco cessation services into their routine practice, particularly in primary care. 1.2. WHO POLICY ON TOBACCO CESSATION Supporting current tobacco users to quit, consistent with Article 14 of the WHO FCTC, has been recommended by WHO as part of a comprehensive tobacco control package to achieve voluntary global targets related to tobacco use, as well as the premature mortality target in the WHO Global Action Plan for the Prevention and Control of Noncommunicable Diseases (2013–2020) (5). There is strong evidence that supporting current tobacco users to quit synergistically with other population-level tobacco control measures can bring about significant changes in the prevalence of tobacco use and tobacco-related death and disease in the short- to medium-term. It was estimated that if adult tobacco consumption were to decrease by 50% by 2020, about one third of global tobacco-related deaths could be avoided within 30 years (6). Currently, only 15% of the world population has access to comprehensive tobacco cessation services, and 97 countries are providing tobacco cessation support in some or most primary care facilities with some cost coverage, according to the WHO Report on the Global Tobacco Epidemic 2015 (7). Therefore, technical assistance to WHO Member States in establishing and improving their national tobacco cessation and treatment systems is urgently needed. PART III: INTEGRATING BRIEF TOBACCO INTERVENTIONS INTO ORAL HEALTH PROGRAMMES IN PRIMARY CARE: POLICY RECOMMENDATIONS 36 WHO MON O GRA P H ON TO B AC C O C ES SA TI O N A ND OR AL H EA LTH INTEG R ATIO N  Guidelines for the implementation of Article 14 of the WHO FCTC recommend integrating brief tobacco interventions into existing health care systems as a first step for Parties to develop comprehensive treatment systems. Although brief tobacco interventions should be made available throughout a country’s health system at all levels of service delivery, the primary care setting should be the main focus. It has the potential to reach the majority of tobacco users in many countries, where the cost of service delivery in primary care settings is relatively low. National oral health programmes could provide a priority health care platform for integration of brief tobacco interventions in primary care because oral health professionals are in a unique position to identify and help tobacco users, especially those who are young and “healthy” (8). 1.3. THE UNIQUE ROLE OF ORAL HEALTH PROFESSIONALS IN HELPING TOBACCO USERS Oral health professionals are able to reach large numbers of tobacco users and have considerable potential in persuading them to quit. In developed countries, more than 60% of tobacco users see their dentist or dental hygienist annually (9). As emphasized in the World Oral Health Report 2003 (8), there are also ethical, moral and practical reasons why oral health professionals can play an important role in helping tobacco users to quit: They are particularly concerned about the adverse effects caused by tobacco use in the oropharyngeal area of the body. They typically have access to children, young people and their caregivers, thus providing opportunities to influence individuals to quit or never begin using tobacco. They often have more time with patients than many other health professionals, providing opportunities to integrate tobacco cessation interventions into practice. They often treat women of childbearing age, and are thus able to explain the potential harm to babies from tobacco use. They are as effective as other health professionals in helping tobacco users quit. They can build their patient’s interest in discontinuing tobacco use by showing actual tobacco effects in the mouth. PART III: INTEGRATING BRIEF TOBACCO INTERVENTIONS INTO ORAL HEALTH PROGRAMMES IN PRIMARY CARE: POLICY RECOMMENDATIONS W H O MON OG RA P H O N TO BA CCO CE SSAT IO N AN D O R AL H EAL TH IN T EG R A TIO N 37  2. What should a national oral health programme do to promote tobacco cessation? National oral health programmes can promote tobacco cessation both in the clinical setting where dental/oral patients are diagnosed and treated, and outside the clinical setting. In a clinical setting, such programmes should strengthen the oral health care service to ensure that every oral disease patient who uses tobacco is identified and provided with at least brief tobacco intervention. Outside the clinical setting, oral health professionals – both individually and through their professional associations - can actively support the implementation of tobacco control measures contained in other articles of the WHO FCTC to promote tobacco cessation and increase demand for tobacco cessation services. 2.1. ORAL HEALTH PROFESSIONALS SHOULD ROUTINELY OFFER BRIEF TOBACCO INTERVENTIONS TO ALL TOBACCO USERS IN PRIMARY CARE There are a range of effective treatments for tobacco dependence, including brief advice to stop tobacco use (brief tobacco interventions) by health care professionals, more intensive behavioural support to quit (given individually, in a group or by phone), and pharmacological treatments. In line with the WHO FCTC Article 14 guidelines, WHO recommends that oral health professionals should at least deliver brief tobacco interventions as part of routine services in primary care. Available evidence suggests that behavioural counselling (typically brief) conducted by oral health professionals in conjunction with an oral examination in the dental office or community setting can increase tobacco abstinence rates by 70% (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.44 to 2.03) at six months or longer (10). Helping oral patients to quit smoking as part of oral health care providers’ routine practice takes only three-to-five minutes and is feasible, effective and efficient. The algorithm below can guide them to deliver three-to-five minute, brief tobacco interventions to oral patients in primary care by using the 5As and 5Rs models (Figure 16). PART III: INTEGRATING BRIEF TOBACCO INTERVENTIONS INTO ORAL HEALTH PROGRAMMES IN PRIMARY CARE: POLICY RECOMMENDATIONS 38 WHO MON O GRA P H ON TO B AC C O C ES SA TI O N A ND OR AL H EA LTH INTEG R ATIO N  Figure 16. Algorithm for delivering brief tobacco interventions Every oral health care provider should also educate about the dangers of second-hand smoke, and encourage their patients to avoid exposure to second-hand smoke and to create a smoke-free home for their children. 2.1.1. The 5As model to help patients ready to quit There are several structured models available to help deliver brief tobacco interventions. The 5As and 5Rs are the most widely used delivery models for brief tobacco intervention in primary care. The 5As (Ask, Advise, Assess, Assist, Arrange) summarize all the activities that an oral health care provider can do to help a tobacco user make a quit attempt within three- to-five minutes in a primary care setting (11). Ask – Systematically identify all tobacco users at every visit. Advise – Advise all tobacco users that they need to quit. Assess – Determine readiness to make a quit attempt. Assist – Assist the patient with a quit plan or provide information on specialist support. Arrange – Schedule follow-up contacts or a referral to specialist support. Ask: We need to ask ALL our patients if they use tobacco and make it part of our routine. Only then can we start to make a real difference to the tobacco use rates around us. Tobacco use should be asked about in a friendly way – it is not an accusation! PART III: INTEGRATING BRIEF TOBACCO INTERVENTIONS INTO ORAL HEALTH PROGRAMMES IN PRIMARY CARE: POLICY RECOMMENDATIONS W H O MON OG RA P H O N TO BA CCO CE SSAT IO N AN D O R AL H EAL TH IN T EG R A TIO N 39  Advise: Your advice should be clear and positive. It should also be tailored to the particular patient’s characteristics and circumstances. Assess: This will be determined by whether the patient wants to be a non-tobacco user, and whether they think they have any chance of quitting successfully. Assist: If the patient is ready to quit then he or she will need some help from us. We need to assist tobacco users in developing a quit plan or to tell them about specialist support if it is available. The support needs to be described positively but realistically. Arrange: If the patient is willing to make a quit attempt we should arrange follow-up around one week after the quit date, or arrange referrals to the specialist support. The 5As model can guide oral health care providers to talk about tobacco use and deliver advice to patients who are ready to quit. Below are recommended actions and strategies for implementing each of the 5As (Table 1) (12). Table 1. The 5As brief tobacco interventions for patients ready to quit 5A’s Action Strategies for implementation Ask - Ask ALL of your patients Tobacco use should be asked about in a friendly Systematically at every encounter if way – it is not an accusation. identify all tobacco they use tobacco and Keep it simple, some sample questions may include: users at every visit. register the information – “Do you smoke cigarettes?” in the patient’s dental – “Do you use any tobacco products?” treatment card. Tobacco use status should be included in all medical Make it part of your notes. Countries should consider expanding the vital routine. signs to include tobacco use, or using tobacco use status stickers on all patient charts, or indicating tobacco use status via electronic medical records. Advise - Urge every tobacco Advice should be: Persuade all user to quit in a clear, Clear – “It is important that you quit smoking (or tobacco users that strong and personalized using chewing tobacco) now, and I can help you.” they need to quit. manner. “Cutting down while you are ill is not enough.” “Occasional or light smoking is still dangerous.” Strong – “As your dentist, I need you to know that quitting tobacco use is the most important thing you can do to protect your health now and in the future. We are here to help you.” Personalized – Tie tobacco use to: − Demographics: For example, women may be more interested in the effects of smoking on fertility, bad breath, stained teeth and dark lips. PART III: INTEGRATING BRIEF TOBACCO INTERVENTIONS INTO ORAL HEALTH PROGRAMMES IN PRIMARY CARE: POLICY RECOMMENDATIONS 40 WHO MON O GRA P H ON TO B AC C O C ES SA TI O N A ND OR AL H EA LTH INTEG R ATIO N  5A’s Action Strategies for implementation − Health concerns: Asthma sufferers may need to hear about the effect of smoking on respiratory function, while those with periodontal disease may be interested in the effects of smoking on oral health. “Continuing to smoke makes your periodontal disease worse, and quitting may dramatically improve your oral health.” − Social factors: People with young children may be motivated by information on the effects of second-hand smoke, while a person struggling with money may want to consider the financial costs of tobacco use. “Quitting smoking may reduce the number of ear infections your child has.” In some cases, how to tailor advice for a particular patient may not always be obvious. A useful strategy may be to ask the patient: − “What do you not like about being a smoker?” The patient’s answer to this question can be built upon by you with more detailed information on the issue raised. − Example: Dentist: “What do you not like about being a tobacco user?” Patient: “Well, I don’t like how much I spend on tobacco.” Dentist: “Yes, it does build up. Let’s work out how much you spend each month. Then we can think about what you could buy instead!” Assess - Ask two questions in Any answer in the shaded area indicates that the Determine relation to “importance” tobacco user is NOT ready to quit. In these cases readiness to make and “self-efficacy”: you should deliver the 5 R’s intervention (see a quit attempt 1. “Would you like to be a Session 4.1.2). non-tobacco user?” Question 1 Yes Unsure No 2. “Do you think you have a chance of quitting Question 2 Yes Unsure No successfully?” If the patient is ready to go ahead with a quit attempt you can move on to Assist and Arrange steps. PART III: INTEGRATING BRIEF TOBACCO INTERVENTIONS INTO ORAL HEALTH PROGRAMMES IN PRIMARY CARE: POLICY RECOMMENDATIONS W H O MON OG RA P H O N TO BA CCO CE SSAT IO N AN D O R AL H EAL TH IN T EG R A TIO N 41  5A’s Action Strategies for implementation Assist - Help the patient develop Use the STAR method to facilitate and help your Help the patient a quit plan patient to develop a quit plan: with a quit plan Provide practical – Set a quit date ideally within two weeks. counseling – Tell family, friends, and coworkers about quitting, Provide intra-treatment and ask for support. social support – Anticipate challenges to the upcoming quit attempt. Provide supplementary – Remove tobacco products from the patient’s materials, including environment and make their home tobacco free. information on quit Practical counseling should focus on three elements: lines and other referral – Help the patient identify the danger situations resources (events, internal states, or activities that increase Recommend the use of the risk of smoking or relapse). approved medication if – Help the patient identify and practice cognitive needed and behavioral coping skills to address the danger situations. – Provide basic information about smoking and quitting Intra-treatment social support includes: – Encourage the patient in the quit attempt – Communicate caring and concern – Encourage the patient to talk about the quitting process Make sure you have a list of existing local tobacco cessation services (quit lines, tobacco cessation clinics and others) on hand whenever a patient enquires. The support given to the patient needs to be described positively but realistically. Arrange - Arrange a follow-up When: The first follow up contact should be Schedule follow- contact with your dental arranged during the first week after the quit date. up contacts or a patient either in person A second follow up contact is recommended one referral to specialist or by telephone. month thereafter. support Refer the patient to How: Use practical methods such as telephone, specialist support if personal visit and mail/email to follow up. Following needed up with patients is recommended through a team approach if possible. What: For all patients: – Identify problems already encountered and anticipate challenges. – Remind patients of available extra-treatment social support. – Assess medication use and problems. – Schedule next follow up contact. For patients who are abstinent: – Congratulate them on their success For patients who have used tobacco again: – Remind them to view relapse as a learning experience. – Review circumstances and elicit recommitment. – Link to more intensive treatment if available. PART III: INTEGRATING BRIEF TOBACCO INTERVENTIONS INTO ORAL HEALTH PROGRAMMES IN PRIMARY CARE: POLICY RECOMMENDATIONS 42 WHO MON O GRA P H ON TO B AC C O C ES SA TI O N A ND OR AL H EA LTH INTEG R ATIO N  2.1.2. The 5Rs model to increase motivation to quit. The 5Rs – relevance, risks, rewards, roadblocks and repetition – should be addressed during a motivational counselling intervention to help those who are not ready to quit. Tobacco users may be unwilling to quit because they don’t think it is important to them, or they don’t feel confident in their ability. Therefore, after asking about tobacco use, advising the tobacco user to quit, and assessing the willingness to make a quit attempt, it is important to provide the 5Rs motivational intervention (11). Relevance – How is quitting personally relevant to you? Risks – What do you know about the risks of tobacco use? Rewards – What would be the benefits of quitting in that regard? Roadblocks – What would be difficult about quitting? Repetition – Repeat assessment of readiness to quit; if still not ready to quit, repeat intervention at a later date. If the patient doesn’t want to be a non-tobacco user (doesn’t think that quitting is important), the oral health care providers should focus more time on “Risks” and “Rewards”. If the patient wants to discontinue tobacco use but doesn’t think he or she can quit successfully (doesn’t feel confident in their ability to quit), more time should be spent on the “Roadblocks”. If patients are still not ready to quit, we need to end positively with an invitation to return if they change their minds. Table 2 summarizes useful strategies to deliver a brief motivational intervention in primary care (12). Table 2. The 5Rs brief motivational intervention for patients not ready to quit 5Rs Strategies for implementation Example Relevance Encourage the patient to indicate how quitting is Oral Health Care Provider (OHCP): personally relevant to him or her. “How is quitting most personally relevant to you?” Motivational information has the greatest impact if it is relevant to a patient’s disease status P: “I suppose smoking is bad for my or risk, family or social situation (e.g. having health.” children in the home), health concerns, age, sex, and other important patient characteristics (e.g. prior quitting experience, personal barriers to cessation). PART III: INTEGRATING BRIEF TOBACCO INTERVENTIONS INTO ORAL HEALTH PROGRAMMES IN PRIMARY CARE: POLICY RECOMMENDATIONS W H O MON OG RA P H O N TO BA CCO CE SSAT IO N AN D O R AL H EAL TH IN T EG R A TIO N 43  5Rs Strategies for implementation Example Risks Encourage the patient to identify potential OHCP: “What do you know about the negative consequences of tobacco use that risks of smoking to your health? What are relevant to him or her. particularly worries you?” Examples of risks are: P: “I know it causes oral cancer. Acute risks: shortness of breath, exacerbation of That must be awful.” asthma, increased risk of respiratory infections, OHCP: “That’s right – the risk of having harm in pregnancy, impotence and infertility. oral cancer is many times higher Long-term risks: heart attacks and strokes, among tobacco users.” lung and other cancers (e.g. larynx, oral cavity, pharynx, esophagus), chronic obstructive pulmonary diseases, osteoporosis, long-term disability and need for extended care. Environmental risks: increased risk of lung cancer and heart disease in spouses; increased risk for low birth-weight, sudden infant death syndrome, asthma, middle ear disease and respiratory infections in children of smokers. Rewards Ask the patient to identify potential relevant OHCP: “Do you know how stopping benefits of stopping tobacco use. tobacco use would affect your risk of oral cancer?” Examples of rewards could include: − improved health; P: “I guess it would be lower if I quit.” − improved sense of taste; OHCP: “Yes, and it doesn’t take − improved sense of smell; long for the risk to decrease. But it’s − saving money; important to quit as soon as possible.” − better self-esteem; − home, car, clothing and breath will smell better; − setting a good example for children and decreasing the likelihood that they will smoke; − healthier babies and children; − feeling better physically; − performing better in physical activities; − improved appearance, including reduced wrinkling/ageing of skin and whiter teeth. Roadblocks Ask the patient to identify barriers or OHCP: “So what would be difficult impediments to quitting and provide treatment about quitting for you?” (problem-solving counselling, medication) that P: “Cravings – they would be awful!” could address barriers. Typical barriers might include: OHCP: “We can help with that. We can – withdrawal symptoms; give you nicotine replacement therapy – fear of failure; (NRT) that can reduce the cravings.” – weight gain; P: “Does that really work?” – lack of support; – depression; OHCP: “You still need will-power, but – enjoyment of tobacco; study shows that NRT can double your – being around other tobacco users; chances of quitting successfully.” – limited knowledge of effective treatment options. PART III: INTEGRATING BRIEF TOBACCO INTERVENTIONS INTO ORAL HEALTH PROGRAMMES IN PRIMARY CARE: POLICY RECOMMENDATIONS 44 WHO MON O GRA P H ON TO B AC C O C ES SA TI O N A ND OR AL H EA LTH INTEG R ATIO N  5Rs Strategies for implementation Example Repetition Repeat assessment of readiness to quit. If OHCP: “So, now we’ve had a chat, still not ready to quit repeat intervention at a let’s see if you feel differently. Can you later date. answer these questions again…?” The motivational intervention should be repeated (Go back to the Assess stage of the every time an unmotivated dental patient visits the 5As. If ready to quit then proceed clinic setting. with the 5As. If not, end intervention positively by saying “This is a difficult process but I know you can get through it and I am here to help you”.) 2.2. STRENGTHENING ORAL HEALTH CARE SYSTEMS TO IMPROVE INTEGRATED DELIVERY OF BRIEF TOBACCO INTERVENTIONS BY ORAL HEALTH PROFESSIONALS While oral health professionals are in a favourable position to help tobacco users, more than 40% do not routinely query tobacco use and 60% do not routinely advise tobacco users to quit (13). Health systems performance assessments suggests that the whole health-care system should function well in order to ensure that oral health professionals routinely identify and provide brief tobacco interventions to all tobacco users at every visit. It is the responsibility of oral health service managers and the appropriate authorities to ensure a well-functioning system to support oral health professionals. The WHO Health System Framework (six building blocks) (Figure 17) can be a good tool for oral health service managers to build a well-functioning oral health-care system to support providers to routinely deliver brief tobacco interventions. This framework illustrates the basic functions required by health systems have to carry out and defines a set of six essential building blocks to develop an understanding of how to strengthen health systems. The building blocks are: – service delivery; – health workforce; – information support; – medical products and technologies; – financing; – leadership and governance. PART III: INTEGRATING BRIEF TOBACCO INTERVENTIONS INTO ORAL HEALTH PROGRAMMES IN PRIMARY CARE: POLICY RECOMMENDATIONS W H O MON OG RA P H O N TO BA CCO CE SSAT IO N AN D O R AL H EAL TH IN T EG R A TIO N 45