In the spring of 1985, I attended my first National Oral Health Conference in Salt Lake City. This conference is the annual meeting of the Association of State and Territorial Dental Directors, in concert with the U.S. Public Health Service and Centers for Disease Control and Prevention. At the conference, Dr. Gregory Connolly, then dental director for the state of Massachusetts, presented a major overview of a disturbing "new" dental public health problem: the alarming state survey evidence of trends of heavy use of smokeless tobacco products among male adolescents. Dr. Connolly’s message reinforced one sent at the previous year’s meeting by Dr. Michael Morgan, dental director for the Oklahoma Department of Health. Dr. Morgan had sounded the smokeless tobacco alarm after the death of Sean Marsee, an Oklahoma youth who died of oral cancer after seven years of smokeless tobacco use, and he had introduced a successful resolution by the Oklahoma Dental Association that organized dentistry take action.
After Dr. Connolly’s presentation, there was much discussion about a dental public health response. What additional data were necessary? What would be future oral cancer outcomes? What would be dentistry’s response? What should be done as a federal response?
I had just been appointed dental director for the Wisconsin Division of Health. Now, as a result of Dr. Connolly’s presentation, I had the sudden realization that my new position would involve a great deal of work on tobacco-use intervention issues.
I was a dentist 12 years out of dental school and five years out of my specialty graduate training in dental public health. My only tobacco-associated recollections of dental school involved slides of "snuff-dippers’ pouch" and nicotine stomatitis—and the remembrance of faculty, students, staff and patients smoking in school lounges. Of course, the curriculum had included training in oral cancer detection and treatment, but nothing about tobacco-use prevention or cessation. I had training in a variety of subjects, but no firm foundation in the science that linked tobacco and oral disease. Many dentists practicing today, regrettably, had similar omissions in their education.
Fortunately, I entered a health department that had strong tobacco-use intervention programs, in which I worked with specialists from other health disciplines who were committed to tobacco-use prevention and control. It was a steep learning curve, but I was able to apply dental public health science to tobacco-use problems.
In the 15 years since my secondary career in tobacco-use intervention began, many important events have furthered the good cause of drawing dentistry into tobacco-use intervention issues. A number of dentists and dental hygienists are routinely applying proven tobacco-use intervention principles to patients in clinical practice settings. Dental organizations have adopted strong policies and recommendations regarding tobacco use. The American Dental Association has 15 specific policy statements on tobacco use, all adopted or revised since 1964. Dental education and continuing education have adopted many significant curriculum changes and additions to include education in tobacco-use prevention and cessation.
Many of these dramatic changes have happened in a relatively short time, within the past five or 10 years. The reasons for which these changes occurred, and the people who helped bring them about, are the subject of this overview.
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1985: MARSEE VS. U.S. TOBACCO COMPANY
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Sean Marsee, an Oklahoma high school track star, died at age 19 years of oral cancer. His family brought suit against U.S. Tobacco Company, the maker of the moist snuff that Sean had used since the age of 12 years. This case, although unsuccessful for the family, brought national publicity to the growing problem of adolescents’ consumption of smokeless tobacco products. It also helped publicize a number of surveys showing that young people’s use of smokeless tobacco products was alarmingly high, and it helped generate public and professional support for legislative action at state and federal levels. The story of Sean Marsee’s struggle with oral cancer and his subsequent death continues to be used in anti-tobacco education programs in schools across the country.
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1986: PUBLICATION OF A LANDMARK ARTICLE
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"The Reemergence of Smokeless Tobacco," a landmark overview article published in the New England Journal of Medicine by Dr. Gregory Connolly and colleagues,1 summarized the resurging popularity of smokeless tobacco (primarily moist snuff), particularly among male adolescents. The article broadened the awareness of oral health tobacco issues among other health professionals. It also marked the beginning of a growing renown for Dr. Connolly, who at that point was the dental director for the Massachusetts Department of Public Health. He provided leadership on tobacco issues throughout the next 14 years, and he has become one of the nation’s (and world’s) leading experts on tobacco-use intervention policy in his present role as director of the Massachusetts Tobacco Control Program.
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1986: REPORT TO THE SURGEON GENERAL ON SMOKELESS TOBACCO
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"The Health Consequences of Using Smokeless Tobacco: A Report of the Advisory Committee to the Surgeon General"2 was the U.S. Public Health Service’s "initial examination of smokeless tobacco’s role in the causation of cancer, noncancerous and precancerous oral diseases or conditions, addiction and other adverse health effects." U.S. Surgeon General C. Everett Koop, M.D., brought the full power of his office to bear on smokeless tobacco use as well as on smoking. Dr. Koop went on to a heroic career in tobacco-use control and in championing the cause of good oral health, and he helped bring dentistry into the tobacco-use control movement. Today, years after his retirement from the surgeon generalship, he continues to deliver the message that oral health is a critical component of general health. "You’re not healthy without good oral health," he says.
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1986: FEDERAL SMOKELESS TOBACCO EDUCATION LEGISLATION
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The Comprehensive Smokeless Tobacco Health Education Act of 1986 was stimulated by a 1986 National Institutes of Health Consensus Development Conference on the Health Implications of Smokeless Tobacco; by the activist efforts of Sean Marsee’s mother, Betty; and by the leadership of dental health professionals such as Dr. Connolly.
NO ONE FURTHERED THE CAUSE OF DENTISTRY’S NATIONAL AND GLOBAL INVOLVEMENT IN TOBACCO-USE ISSUES IN THE 1990s MORE THAN DR. ROBERT MECKLENBURG.
Among the act’s major provisions:
- – development and implementation of public health education programs and materials about the risks involved in using smokeless tobacco products;
- – inclusion of a health warning on all smokeless tobacco products and advertisements for them;
- – authorization of research on the effects of smokeless tobacco.
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1989: THE NATIONAL DENTAL TOBACCO-FREE STEERING COMMITTEE
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Tobacco-use intervention by dental professionals gained new momentum in 1988 with the appointment of Dr. Robert Mecklenburg as dental consultant to the National Cancer Institute. Dr. Mecklenburg retired from the U.S. Public Health Service as assistant surgeon general under Dr. Koop. He was a member of the advisory committee for the U.S. Surgeon General’s 1986 report on smokeless tobacco2 during his service as the U.S. Public Health Service’s chief dental officer.
No one furthered the cause of dentistry’s national and global involvement in tobacco-use issues in the 1990s more than Dr. Mecklenburg. He organized and has served as chairperson of the National Cancer Institute’s, or NCI’s, National Dental Tobacco-Free Steering Committee, or NDTFSC, for the past 11 years. The committee’s goal is to ensure that oral health teams and dental organizations are directly, appropriately and routinely involved in influencing patients and the public to avoid or discontinue the use of tobacco. Representatives from 15 national dental organizations (including the ADA) make up the committee. Many of the tobacco-related policies and position statements of U.S. dental organizations have their origins in this committee’s work.
Dr. Mecklenburg and the NCI committee have been primary players in moving dentistry from the narrower focus of smokeless/spit tobacco issues to a wider focus that includes tobacco smoking, cigar use, excise tax, environmental tobacco smoke, tobacco marketing and promotion, legal issues in tobacco control, regulation of products and nicotine dependence.
The NCI recognized that dental professionals treat 62 percent of the U.S. population in a year, including 75 percent of young people aged 5 to 17 years.3 With the application of dental resources to the problems of tobacco use and tobacco-related adverse health conditions, significant progress could be made.
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1989: A NATIONAL DENTAL SYMPOSIUM ON SMOKING CESSATION
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The First National Dental Symposium on Smoking Cessation, held in April 1989 and called "Helping Dental Patients to Quit Smoking," focused the attention and resources of the ADA on tobacco-use cessation. 4 The symposium, held at the ADA headquarters in Chicago, was cosponsored by the ADA, the Indiana University School of Dentistry and the American Association of Dental Schools.
Indiana University’s Dr. Arden Christen, a pioneer in dental office–based tobacco-use cessation efforts, was an organizer of the conference. Dr. Christen began publishing on tobacco issues in the 1970s and started the first dental school–based tobacco-use cessation center. Among Dr. Christen’s many publications on tobacco-use issues was one in the first JADA issue devoted to tobacco use and oral health, published in January 1989.5
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1990: ‘HEALTHY PEOPLE 2000’
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"Healthy People 2000"6 is a U.S. Public Health Service document that set the national strategy for significantly improving the health of the nation during the 1990s. It addresses the prevention of chronic illnesses, injuries and infectious diseases. (Health objectives for the nation are set each decade; Healthy People 2010 is already under way.)
For the first time, a national objective in the tobacco chapter in "Heathy People 2000"6 was established to capitalize on the unique role of primary care providers in tobacco-use intervention. Objective 3.16 reads, "Increase to at least 75 percent the proportion of primary care and oral health care providers who routinely advise cessation and provide assistance and follow-up for all of their tobacco-using patients."
This objective recognized the dentist as a credible source of health information and advice who often sees patients during important "teachable moments" and who has been shown to be effective in providing brief tobacco-use cessation counseling.
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1990: TRAINING THE TRAINERS
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The National Cancer Institute began a national "Train the Trainer" program in 1990, under the direction of Dr. Robert Mecklenburg, with the goal of ensuring that oral health teams and dental organizations were involved in influencing the public to avoid and discontinue the use of tobacco. Dr. Mecklenburg and other NCI dental consultants have presented hundreds of programs and trained thousands of dental health personnel in effectiveness toward promulgating intervention at the clinical level. The "Train the Trainer" program objective was directed toward helping satisfy the above-mentioned Objective 3.16 in "Healthy People 2000."
The NCI also published two monographs, "Tobacco and the Clinician: Interventions for Medical and Dental Practice"7 and "Cigars: Health Effects and Trends,"8 as well as a manual called "Tobacco Effects in the Mouth: An NCI and NIDR Guide for Health Professionals."9
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1991: INTERNATIONAL CONFERENCE ON SMOKELESS TOBACCO
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The First International Conference on Smokeless Tobacco, held in Columbus, Ohio, in 1991, brought together people from areas of smokeless tobacco research, health education, addiction, cessation, public health and health policy.
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1994: SPIT TOBACCO EDUCATION PROGRAM
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In 1994, Oral Health America, a nongovernmental fundraising organization, founded the National Spit Tobacco Education Program, or NSTEP. NSTEP has been responsible for more than $80 million in free radio and television public service announcements, bringing information about oral cancer and other risks of tobacco use to the American public.
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1995: ADA CODE 01320
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The ADA Committee on the Code established the preventive code 01320, "Tobacco Counseling for the Control and Prevention of Oral Disease,"10 in 1995. This code covers tobacco counseling for the control and prevention of oral disease; it reads in part, "Tobacco prevention and cessation services reduce patient risks of developing tobacco related oral diseases and conditions and improves prognosis for certain dental therapies." In addition, since 1998, the ADA Health History Form has included "tobacco use status" and "interest in quitting" questions.
ORAL CANCER IS DIAGNOSED IN AN ESTIMATED 30,000 AMERICANS PER YEAR, AND CAUSES CLOSE TO 8,000 DEATHS PER YEAR.
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1996: SMOKING CESSATION CLINICAL PRACTICE GUIDELINE
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The U.S. Agency for Health Care Policy and Research, or AHCPR (now the Agency for Healthcare Research and Quality), was formed to develop clinical guidelines for health care practitioners, drawing on the knowledge of expert panelists. AHCPR developed a state-of-the-art primer for clinical-based tobacco-use intervention, "Smoking Cessation Clinical Practice Guideline," in 1996.11 A revised, refined version was introduced in June.12 The guideline acknowledges the potential role that dentists and the dental team can play in helping patients stop using tobacco or avoid starting tobacco use.
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1996: A STRATEGIC PLAN FOR PREVENTING ORAL AND PHARYNGEAL CANCER
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Oral cancer is diagnosed in an estimated 30,000 Americans per year, and causes close to 8,000 deaths per year.13 Approximately 75 percent of oral and pharyngeal cancers are attributed to the use of tobacco (primarily cigarette, pipe and cigar smoking) when combined with heavy alcohol intake.13 The 1996 National Strategic Planning Conference for the Prevention and Control of Oral and Pharyngeal Cancer13 brought together a diverse group of health care and human services disciplines to frame a coordinated national effort to prevent oral cancer and to reduce the morbidity and mortality caused by this disease. The conference was cosponsored by the Centers for Disease Control and Prevention, the National Institute of Dental Research and the ADA.
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1998: ‘ADA GUIDE TO DENTAL THERAPEUTICS’
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"ADA Guide to Dental Therapeutics," a chairside resource on the appropriate and accurate use of therapeutic agents in dentistry published in 1998, contains a chapter on cessation of tobacco use.14 The guide recognizes that "tobacco use causes or contributes to various oral diseases and adverse conditions, with periodontal disease being the most common among them. ... It has been established that dentists are as effective as physicians and other clinicians in helping patients stop using tobacco."
The ADA also provides its members with the Tobacco Cessation Resource Packet and Smokeless Tobacco Resource Packet through the Council on Access, Prevention and Interprofessional Relations.
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1999: TOBACCO AND PERIODONTAL DISEASE
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The 1990s concluded with an increased awareness of the role of tobacco use in the prevalence and severity of periodontal disease and subsequent tooth loss. No dentist practicing in the 21st century can ignore the tobacco-use status of his or her patients while offering counsel on the prevention of periodontal disease, advising patients on surgical wound healing, treating periodontal disease or practicing implant dentistry. There is a strong moral and ethical basis for dentists’ provision of clinical tobacco-use intervention services.
Several recently published documents make clear the dentist’s role in the relationship between tobacco use and periodontal disease. The first is a position paper, "Tobacco Use and the Periodontal Patient," prepared for the American Academy of Periodontology.15 The paper provides dental professionals with a general overview of the relationship between tobacco use and periodontal disease and reviews the epidemiologic and clinical findings that have led to the understanding of the role of tobacco use in relation to periodontal diseases and their treatment. Another is a chapter in a new textbook, "Periodontal Medicine." This chapter, called "Tobacco Use and Intervention" and authored by Drs. Robert Mecklenburg and Sara Grossi,16 offers an overview of tobacco-related periodontal risk factors, reviews subjects such as the dental profession’s role in treating nicotine addiction and lists recommended methods of brief clinical tobacco-use intervention.
Drs. Scott Tomar and Samira Asma17 examined oral health results from the Third National Health and Nutrition Examination Survey, or NHANES III. Drs. Tomar and Asma’s findings on smoking-attributed periodontitis are remarkable. More than 50 percent of the cases of periodontitis affecting the nation’s adults may be attributable to cigarette smoking. In current smokers, 75 percent of cases of periodontitis may be caused by smoking. They suggested that the costs of treating the estimated 8.1 million cases of smoking-attributed periodontitis should be added to the $50 billion spent annually in the United States to treat smoking-related diseases.
Contemporary research in tobacco and periodontal disease has shown periodontal disease to be significantly more prevalent in smokers. As the amount of tobacco use increases, relative risk of developing severe periodontitis increases significantly. It has been suggested that a "smoking-associated periodontitis" be created as a separate disease category18 and that smoking is a contraindication for surgical periodontal treatment.19 It also is postulated that periodontal disease, alveolar bone loss, increased probing depth and visible intraoral lesions may more strongly motivate patients to stop using tobacco than does the threat of lung cancer or cardiovascular disease later in life.19
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THE FUTURE: THE GOOD DENTIST CLUB
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In 1995, Michael Fiore, M.D., a tobacco researcher and the lead author of the AHCPR smoking cessation clinical practice guideline,11 lamented in an American Journal of Public Health editorial that "American clinicians in large numbers continue to neglect tobacco use."20 We still have much work to do to motivate dentists to routinely confront tobacco use. The "Healthy People 2000" objective has not been achieved.
Dr. Fiore addressed physician motivation by quoting Thomas Kottke, M.D., another noted physician tobacco researcher, who said, "Until physicians believe that providing smoking cessation [counseling] for all smokers is a requirement for continued membership in ‘the good doctor club,’ their behavior will not fundamentally change." To extrapolate this to dentistry, we must continue to change the clinical culture and practice patterns so that a dentist who does not institutionalize tobacco-use intervention does not qualify for the "good dentist club."
Dr. Fiore’s essential changes for medical practice (which I paraphrase here for dental practice) hold true for dentistry in the year 2000.
- – Dental care practices must continue to change so that tobacco-use prevention and cessation intervention is institutionalized.
- – Dentists and their patients must be reimbursed by insurers for tobacco-use intervention (or patients must pay out-of-pocket). Alternatively, the service can be integrated as a component of other services in which tobacco use would compromise the treatment and/or worsen the prognosis.
- – The culture of dentistry must change so that dentists realize that they are practicing "bad dentistry" if they do not intervene in a timely and appropriate manner with their patients who use tobacco.
We must teach state-of-the-art clinical tobacco-use intervention techniques to all dental and dental hygiene students across the country. We must enlighten practicing dentists regarding brief, effective and practical intervention.
Dr. C. Everett Koop, speaking at the 1999 NDTFSC meeting, said dentistry is moving in the right direction. "With proper leadership," he said, "the dental profession could own the programs of primary and secondary prevention of the health toll of the use of tobacco."21 He noted that dental clinicians have a unique opportunity to speak to their patients about tobacco use—unique because providers in other fields have less and less time to spend with patients because of the influence of managed care. (In fact, Dr. Fiore pointed out, the median visit with a physician in the United States is now down to 12 minutes.20)
We have a captive audience, a teachable moment, a preventive recall protocol by which we see and treat patients periodically. We need to take full advantage of this in the 21st century. It’s a win-win situation for our profession, for our patients and for the communities in which we live.
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ABSTRACT
1985: MARSEE VS. U.S....
