The 5 A’s. Specifically, the guideline urges every health care provider to follow a 5 A’s protocol with all tobacco users who are willing to quit. The 5 A’s are the following: ask about smoking at every opportunity; advise all smokers to stop; assess willingness to make a quit attempt; and, if the patient is willing to quit, assist the patient in stopping and arrange follow-up visits.

Asking can be a simple question about current tobacco use, but the guideline urges the use of an office-wide system that documents every patient’s smoking status during every office visit. Once a tobacco user is identified, the health care provider should urge him or her, in a "clear, strong and personalized manner," to quit. The provider can assist tobacco users by helping them set a quit date; referring them to a telephone counseling service, cessation group or intensive smoking-cessation program; helping them identify smoking triggers and anticipate challenges to a quit attempt; prescribing pharmacotherapy; and providing educational materials about smoking cessation. Follow-up contact to support and guide a patient’s quit attempt should be arranged within one week after the quit date and again within the first month after the quit date.

The 5 R’s. If the patient is unwilling to quit, the guideline recommends a motivational counseling intervention that emphasizes the 5 R’s: relevance to the patient, risks of smoking, rewards of quitting, roadblocks to quitting and repetition. Such counseling involves talking about smoking and quitting and then reinforcing the points most likely to motivate patients to quit. Information should be relevant to the patient, such as health concerns, rewards or specific barriers to quitting. A discussion of the many health effects of smoking and the many benefits of quitting (such as improved health and financial savings) may allow the clinician to identify and highlight risks and rewards that seem most relevant to the patient. Identifying the patient’s perceptions of roadblocks to quitting, such as fear of withdrawal symptoms or weight gain, allows the clinician to discuss treatment options that address those barriers. The guideline calls for repeating the motivational intervention during every office visit by a smoker who is unwilling to quit.

The guideline concludes that treatment for tobacco dependence offers clinicians "their greatest single opportunity to staunch the loss of life, health and happiness caused by this chronic condition," and the 2000 surgeon general’s report on oral health, as well as many dental and dental hygiene organizations, have urged dental care providers to incorporate tobacco-use intervention into their practices.^31–34 In 2003, the American Dental Association incorporated this clinical guideline into the third edition of the ADA Guide to Dental Therapeutics.³⁵

However, health care providers do not consistently assess and treat their patients for tobacco use,^15,36,37 and dentists are among those least likely to do so.^{16,25,38–41} Estimates of how many dentists advise smokers to quit range from 24 percent in a patient survey to 90 percent in a provider survey; typically, 30 to 50 percent of U.S. dentists report that they do so.^{2,7,8,10–12,16,41–47} Fewer dentists follow giving advice with offering assistance. In a study conducted by the ADA, only 4 percent of providers routinely did so.⁴⁸ Hastreiter and colleagues¹¹ conducted a survey of providers and found that 20 percent discussed strategies for quitting and only 2 percent offered a follow-up intervention. In studies comparing health care provider groups, dentists ranked lowest in tobacco-use cessation knowledge and skills, as well as in the quantity and quality of treatment.^16,37

Lack of knowledge, skills and confidence in helping patients quit are among the barriers to tobacco-use counseling frequently cited by health care providers, along with lack of reimbursement, time constraints and patient resistance.^{10,22,39,49,50} Studies have documented that improving providers’ confidence in their tobacco-use intervention efforts increases counseling frequency and can improve smokers’ quit rates.^{39,41,51–55} Gould and colleagues³⁸ found that a National Cancer Institute training program significantly increased the proportions of dentists who asked patients about smoking and assisted them in quitting. We are not aware of any study assessing the relationship between dentists’ knowledge and practice of the 5 R’s among smokers who are currently unwilling to quit.

The goal of our study was to assess dentists’ tobacco-control attitudes and activities in Texas. The objectives were to determine how many dentists followed the clinical guideline, assess dentists’ knowledge of the guideline, explore whether knowledge of the guideline was associated with adherence to it and with the amount of time spent on tobacco-use counseling, and identify barriers to following the guideline.

	SUBJECTS AND METHODS

TOP ABSTRACT CLINICAL PRACTICE GUIDELINE SUBJECTS AND METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Sample. Dentists targeted for this survey practiced in east Texas. The primary sources of all dentists’ names were licensing rosters maintained by the Texas State Board of Dental Examiners. To be eligible for selection, dentists had to work more than 26 weeks per year in active practice and could not specialize in pediatric dentistry. We used a stratified probability sampling method with geographically proportional allocation to randomly select 1,500 dentists from the defined sampling frame of 4,149 dentists.

Sample size considerations. The sample size of 1,500 was based on several considerations. We set the precision to be within ± 3 percentage points of the true population tobacco-use rate with 95 percent confidence. The primary variable of interest was the current cigarette smoking rate, which we predicted to be 25 percent on the basis of the 2001 report from Texas.⁵⁶ Response rates to surveys among health care providers have varied from 20 percent^57–61 to 50 percent.^57,58 We predicted conservatively that the response rate would be 40 percent, providing adequate power to generalize the results to all dentists in east Texas. Seven hundred eighty-three dentists returned a completed survey, for a response rate of 54 percent.

Data collection. We designed a mail survey and conducted it from September 2003 through January 2004. The first mailing contained the survey along with a cover letter from three faculty members at the University of Texas Dental Branch at Houston explaining the purpose of the survey and providing assurances of confidentiality. A stamped return envelope was provided. Two weeks later, we sent a postcard reminder to all dentists. One month after the initial mailing, we sent a similar letter and the questionnaire to nonrespondents. Three months later, a third mailing was sent to nonrespondents.

Measurement and data analysis. The 43-item study questionnaire assessed a wide range of sociodemographic characteristics, knowledge, attitudes and activities related to patients’ smoking-cessation efforts. Demographic items included questions about the dentist’s patient load, specialty area, sex and years in practice. Tobacco-related activity items focused on adherence to the 5 A’s and 5 R’s.

5 A’s. The survey questions assessing the 5 A’s have been used in previous studies.^59,60 Concerning adult patients ( 18 years of age) whom dentists treat at their clinics, the survey asked respondents how often they asked patients whether they smoke cigarettes, a pipe or cigars; asked patients whether they use smokeless tobacco; urged patients who use tobacco to quit (advise); and asked tobacco-using patients whether they are willing to quit (assess).

Five survey items assessed dentists’ assistance activities for tobacco-using patients who were willing to quit: how often the dentists helped patients set specific quit dates; how often they referred patients to a tobacco-use cessation group or program; how often they prepared patients for withdrawal symptoms and other triggers; how often they prescribed nicotine replacement therapy (NRT) or bupropion hydrochloride (Zyban, GlaxoSmithKline, Research Triangle Park, N.C.); and how often they provided educational materials about quitting. Finally, dentists were asked how often they arranged a follow-up dental contact for their patients who are in the process of quitting.

5 R’s. We modified the survey questions assessing the 5 R’s, which address tobacco-using patients who are unwilling to quit, according to the clinical practice guideline. The survey questionnaire asked dentists how often they identified specific reasons why patients should quit (relevance); discussed the health effects of tobacco use (risks); highlighted the benefits of quitting (rewards); talked about difficulties related to quitting (roadblocks); and tried at every office visit to motivate patients to quit (repetition). Each 5-A and 5-R item had five possible Likert-scale responses: never (coded 1), sometimes (coded 2), one-half of the time (coded 3), usually (coded 4) and always (coded 5). The questionnaire was reviewed by several experts and pretested with 20 dentists in Houston.

Knowledge and formal training associated with the guideline. The survey asked dentists how well they knew the 5 A’s and 5 R’s. Response options were "I have not heard about them," "I know something about them" and "I know them well." We also asked respondents whether they had received any formal training in using the guideline, such as at school or through continuing dental education.

Barriers to following the guideline. Dentists were asked how strongly they agreed or disagreed with the following five items:

– they would lose patients if they talked to them about tobacco cessation;

– they are too busy to talk to patients about tobacco use;

– they need more training to help patients who use tobacco;

– they prefer to diagnose and treat patients rather than give preventive advice;

– they would upset many of their patients if they talked to them about their tobacco use.

Each item had five possible Likert-scale responses: strongly disagree (coded 1), disagree (coded 2), hard to say (coded 3), agree (coded 4) and strongly agree (coded 5).

Our analyses were based on dentists’ self-reporting. We used a ² test to compare proportions by sex, specialty, years in practice and level of awareness of the clinical guideline. We performed all analyses using statistical software (SPSS for Windows, Release 12.0, SPSS, Chicago).

	RESULTS

TOP ABSTRACT CLINICAL PRACTICE GUIDELINE SUBJECTS AND METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Characteristics of respondents. As shown in Table 1, the demographic characteristics of the 783 responding dentists closely resembled those of the 717 nonrespondents and the 2,649 nonselected dentists, with no significant variation for any variable. Among responding dentists, 90.4 percent were male and 9.6 percent were female; they had graduated from dental school an average of 27.5 years earlier and worked an average of 48.9 weeks annually. Most respondents (81.7 percent) described themselves as working in general dentistry.

Even smaller proportions of dentists said they usually or always follow guideline recommendations regarding assistance. Only 6.8 percent of respondents said they advise patients who are willing to quit to set a specific date; 7.6 percent said they refer smokers to a smoking-cessation program; 12.3 percent said they discuss likely withdrawal symptoms and smoking triggers with patients who smoke; and 15.2 percent said they provide patients with educational material on tobacco-use cessation and smoking prevention.

A prescription for NRT or bupropion was the most common form of quitting assistance reported in this study, and it usually or always was provided by 27.2 percent of responding dentists. However, a higher proportion of dentists (29.6 percent) said they never offer such a prescription to patients willing to quit smoking.

Overall, 35.5 percent of dentists said they usually or always perform at least one of the five recommended activities to assist patients in quitting. Only 5.3 percent of respondents said they usually or always practice the fifth A: arranging follow-up contact to support a patient’s attempt to quit smoking. The overwhelming majority, 77.9 percent, said they never follow up.

We analyzed the proportions of dentists practicing the 5 A’s by sex and years since graduation (Table 3, page 176). The results show that female dentists were more likely to practice the 5 A’s than were male dentists, especially with regard to asking about smoking, advising smokers to quit, assessing smokers’ willingness to quit and referring smokers to a tobacco-use cessation program (P < .05). Dentists who had graduated less than 27 years earlier were significantly more likely to ask their patients about their tobacco-use status and offer assistance in patients’ quit attempts than were dentists who had graduated more than 27 years earlier (P < .05).

A majority of surveyed dentists said they usually or always discuss the health risks of tobacco use and make quitting personally relevant to their patients who smoke by identifying specific reasons why they should quit. Less than one-half usually or always highlight the benefits of quitting. Less than one-third of dentists said they usually or always identify and discuss patients’ specific roadblocks to quitting. One-fourth consistently try to motivate their patients to quit at every office visit.

Analyses of dentists’ practices of the 5 R’s by sex and years since graduation showed the same pattern as that with the 5 A’s (Table 3). Female dentists were more likely to practice the 5 Rs than were male dentists, especially with regard to the first three R’s (P < .05). Dentists who graduated less than 27 years earlier were more likely to practice the 5 R’s than were older colleagues.

Knowledge and formal training associated with adherence. The likelihood that dentists would practice the protocols for the 5 A’s and 5 R’s was significantly associated with their knowledge of the clinical guideline. An overwhelming majority (89 percent) were unaware of the clinical guideline, 10 percent knew something about the guideline and only 1 percent were familiar with the guideline. As Table 3 indicates, dentists who were familiar with the guideline were significantly more likely to practice the 5 A’s than were dentists who were not familiar with the guideline (P < .01). Compared with dentists who were unfamiliar with the guideline, dentists who knew something about the guideline were almost twice as likely to assess patients’ willingness to quit smoking (P < .01), two to four times as likely to take various steps to assist smokers with cessation (P < .05) and five times as likely to arrange a follow-up visit with the dentist (P < .01).

Table 3 shows a similarly clear association between familiarity with the guideline and practice of the 5 R’s (P < .01). While 76.1 percent of dentists who were familiar with the guideline usually or always discussed the risks of smoking with patients who were unwilling to quit, the proportion dropped to 52 percent among dentists who were not familiar with the guideline. Among dentists who were familiar with the guideline, 54.5 percent usually or always discussed roadblocks to quitting; this was true of only 26.9 percent of dentists who were unfamiliar with the guideline.

Only 10.5 percent of surveyed dentists had received formal training in tobacco-use cessation counseling, and they were significantly more likely to practice the 5 A’s and 5 R’s. On each of the 5 A’s and 5 R’s, the proportion of dentists who usually or always practiced it was about 20 percent higher among dentists who had received formal training than among those who had not.

Training significantly increased the likelihood that dentists would assist patients in quitting. More than one-fifth of trained dentists usually or always helped patients set a specific date for quitting, compared with 5 percent of dentists who had not been trained in tobacco-use cessation counseling (P < .01). More than one-fourth of trained dentists usually or always referred patients who smoked to a tobacco-use cessation program, compared with about 5 percent of untrained dentists (P < .01). Trained dentists were about twice as likely as their untrained colleagues to prepare patients for withdrawal symptoms and other smoking triggers (such as seeing friends smoking) and to prescribe NRT or buproprion (P < .01). Trained dentists were three times as likely to provide patients with educational material about quitting and almost four times as likely to arrange follow-up contact with the dentist than were untrained dentists (P < .01 for both).

Time spent talking to patients about tobacco use. Similarly, knowledge of the guideline and formal training in tobacco-use cessation counseling were significantly associated with the amount of time dentists spent counseling patients. In general, the longer a dentist’s intervention lasts, the more likely the patient is to become and stay tobacco-free, although even an intervention lasting less than three minutes can be effective.²⁷ Table 3 shows the amount of time that respondents spent counseling patients.

Barriers to following the guideline. Lack of training in cessation counseling was the most frequently cited barrier to following the guideline, especially among female dentists, younger dentists and dentists without formal training or knowledge of the guideline (P < .05) (Table 3). Overall, 60.8 percent of dentists agreed or strongly agreed that they need more training to talk to patients about tobacco use. Dentists’ focus on treatment rather than on preventing the development of disease was another barrier to following the guideline. Those who believed that the focus should be on treatment rather than on prevention were more likely to be male (P < .01), older (P < .05) and unfamiliar with the clinical practice guideline (P < .05). Less than 10 percent of dentists agreed or strongly agreed that they lacked the time for tobacco use counseling or feared upsetting or losing patients.

	DISCUSSION

TOP ABSTRACT CLINICAL PRACTICE GUIDELINE SUBJECTS AND METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
The clinical practice guideline recommends that dentists systematically follow the 5 A’s protocol with all patients who are willing to quit using tobacco and the 5 R’s protocol with all patients who are not willing to quit. Our survey indicates, however, that almost one-half of dentists do not even take the first step by asking patients whether they use tobacco, and about two-thirds do not typically assess their patients’ willingness to quit or offer assistance to those expressing a willingness to quit. Clearly, dentists in east Texas are falling short of the clinical practice guideline and are missing important opportunities to improve patients’ health.

Unfamiliarity with the guideline. The study findings show that dentists are unfamiliar with the clinical guideline and suggest that lack of training is a major reason for nonadherence. Nine years after publication of the 5 A’s protocol, nine of 10 surveyed dentists still were unaware of its principles, and few have received training in tobacco-use control counseling. Compared with colleagues who were unfamiliar with the guideline, dentists with at least some knowledge of the guideline were more likely to practice the 5 A’s and 5 R’s and were more likely to engage in longer tobacco-use cessation counseling with patients.

Need for training. Dentists’ deficiencies in tobacco-use cessation knowledge and counseling skills suggest a need for mandatory training in counseling in dental school and as part of continuing education. Training based on the evidence-based principles of the guideline should cover the dentist’s activities with regard to the 5 A’s and 5 R’s, as well as office-level activities, including documentation of all patients’ smoking status at every office visit, making cessation materials and information about cessation resources readily available, and establishing an effective system for support and follow-up during the first critical weeks after patients quit using tobacco.

Consistent with previous research, our study findings show that dentists ask and advise at much higher rates than they assist with patients’ quit attempts.^25,62 Only a few dentists cited lack of time or fear of upsetting or losing patients as a barrier to carrying out the initial counseling steps. Low involvement in the assisting and arranging behaviors likely is a reflection of dentists’ readily acknowledged shortage of skills in supporting patients who are trying to quit. Almost two-thirds of dentists admitted that they needed additional training in this area.

Training should emphasize that patients who smoke and are unwilling to quit should not be viewed as hopeless cases. Instead, each office visit is an opportunity to motivate them to quit by exploring and highlighting specific concerns, barriers and rewards relevant to the individual patient, as well as by providing treatment options that address the patient’s specific needs. Trainers also should make the point that even brief counseling is preferable to no counseling at all.^17,27,63

We consider the 54 percent response rate to be quite satisfactory, considering that low response rates are typical of health care provider surveys,^57,58 data were collected via a mailed questionnaire and no incentives were offered to respondents. Our demographic analysis of the targeted population and the sample showed no significant bias. One limitation of the data is that information about the interaction between dentists and patients is based on dentists’ self-reports. Evidence shows that health care professionals’ self-reports tend to overestimate their actual performance.⁶⁴ Future investigations should better validate the prevalence and intensity of counseling behaviors using medical records and observation.

This study was limited to dentists in east Texas, which may affect the generalizability of its results. However, the sample’s large size and demographic characteristics, which are comparable to those of the general populations of dentists in east Texas and the United States,^34,65 suggest that the findings may be applicable to other areas. Moreover, our findings that dentists’ tobacco-use counseling knowledge, training and activities are inadequate are consistent with the findings of dentist surveys conducted in other parts of the United States and in Britain, Sweden, Australia and New Zealand.^{10,39,46,66–70} Thus, the survey findings strengthen the case for preparing and enabling dentists to make tobacco-use cessation counseling a regular part of their clinical practice.

	CONCLUSION

TOP ABSTRACT CLINICAL PRACTICE GUIDELINE SUBJECTS AND METHODS RESULTS DISCUSSION CONCLUSION REFERENCES

 
Less than one-third of the dentists in this study reported that they always inquired about their patients’ tobacco use, although asking is the first phase of cessation interventions. Furthermore, despite the fact that the clinical guideline for tobacco-use cessation was first published almost one decade ago, two-thirds of dentists still fail to consistently advise their patients to quit using tobacco. Few dentists reported that they assist patients in quit attempts. The results of this study show that the main obstacle to providing counseling to patients was dentists’ reported deficiencies in tobacco-use cessation counseling skills.