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| Figure 2. Providing a chair side tobacco intervention can easily be made a part of the existing oral hygiene visit - in most cases adding no more than five minutes to the appointment. |
Brief Clinical Interventions
Due to the time constraints of the dental hygiene appointment, the most practical application of the Guideline is to incorporate motivational interviewing while applying the 5 A’s and 5 R’s.
The 5 A’s
A summary of the 5 A’s, the Stages of Change, and the 5 R’s can be found in Table 1 (A suggested use: make a copy, laminate it, place a copy in each operatory as a handy reference). For great intervention dialogs, read the article entitled, “Tobacco Cessation Intervention: How to Communicate with Tobacco Using Patients,” Stafne EE, Bakdash B. J Contemp Dent Pract. 2000;(1)4: 037-047.
Ask: The first step in providing tobacco cessation is to gather information on the patient’s tobacco use (Figure 2). By including three or four specific questions on a standard medical health history, a fairly accurate tobacco use risk assessment can be accomplished. An important step in gaining the patient’s trust is to reflect back and review the information they put on the tobacco use section. This will help the clinician gain a better understanding of the patient’s attitude toward their tobacco use and readiness to quit.
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| Figure 2. Providing a chair side tobacco intervention can easily be made a part of the existing oral hygiene visit - in most cases adding no more than five minutes to the appointment. |
Advise: The Clinical Practice Guideline recommends every tobacco user be given a strong, clear message to quit smoking or using smokeless tobacco at every appointment. This could be as simple as saying, “I see on your health history you smoke. Today would be a great day to quit. What do you think?” Or, a stronger message could be, “I see you use snuff–as your dental hygienist, I highly recommend that you quit. We have various resources to help you. What are your thoughts?” However, saying this to a patient not ready to quit every six months may cause the patient unnecessary anxiety and possible avoidance of dental care. The author’s personal clinical experience has lead her to assess the patient’s willingness to quit first, conduct the oral cancer exam, then provide the clear, strong quit message taking into account the patient’s readiness to quit. This approach includes the entire recommended component without offending the patient. Each clinician should decide the most effective approach for their patients.
Assess: An effective model to assess a person’s willingness to change smoking behavior is Prochaska and DiClemente’s Transtheoretical Model commonly known as the Stages of Change detailed below.5, 6 By asking a few basic questions, this model gives clinicians insight into whether a tobacco user is ready to quit, and if so, when.
Precontemplation - not willing to quit. When a patient is in precontemplation, they are not interested in quit information—they want to use tobacco. A short, clear quit message followed-up with an offer to help them by providing a basic informational pamphlet may be the most appropriate message for this patient. It is very important to ask and assess precontemplators at each recall visit since they may be ready to quit at any time and need assistance.
Contemplation - willing to quit in the next six months. A patient in contemplation regularly thinks about quitting and is interested in any information. Unfortunately, contemplators may stay in this stage for years and never actually make a serious quit attempt. A contemplator wants to be shown the oral consequences of their tobacco use and is interested in quit pamphlets. Though the patient may not make a quit attempt at this time, moving them closer to action is a success in itself.
Preparation - willing to quit within the next months. A patient ready to quit is in need of verbal support, specific quit information, and advice on pharmacotherapies. The tobacco user about to quit knows what is coming – withdrawal and a complete life change. Stressing the benefits of quitting is more important at this time than focusing on negative side effects.
Action - has recently quit. A patient who has recently quit using tobacco may be experiencing withdrawal symptoms and needs emotional support affirming their positive choice. Relapse, or starting to use again, is most common three months after quitting. A review of coping strategies, social support, and how the patient is using cessation medication should be provided.
Maintenance - has abstained for at least six months. Patients who are former tobacco users may be at lifelong risk of relapse and need support to stay tobacco free. A clinician’s short but sincere, “Great job! You made a very good choice” may provide them with the support they need at that moment.
The Health Behavior Change model is another strategy available to healthcare professionals to help accurately assess if the patient is ready to quit. The clinician6 is encouraged to explore:
Assist: The Assist segment of the 5 A’s, to some degree, has been covered in the discussion of the Stages of Change. Patients who are in the preparation or action stage will be the most receptive to assistance to quit. A summary of the 5A’s, 5Rs, and Stages of Change can be found in Table 1.
Arrange: The dental team may choose to establish a follow-up system for patients who have recently quit or set a quit date. Arranging follow-up could be provided by a call, letter, post-card, or referral to a local or state “quit line” (Figure 3). Quit lines are available in most states and provide personalized support and follow-up from tobacco dependence specialists. The use of phone quit lines or web based quit resources have been found to be very effective in helping tobacco users quit.8 The American Dental Hygienists’ Association recognizes clinicians may only have limited time when providing tobacco cessation and advocate utilizing the Ask and Advise of the Five A’s and then refer to external resources.
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| Figure 3. Tobacco quit lines can be found at http://smokefree.gov/usmap.html. Click on a state and the “quit line” number for that state will appear. |
Smoking Quit Line of the National Cancer Institute
Phone: 1-877-44U-QUIT
Web site: http://smokefree.gov/
Ask, Advise & Assist. Smoker’s Help Line of the Alberta Cancer Board
Phone 1-866-33AADAC
CDC’s Quit Resources
Web site: www.cdc.gov/tobacco/how2quit.htm
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| Citation Number: Vol. 6, No. 4, Page 180 |
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