Given that Tobacco use prevention and cessation (TUPAC) in the dental treatment setting occurs in brief interventions over repeated visits, dental practitioners should consider adopting the following level of care model.

Basic Care: brief interventions of a few minutes in order to identify tobacco users, assess readiness to quit, request permission to re-address tobacco use at a subsequent visit, and if preferred, refer for further TUPAC counselling.

Intermediate Care: interventions of 5 to 10 or more minutes consisting of (brief) motivational interviewing sessions to build on readiness to quit, enlist resources to support change, and to include cessation medications. If preferred, refer for further TUPAC counselling.

Advanced Care: multiple intensive interventions of 20 or more minutes for complex care patients to develop a detailed quit plan including the use of suitable pharmacotherapy, past failure exploration, and recommendation adjustments as needed.

The level of care model was originally published by Davis et al. 2010 and summarized in the 2nd OHNTPC European Workshop Consensus Report by Ramseier et al. 2010.

Basic Care: tobacco use brief interventions

Ask

Ask all patients aged 16 years and over (younger if appropriate):

“Do you use tobacco?”

It is well recognized that the medical history form plays a critical role in developing an oral health care plan that is cognisant of the general health status. The inclusion of the patients’ tobacco use history is shown to be a vital component of the medical history form on a myriad of levels that are integral to the promotion of tobacco use prevention and cessation. For example, if the patient identifies as a never-smoker, it enables the oral health professional to reinforce the benefits of this lifestyle choice.

Particularly in the case of young adults, the opportunity to congratulate their decision to remain tobacco free offers a positive counter to the efforts of peer pressure, advertising or other adverse influence. Should the patient identify as a former smoker, the opportunity arises again to provide positive reinforcement to the decision to change.

Assess

With all tobacco users assess readiness to quit:

“Are you interested in stopping?”

When asked about their readiness to quit smoking, tobacco users often reply that they want to quit smoking "sometime" but that the time is not yet right. There are certain things they need to do first, which are seen as more important than giving up smoking. Even if the patient feels that they are ready to quit smoking, there still may be some uncertainty about the next steps. They may experience a lack self-efficacy to achieve this goal and feel under prepared to make a quit attempt. Behind this attitude is often the fear of failure, potential change to social habits, or worry about gaining unwanted weight.

(Brief) Motivational Interviewing, (B)MI

Numerous behavioral studies have demonstrated predictable success in supporting patients to change using Motivational Interviewing (MI). MI is a patient-centred method to enhance the patient’s intrinsic motivation to change by exploring and resolving ambivalence (Miller and Rollnick 2002). A "short form" of MI known as "Brief Motivational Interviewing" (BMI) appears to be suitable for use during short interventions for tobacco use prevention and cessation in dental practices. The aim of BMI is to achieve the following objectives within a relative short amount of time:

1. to ask the patient about his or her motivation to change,

2. to ask the patient’s self-efficacy to change, and

3. to get the patient’s commitment to discuss the change in behavior at the next visit.

Understanding the current levels of recognized motivation and self-efficacy as indicators of the readiness to change can greatly assist the process of supporting the patient through a quit attempt (Rollnick et al. 1997).

For example, asking the patient to use a number scale to rate how motivated he or she is to quit smoking will give a direction for the oral health professional to follow. Using the same number scale to rate how confident they are in achieving this goal will further direct the conversation towards identifying the type of support the patient may need.

Intermediate Care: behavior support for tobacco use cessation

Assist

Providing assistance for the patient who wants to quit using tobacco often requires a combination of behavioral modification techniques and pharmacological support. Making arrangements for on-going support either via the dental office or other health agencies provides the patient with a valuable sense of reassurance as they undertake a quit attempt.

“How would you like to stop?”

When available, refer to TUPAC specialist service, whether in-house (including suitably trained dental personnel) or external (i.e. www.quitline.com)

If no TUPAC specialist service is available or patient declines referral consider to offer behavioral support and pharmacotherapy as outlined in the following step-by-step protocol.

Assist: Step-by-step protocol

People who want to kick the smoking habit do not always participate in carefully controlled nicotine withdrawal programs, e.g. in linear fashion and from start to finish. Nevertheless, simple instructions – like those offered in the "Assist" (to help) and "Arrange" (to organize follow-up visits) – can be valuable tools for dental professionals supporting their patients to quit smoking.

Some smokers may even be euphoric about quitting smoking that would therefore tend to quit in a premature – e.g. unprepared – manner. Even if this approach works for some smokers, others require varying amounts of support. This support can be given in an individual way manner by adapting the following four steps:

Step 1: Ask the patient to fill in the tobacco use journal

Every smoker has his or her individual smoking habits. To pinpoint the behavioral changes required in each particular case, it is recommended to fill in a tobacco use journal for several days. The patient will be instructed to fill in every column in the jornal.

• Instructions for the period up to the patient's next appointment: Fill in each cigarette and the time it is smoked; again, be sure to fill in all four columns of the journal labelled as “Time”, “Place or activity”, “Companion”, “Importance”, and “Alternative”.

Step 2: Evaluate the tobacco use journal

Reading through the journal entries at the follow-up appointment may reveal patterns of smoking and assessments of importance which may not have been aware to the patient. This information will serve as the basis for re-assigning new habits for the patient in order to give up smoking (ideally without withdrawal symptoms) and to replace the old habit with new patterns of behavior. During this period, the patient will be advised to reduce tobacco use to a bearable minimum.

The four columns of the journal contain information on four important elements of the cessation protocol:

• "Time": Patients who smoke regularly throughout the day are primarily advised to alleviate the physical symptoms of withdrawal with sustained-release nicotine patches. On the other hand, patients who only smoke at certain times throughout the day are generally advised to use nicotine gum, sublingual tablets or lozenges. The smoking behavior that has been evaluated can be entered later in the form labelled "Recommendations for Use of Nicotine Replacement Therapy" (see below).

• "Place or Activity" and "Companion": Instructions for the period up to the patient's next appointment: Attempt to change situations. Example: Spend your work break with different colleagues and at a different location than usual.

• "Importance": Instructions for the period up to the patient's next appointment: Try to reduce the number of "less important" cigarettes.

• "Alternative": Instructions for the period up to the patient's next appointment: The patient should try to find his or her own personal alternatives – so-called replacements – which could help them to resist. In this context, they should take care to alternatively distract their mind (mental), their hands (physical) and their mouths (oral). Examples: Play a game that requires mental concentration or manual dexterity. Do not select alternatives that simulate smoking. Example: chewing on a stick of liquorice.

Step 3: Behavioral changes and nicotine dependence

The process of successfully replacing smoking habits with other activities can be difficult and time-consuming. Each patient should identify replacements (see above) that contain a personal reward. It might be wise to schedule and arrange additional consultation time as this point so that enough emphasis can be devoted to this important step.

• Note the replacements identified.

• Determine the degree of nicotine dependence: This can be assessed easily by asking the following questions (Fagerström 1978):

1. "Have you already attempted to give up smoking?"

2. "How many cigarettes do you smoke a day?"

3. "How many minutes after waking-up in the morning do you smoke your first cigarette?"