Keeping your mouth healthy
Tobacco can be smoked, chewed or sniffed (as snuff). The best thing that people who use tobacco products can do for their health is to stop using them. This lowers the risk of lung cancer and other diseases, including mouth cancer and gum disease.
Many people visit a dental professional at least once a year; some may visit more often. Dental professionals could motivate people to stop using tobacco by telling them about the health risks of continuing and the health benefits of quitting. Dental professionals include:
· dental hygienists;
· dental therapists; and
· dental nurses (referred to as dental assistants in some countries).
Why we did this Cochrane Review
We wanted to find out if dental professionals could help people to stop using tobacco by offering them advice and support. We also wanted to know if support from dental professionals had any unwanted effects.
What did we do?
We searched for studies that tested whether advice and support from dental professionals helped people to stop smoking, chewing or sniffing tobacco.
We looked for randomised controlled studies, in which the people taking part were assigned to different treatment groups using chance to decide which people received support to stop using tobacco. This type of study usually gives reliable evidence about the effects of a treatment.
Search date: we included evidence published up to February 2020.
What we found
We found 20 studies in 14,897 people who used tobacco products (smoking, chewing or sniffing tobacco). The studies took place in the USA (13 studies), the UK (two studies), Sweden (two studies), Japan (one study), Malaysia (one study) and India (one study). Most studies (16) were in dental clinics and four were conducted in schools or colleges.
All studies used behavioural programmes to help people stop using tobacco; these programmes aimed to boost motivation and offer advice on stopping. Four studies also included offering people nicotine replacement therapy (NRT) or e-cigarettes as well as a behavioural programme.
Nineteen studies were funded by government agencies or universities; one study reported that it received no funding.
For each type of behavioural programme tested, the studies measured how many people stopped smoking or using tobacco products for at least six months.
In all studies, the effect of receiving behavioural support from dental professionals was compared with:
· usual care (the studies did not state what this included);
· no support or advice;
· brief advice to stop smoking to improve health; or
· a less active form of behavioural support.
What are the main results of our review?
Behavioural programmes involving dental professionals and NRT or e-cigarettes probably help more people to stop smoking. On average, 74 out of 1000 people stopped compared with 27 out of 1000 people who did not receive behavioural support (evidence from four studies in 1221 people).
Several sessions of behavioural programmes involving dental professionals may help people to stop using tobacco. On average,106 out of 1000 people stopped compared with 56 out of 1000 people who did not receive behavioural support (seven studies; 2639 people).
A single session of a behavioural programme may also help people to stop: on average, 45 out of 1000 people stopped compared with 24 out of 1000 who did not receive behavioural support (four studies; 6328 people).
We are uncertain about the effect of advice and support from dental professionals in settings other than a dental practice (such as in a school or college), because the studies that tested this were too small to show a reliable effect (three studies; 1020 people).
We are uncertain if behavioural programmes given by dental professionals had any unwanted effects, because only one study reported this information.
Our confidence in our results
We are moderately confident about the benefit of support from dental professionals plus NRT or e-cigarettes. We are less confident about the benefits of one, or several, sessions of behavioural support from dental professionals.
We found weaknesses in the evidence. Some studies only asked people if they had stopped using tobacco, and did not use tests – such as testing their breath or saliva – to find out if they had stopped. Some studies did not describe clearly how they were conducted, or how they assigned people to the different groups. In some studies more than half of the people dropped out of the study before it ended.
Our results may change when more, high-quality evidence becomes available.
Advice and support from dental professionals that involves NRT or e-cigarettes is more likely to help people to stop smoking.
Single or multiple sessions of advice and support may help people to stop smoking or using tobacco products.
There is very low-certainty evidence that quit rates increase when dental professionals offer behavioural support to promote tobacco cessation. There is moderate-certainty evidence that tobacco abstinence rates increase in cigarette smokers if dental professionals offer behavioural support combined with pharmacotherapy. Further evidence is required to be certain of the size of the benefit and whether adding pharmacological interventions is more effective than behavioural support alone. Future studies should use biochemical validation of abstinence so as to preclude the risk of detection bias. There is insufficient evidence on whether these interventions lead to adverse effects, but no reasons to suspect that these effects would be specific to interventions delivered by dental professionals. There was insufficient evidence that interventions affected oral health.
Dental professionals are well placed to help their patients stop using tobacco products. Large proportions of the population visit the dentist regularly. In addition, the adverse effects of tobacco use on oral health provide a context that dental professionals can use to motivate a quit attempt.
To assess the effectiveness, adverse events and oral health effects of tobacco cessation interventions offered by dental professionals.
We searched the Cochrane Tobacco Addiction Group's Specialised Register up to February 2020.
We included randomised and quasi-randomised clinical trials assessing tobacco cessation interventions conducted by dental professionals in the dental practice or community setting, with at least six months of follow-up.
Two review authors independently reviewed abstracts for potential inclusion and extracted data from included trials. We resolved disagreements by consensus. The primary outcome was abstinence from all tobacco use (e.g. cigarettes, smokeless tobacco) at the longest follow-up, using the strictest definition of abstinence reported. Individual study effects and pooled effects were summarised as risk ratios (RR) and 95% confidence intervals (CI), using Mantel-Haenszel random-effects models to combine studies where appropriate. We assessed statistical heterogeneity with the I2 statistic. We summarised secondary outcomes narratively.
Twenty clinical trials involving 14,897 participants met the criteria for inclusion in this review. Sixteen studies assessed the effectiveness of interventions for tobacco-use cessation in dental clinics and four assessed this in community (school or college) settings. Five studies included only smokeless tobacco users, and the remaining studies included either smoked tobacco users only, or a combination of both smoked and smokeless tobacco users. All studies employed behavioural interventions, with four offering nicotine treatment (nicotine replacement therapy (NRT) or e-cigarettes) as part of the intervention. We judged three studies to be at low risk of bias, one to be at unclear risk of bias, and the remaining 16 studies to be at high risk of bias.
Compared with usual care, brief advice, very brief advice, or less active treatment, we found very low-certainty evidence of benefit from behavioural support provided by dental professionals, comprising either one session (RR 1.86, 95% CI 1.01 to 3.41; I2 = 66%; four studies, n = 6328), or more than one session (RR 1.90, 95% CI 1.17 to 3.11; I2 = 61%; seven studies, n = 2639), on abstinence from tobacco use at least six months from baseline. We found moderate-certainty evidence of benefit from behavioural interventions provided by dental professionals combined with the provision of NRT or e-cigarettes, compared with no intervention, usual care, brief, or very brief advice only (RR 2.76, 95% CI 1.58 to 4.82; I2 = 0%; four studies, n = 1221). We did not detect a benefit from multiple-session behavioural support provided by dental professionals delivered in a high school or college, instead of a dental setting (RR 1.51, 95% CI 0.86 to 2.65; I2 = 83%; three studies, n = 1020; very low-certainty evidence). Only one study reported adverse events or oral health outcomes, making it difficult to draw any conclusions.