Implementing a Tobacco Assisted Referral Program in Dental Practices Sally J. Little, RDH, MS; Jack F. Hollis, PhD; Jeffrey L. Fellows, PhD; John J. Snyder, DMD; John F. Dickerson, MS Abstract Objectives: The objectives of this study are to design and implement a system- level tobacco-control intervention in a large prepaid dental group practice and assess effects on staff performance measures and patient satisfaction. Methods: We matched 14 dental facilities on size, socioeconomic status, smoking rate, and periodontal status, and then randomly assigned them to intervention or usual-care control. We trained intervention staff in an “Assisted Referral” team approach for assessing tobacco use, providing tailored advice and brief counseling, and encour- aging smokers to talk by telephone with a specially trained tobacco counselor. Patients could call from the office or ask that the counselor call them later. Telephone counselors helped patients explore motivations and barriers for quitting; review available cessation-support strategies, programs, and medications; and identify next steps. Results: During the 14-month study period, 66,516 members had annual- or new-patient examinations. Both intervention and control sites had high rates of tobacco assessment (97 percent) and advice (93 percent). Intervention patients were more likely than controls (69 percent versus 3 percent, P < 0.01) to receive additional chair-side tobacco counseling and assistance, and 11 percent agreed to receive additional telephone counseling. Intervention patients were more satisfied than controls with the dental team’s tobacco-control efforts (P < 0.03). Referral rates varied substantially for different staff. Conclusions: The Assisted Referral approach was successfully integrated into routine dental care, was well received by patients, and resulted in increased patient satisfaction. Because free telephone-based tobacco counseling is now available nationwide, the approach may be a practical strategy for most dental-care settings. Key Words: tobacco cessation, dentists, dental hygienists, behavior intervention, prevention, quality improvement, translation research Introduction Tobacco use remains the number one preventable health threat in our nation. In addition to affecting general health, it significantly increases risk of periodontal disease and oral cancer (1-4). Most patients report that medical and dental staff should offer tobacco-cessation ser- vices and that they are more satisfied with their care when tobacco is addressed (5,6). More importantly, meta-analyses indicate that brief tobacco interventions by both dental- and medical-care providers effec- tively increase quit rates (1,5,7-9). Few dental professionals, however, systematically offer the full range of recommended tobacco-cessation assistance (10,11). Disease prevention and patient education are central to the mission of dentistry (12). Tobacco-use status should be routinely evaluated during periodic oral exams, and cessation advice should be a routine part of prophylaxis treatment, which offers a “teachable moment” when many patients are more open to consider- ing cessation (8,13). Recommended tobacco-control interventions in- clude the “5As”: Ask about tobacco use, Advise users to quit, Assess readiness to quit, Assist interested smokers in quitting, and Arrange for follow up (12). Many dental professionals already provide advice to quit, which is rela- tively easy to do and takes little time (<60 seconds), but few regularly deliver the all-important “Assistance” and “Arrange” components of the 5A model. Meta-analyses (12) show that it is precisely these more intensive Assist and Arrange components that have the greatest impact on cessation rates (12,14-16). Many clinicians, however, do not have the time, train- ing, knowledge, or skills to provide tobacco-cessation assistance, which includes helping patients identify their motivations and barriers for quitting, consider alternate cessation strategies, and learn about options for group, telephone, and pharmaco- logical support. More powerful, innovative, and practical tobacco interventions are needed for dental offices to take advantage of the clini- cal encounter. Realistically, the den- tists’ and hygienists’ role should focus on asking about tobacco use and providing brief advice, but assessment of interest in quitting, meaningful cessation assistance, and follow-up support should also somehow be provided. A potentially more effective and sustainable “Assisted Referral” strat- egy for doing these would involve encouraging tobacco users to talk Send correspondence and reprint requests to Dr. Jack F. Hollis, Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Avenue, Portland, OR 97227-1110. Tel.: 503-335-6754; Fax: 503-335-2428; e-mail: jack.hollis@kpchr.org. Sally J. Little, Jack F. Hollis, Jeffrey L. Fellows, and John F. Dickerson are with the Center for Health Research, Kaiser Permanente Northwest. John J. Snyder is with Permanente Dental Associates. Manuscript received: 1/1/08; accepted for publication: 10/8/08. Support: National Institute of Drug Abuse grant number 5 R01 DA017974. Principal Investigator: Jack F. Hollis, PhD. Vol. 69, No. 3, Summer 2009 149 © 2008, American Association of Public Health Dentistry DOI: 10.1111/j.1752-7325.2008.00113.x