March 2005

Grant Results

SUMMARY

From 2000 through 2003, researchers from the Oregon Research Institute, Eugene, Ore., implemented and evaluated a tobacco cessation program that dentists provided to low-income people in public clinics.

Researchers from the Oregon Research Institute created the CRUSE program, which teaches dentists and dental hygienists to routinely assess patients' tobacco use and advises them on ways to help their patients quit.

(The CRUSE acronym is based on the five steps of the intervention: Check tobacco use status; Relate tobacco-related oral health findings; Urge tobacco users to quit; Supply self-help cessation materials; Encourage the patient via follow-up.)

The CRUSE program, however, was designed for dentists in HMO and private practices. No one had implemented and evaluated a tobacco cessation program for low-income patients who see dentists in public clinics.

Key Findings

  • Dentists and dental hygienists were more likely to discuss smoking with their patients and provide them with resources to quit after receiving the training in intervention.
  • Controlling for differences in age, race/ethnicity and time to first morning cigarette, researchers found that patients in the intervention group were three to four times more likely to report at three months and six months that they had quit using tobacco than patients receiving usual care.
  • The data suggest that African Americans quit at higher rates than whites or Hispanics. However, the sample size within each racial/ethnic group was too small to support statistical testing with adequate power, and current findings are unclear about possible mechanisms for such differences.

Funding
The Robert Wood Johnson Foundation (RWJF) provided $315,240 to fund this research between June 2000 and October 2003.

 See Grant Detail & Contact Information
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THE PROBLEM

Brief counseling interventions by physicians and dentists have proved successful in helping people to quit using tobacco, according to the principal investigator.

To help dentists integrate the U.S. Public Health Service's clinical practice guidelines on tobacco use into their care, researchers from the Oregon Research Institute created the CRUSE program, which teaches dentists and dental hygienists to routinely assess patients' tobacco use and advises them on ways to help their patients quit. (The CRUSE acronym is based on the five steps of the intervention: Check tobacco use status; Relate tobacco-related oral health findings; Urge tobacco users to quit; Supply self-help cessation materials; Encourage the patient via follow-up.)

The CRUSE program, however, was designed for dentists in HMO and private practices. No one had implemented and evaluated a tobacco cessation program for low-income patients who see dentists in public clinics, according to the principal investigator.

Reaching this population is important because the percentage of people who smoke and use smokeless tobacco products is higher among those with lower incomes, according to a survey of members of the Oregon Health Plan, the state's insurance plan that serves patients on public assistance.

It showed that plan members have one of the highest prevalence rates for tobacco use in the country. Forty-four percent of its enrolled patients use tobacco compared to 22 percent of adults in the general population. Cigarette smoking and smokeless tobacco put users at a greater risk for tobacco-related dental diseases, including oral cancer, periodontitis, gingival recession and soft-tissue changes.

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RWJF STRATEGY

In 2000, the U.S. Public Health Service and the Centers for Disease Control and Prevention issued Treating Tobacco Use and Dependence, Clinical Practice Guideline, an update of a 1996 publication. An RWJF grant to the Center for Tobacco Research and Intervention provided partial funding for the update. (See Grant Results on ID# 034068.)

Numerous public and private funders, including RWJF (see Grant Results on ID#s 029389, 030329, 030520, 030375, 030525 and 030254), have supported dissemination of these evidence-based tobacco cessation guidelines, but early efforts lacked the coordination necessary for maximum impact and efficiency.

Recently, major funders have begun joining together to co-fund national dissemination blueprints to integrate their efforts and leverage their investments. For example, in conjunction with other organizations, RWJF funded the development of a blueprint for adolescents (see Grant Results on ID#s 037525 and 041053 to form the Youth Tobacco Cessation Collaborative).

Also, in conjunction with other organizations, RWJF funded the development of a blueprint for pregnant smokers through its national program, Smoke-Free Families: Innovations to Stop Smoking During and Beyond Pregnancy (see Grant Results). RWJF also played a lead role in designing and funding the National Partnership to Help Pregnant Smokers Quit in concert with the leadership of Smoke-Free Families. See www.smokefreefamilies.org.

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THE PROJECT

Oregon Research Institute is a nonprofit organization based in Eugene that studies human behavior and develops programs to improve the health and well-being of individuals, families and communities. In this project, researchers modified the CRUSE program used by dental offices in HMO and private practices to be more appropriate for use with low-income patients in public dental clinics. Enhancements included:

  • Broadening the role of dentists and dental hygienists by having them discuss tobacco use at all visits, not just checkups.
  • Additional training of dentists and hygienists in the oral health effects of smoking and the use of nicotine replacement therapy.
  • Free nicotine patches and gum for dentists to provide to patients who set a date to stop smoking.

The researchers trained dentists and dental hygienists to deliver the intervention in two public dental clinics in Oregon. The first clinic was located in Portland. Because participant recruitment was slow, researchers added a second clinic to increase the number of participants. This clinic, located in the smaller, less urban community of Eugene, served a higher proportion of homeless people and migrant workers than the Portland clinic.

Researchers compared patients who were seen in the six months prior to the training (the comparison group) to those seen after the training (the intervention group). A total of 386 patients participated in the study — 178 in the comparison group and 190 in the intervention group. All these patients had incomes at or below the federal poverty level. The vast majority of them (96 percent) were cigarette smokers, 1 percent used smokeless tobacco, and 3 percent used both. Smokers reported smoking an average of 15 cigarettes per day for 21 years.

Researchers surveyed the participants at six weeks to explore their interaction with the dentists and dental hygienists to assess the extent to which they received the intervention protocol. Researchers also surveyed patients at three and six months on their tobacco use behaviors. A total of 186 (51 percent) completed the three-month assessment, 170 (46 percent) completed the six-month assessment, 234 (61 percent) completed either the three-or six-month assessment, and 134 completed both. Nine patients (2 percent) dropped out of the study after enrollment, and researchers were unable to locate 68 individuals (18 percent).

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FINDINGS

The research team reported the following findings to RWJF in 2004:

  • Dentists and dental hygienists were more likely to discuss smoking with their patients and provide them with resources to quit after receiving the training in intervention. Patient reports of their interactions with their dentists and dental hygienists showed that providers adhered to the intervention's protocol. For example, 32 percent of patients who received the intervention received tips on how to quit, compared to 11 percent of patients in the comparison group.
  • Controlling for differences in age, race/ethnicity and time to first morning cigarette, researchers found that patients in the intervention group were three to four times more likely to report at three months and six months that they had quit using tobacco than patients receiving usual care. However, the sample size was too small to detect statistical results when looking at those who reported non-use at both three months and six months, which would have provided a more rigorous measure of sustained quit rates.
  • The data suggest that African Americans quit at higher rates than whites or Hispanics. However, the sample size within each racial/ethnic group was too small to support statistical testing with adequate power, and current findings are unclear about possible mechanisms for such differences.

Limitations

This research employed a non-experimental pretest-posttest design — that is, researchers compared patients who were seen by dentists who were not trained in delivering the intervention to those seen by dentists after they had been trained. Other variables not related to the interventions (e.g., another tobacco cessation program or a media campaign) could have influenced the tobacco use of the people in this study.

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CONCLUSIONS

This intervention was more effective than similar ones conducted with smokers in private dental practices. The researchers believe that two factors might be at play:

  • Low-income patients may not have as much access to smoking cessation resources as higher income patients in private clinics. Although participants may have been ready to quit for some time, they may not have had the opportunity for treatment nor the support to do so. Similar findings have emerged from studies of primary care interventions for low-income medical patients.
  • The public clinic setting may be more conducive to delivering the intervention. Because more patients in the public clinics saw a dentist for an acute problem, they received the intervention from both the dentists and the dental hygienists. In private dentists' offices, the primary interventionist was the dental hygienist, who delivered the intervention to patients coming in for a checkup.

Communications

The researchers presented their findings at several national tobacco control conferences and have two articles in press at national journals, including the Journal of the American Dental Association. See the Bibliography for more details.

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LESSONS LEARNED

  1. It is important to get the buy-in of the staff members who will be implementing the intervention in addition to the person who has the authority to approve it. Although the researchers received approval from the clinic director to conduct the project, they found they needed to get staff opinion leaders and advocates to encourage other staff members to be supportive of the project. (Project Director)
  2. Researchers conducting studies in a public health setting may need to overcome a lack of resources. Staff turnover was much higher than anticipated and as a result the research team needed to conduct more training sessions for the dentists. The research team also provided stipends to the clinics so that dental staff could attend the training during working hours. (Project Director)

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AFTER THE GRANT

The research team submitted a proposal to the National Cancer Institute to assess the program through a more rigorous randomized clinical trial in 14 public health dental clinics in Mississippi, New York and Oregon.

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GRANT DETAILS & CONTACT INFORMATION

Project

Promoting Tobacco Cessation through Managed Care Dental Providers

Grantee

Oregon Pacific Research Institute (Eugene,  OR)

  • Amount: $ 315,240
    Dates: June 2000 to October 2003
    ID#:  038987

Contact

Judith S. Gordon, Ph.D.
(541) 484-2123
Judith@ori.org

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Gordon JS, Andrews JA, Lichtenstein E, and Severson HH. "The Impact of a Brief Tobacco-Use Cessation Intervention in Public Health Dental Clinics." Journal of the American Dental Association, 136(2), 179–186, 2005. Abstract available online.

Gordon JS, Andrews JA, Severson HH, and Stewart DCL. "Reaching Underserved Tobacco Users: Tobacco Cessation via Public Health Dental Clinics." Abstract published in Nicotine and Tobacco Research, 5(5), 778, 2003.

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Report prepared by: Elizabeth Heid Thompson
Reviewed by: Robert Crum
Reviewed by: Molly McKaughan
Program Officer: C. Tracy Orleans

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