Opinions of Dental Students

on Newly Implemented Tobacco Cessation Protocol

Abstract

O
bjectives: Tobacco cessation and tobacco-use cessation counseling are important in the prevention of both oral and
systemic diseases. The University at Buffalo School of Dental Medicine recently added the Tobacco Cessation Coun-
seling Protocol (TCCP) to the predoctoral curriculum, in which students are trained to provide this service to patients.
The purpose of this study was 3-fold: to evaluate the opinions of students regarding the new TCCP, to identify barriers for suc-
cessful implementation of the program, and to explore ways to improve effectiveness of the TCCP from the perspective of den-
tal medicine.

M
ethods: A total of 120 third- and fourth-year
dental students were asked to complete a sur-
vey regarding the TCCP, which included ques-
tions on identification of barriers to counseling,
student/patient relationships, and students’ confidence
about providing tobacco cessation counseling.
Results: The survey was completed by 108 students
(90%). Nearly all (99%) believed that dentists should as-
sist their patients in tobacco cessation. Of the respondents,
63% were confident about assessing and treating their pa-
Othman Shibly, DDS, MS
Diplomate, American Board of Periodontology
Director, Preventive Dentistry
Coordinator, International Advanced Dental
Education
Associate Director, Center for Dental Studies
University at Buffalo School of Dental Medicine
Buffalo, NY
Adeela Khan, BA
MPH Candidate, The George Washington University
School of Public Health and Health Sciences
Washington, DC
Research Assistant
Department of Periodontics and Endodontics
University at Buffalo School of Dental Medicine
Buffalo, NY
tients’ nicotine dependence and 50% reported that they
had sufficient skills to provide tobacco cessation counsel-
ing. Fifty-five percent of students believed they had re-
ceived adequate training in tobacco cessation counseling;
81% of students were somewhat confident about being
able to prevent their patients from starting to use tobacco.
Eighty-three percent of students identified the TCCP serv-
ice fees and 78% identified lack of faculty involvement as
perceived barriers associated with the TCCP.
Conclusions: Students believe helping smokers to quit
using tobacco is a dentist’s professional responsibility. How-
ever, lack of faculty involvement was perceived to be a major
barrier for students’ implementation of tobacco counseling.
Introduction
The US Surgeon General has reported smoking to be a
major factor in the development of oral and maxillofacial
cancers.1 Studies report that tobacco is a causal factor in
the development of stomatitis nicotina, gingival bleeding,
gingival recession, acute necrotizing ulcerative gingivitis,
increased dental calculus, halitosis, and dental staining.2
Recent studies show that even smokeless tobacco causes
systemic effects, such as nicotine dependence, transient hy-
pertension, and cardiovascular disease.3 Tobacco products

Vol. 4, No. 8 (Suppl 1) Dental Learning / August 2010 1

clearly have a negative effect on oral health4-6; however,
in clinical practice many healthcare providers do not ad-
dress tobacco dependence as an oral disease.
In 2008 the Surgeon General declared that tobacco de-
pendence is a chronic disease for which healthcare providers
must provide ongoing counseling as an effective form of to-
bacco cessation.7 Tobacco counseling methods have been in-
tegrated into US dental school curricula since 1989.8,9 An
objective of Healthy People 2010, a national program de-
signed to identify the most significant preventable threats to
health and establish national goals to reduce these threats,
is to increase the percentage of dentists who counsel on to-
bacco cessation.10 Despite such efforts, recent reports suggest
that many dentists do not perform tobacco cessation coun-
seling. A 2006 Texas study found that 90% of dentists were
unfamiliar with the “5 A’s” protocol for tobacco cessation
counseling (Ask, Advise, Assess, Assist, and Arrange),11 and
a 2007 survey of South Carolina dental students reported
that only 39% thought they were adequately trained to pro-
vide tobacco cessation education.10 Additional studies indi-
cate that many dentists are still less active in promoting
tobacco cessation than are other healthcare providers.12-14
It has been demonstrated that incorporating a Tobacco
Cessation Counseling Protocol (TCCP) during the aca-
demic program increases the use of tobacco cessation tech-
niques by dental students.15 Although an increasing
number of tobacco cessation counseling programs have
been implemented throughout US dental schools, there is
little written on the methods for successful implementa-
tion of such programs.16 The purpose of this article is to
explain the model used by the University at Buffalo School
of Dental Medicine (UBSDM) for implementation of its
TCCP and to help improve the new protocol by discussing
students’ feedback. Upon completion of this study, the
data collected will be used to improve the effectiveness of
the TCCP and make it available to other dental schools
and dentists in individual practice.
Methods
University at Buffalo Tobacco Counseling Program
Using a modified form of the traditional 5 A’s ap-
proach, the UBSDM emphasizes the role of the dental
team in including promotion of oral health and preven-
tion of oral diseases. Although traditionally most dental
2 Dental Learning / August 2010
curricula have included only the first two A’s—ask and
advise—our newly designed TCCP consists of all 5 A’s.
(Figure 1) Students are trained to include all five A’s while
counseling patients and prescribing adjunctive medication
as needed. In summary, the modified 5 A’s are:
• Ask patients about their smoking habits, type of to-
bacco used, and frequency of use.
• Advise patients about the effects of tobacco on their
oral health. The patient’s present oral condition, diag-
nosis, prognosis, and clinical outcome must be ex-
plained to the patient with regards to tobacco use.
Therefore, this step is done as part of the treatment
plan, not part of the dental history.
• Assess patients to determine their interest in quitting
on a scale of 1 to 10 (with 10 being “most interested”).
• Assist patients who want to quit by offering nicotine
patches and suggestions on how to avoid the temptation
to smoke (eg, throwing away tobacco products, and stor-
ing ashtrays). Other medications for the treatment of to-
bacco dependence are: nicotine gum (nonprescription),
nicotine inhaler (prescription), nicotine nasal spray (pre-
scription), nicotine lozenge (nonprescription), and bupro-
pion hydrochloride (brand name, Zyban) (prescription).
A relatively new medication is varenicline (brand name,
Chantix). Varenicline blocks the ability of nicotine to ac-
tivate α4β2 receptors which prevents stimulation of the
central nervous mesolimbic dopamine system.17
• Arrange for follow-up visits to the dental clinic to see
how the patients are doing and encourage continued
abstinence.
In the past few years the UBSDM has included several
new protocols in the dental curriculum and dental clinic.
Some of these protocols are tobacco counseling, nutrition
counseling, determination of motivation for plaque con-
trol and oral hygiene, salivary flow rate, and caries risk
test, all of which include a comprehensive risk assessment
for dental and periodontal diseases, including oral can-
cers. In addition, students also receive training to perform
nonjudgmental and personalized tobacco-use assessments
and to counsel by prescibing medications that help pa-
tients reduce nicotine dependency.
The UBSDM is taking a progressive approach to help
patients quit using tobacco. Until 2 years ago there was
limited content in the predoctoral program on the TCCP
Vol. 4, No. 8 (Suppl 1)
for patients who use tobacco. However, the effect of to-
bacco on oral health based on current clinical research was
extensively covered in the dental curriculum. This resulted
in a gap between clinical practice and clinical research
within dental education. To close this gap, the University
at Buffalo developed a comprehensive TCCP, one of the
few programs in the nation that uses each of the “5 A’s”
and includes cessation advice incorporated into a person-
alized dental treatment plan.16 In this program, third- and
fourth-year dental students do not refer tobacco users to a
telephone-based tobacco-use cessation program or tobacco
cessation clinic; rather, the students are taught to imple-
ment nonjudgmental tobacco counseling to encourage
their patients to quit using tobacco, as well as to offer
treatment options to assist their patients who desire to
quit.
Survey
For this study, 120 third- and fourth-year students at
UBSDM were given a self-administered survey in 2008.
The survey used purposive sampling methods, as all third-
and fourth-year students were eligible to take the survey.
Of the 120 students, 108 returned their surveys (response
rate, 90%).
Recruitment attempts included handing students the sur-
vey at the beginning of class or during their clinic. Students
were asked to complete the entire survey. Two attempts were
made to increase response rate. Students individually
handed the completed survey to the instructor. Each stu-
dents’class year was obtained; no personal identifying ma-
terial for the student was necessary for our purposes.
The questions used in this survey were adapted from 2
previous surveys: a survey of pediatric dentists and an ear-
lier Australian study of dental students.18, 9 Students were
evaluated on their readiness and confidence in following
the tobacco cessation protocol while also taking a critical
look at the training provided by the school.
Data entry and analysis were performed using, respec-
tively, Microsoft Office Excel 2007 and the Statistical Pack-
age for Social Sciences, version 6.1 (SPSS Inc). The survey
consisted of 25 questions, with 22 of the questions using a
5-point Likert scale (“strongly agree” to “strongly dis-
agree”). Descriptive statistics were generated and used to
evaluate the differences between the responses for third- and
Vol. 4, No. 8 (Suppl 1)
fourth-year students. Percentages and frequencies were also
generated to determine distributions for several responses.
Results
Role of the Dental Professional
Dental students were asked to evaluate several state-
ments about their professional role in tobacco counseling.
In response to a question about the extent to which they
believe it is the dentist’s role to “assist your patients to
quit using tobacco,” approximately 99%, or 104 students
felt that it was important. Similarly, we found that 81.0%
of third- and fourth-year students agreed or strongly
agreed that good dental care should include tobacco ces-
sation counseling. Our data also indicated that less than
8% of the students surveyed felt that dental students
should not be trained in the TCCP methods. Table 1
shows the breakdown in responses, by class year, to ques-
tions pertaining to the role of dental professionals.
Students’ Perceptions: Patient-Related Barriers
Students were asked to evaluate potential patient-re-
lated barriers that reduce the students’ ability to provide
the TCCP. This was done to rank the specific barriers and
understand student concerns. Figure 1 shows the percent-
ages of students who agreed with the potential barriers we
listed as choices in our survey. Broken down by class,
57.8% of the third-year students believed that patients are
not motivated to quit. Similar numbers of fourth-year stu-
dents (57.1%) agreed with this sentiment.
As shown in Figure 1, the third- and fourth-year stu-
dents identified lack of patient motivation and the idea that
patients do not expect counseling from dental students to
be the strongest barriers with respect to implementation of
a TCCP. Other perceptions with regard to patient-related
barriers included: students feeling too intrusive when ask-
ing patients about tobacco use, patients not listening to den-
tal students’ counselling, fear of upsetting the dentist/patient
relationship, and belief that patients do not consider the
TCCP to be part of the dental professional’s role.
Student Opinions: The TCCP
Table 2 represents student self-assessment of skills
gained from the TCCP training they have received at
UBSDM. The data were not broken down by class be-
Dental Learning / August 2010 3
 1
Table 2 Dental students attitudes regarding the role of the dental professional.
Survey Response Forth Year % Third Year % Total % Combined
Question Students Students (3rd and 4th Year
(N=42) (N=63) Students, N=105)
To what extent do you
think it is part of your role Not Important 1 2.4% 0 0.0% 1.0%
as a dentist to assist your Important 26 61.9% 48 76.2% 70.5%
patients to quit using tobacco? Very Important 15 35.7% 15 23.8% 28.6%

Students should be trained Agree/Strongly Agree 26 61.9% 44 71.0% 66.7%

in smoking cessation counseling. Disagree/
Strongly Disagree 6 14.3% 2 3.2% 7.6%
Neutral 10 23.8% 16 25.8% 24.8%

Good Dental Care should Agree/Strongly Agree 33 78.6% 52 82.5% 81.0%

include tobacco smoking Disagree/
cessation counseling Strongly Disagree 4 9.5% 3 4.8% 6.7%
Neutral 5 11.9% 8 12.7% 12.4%

cause this portion of the data sought to understand how
students on the whole feel about their TCCP education.
The data indicate that students are confident about their
received training, with more than 60% responding that
they are able to treat patients at several levels, including
prevention and intervention. When asked how confident
students were in assisting patients to quit smoking, 67.6%
of students were ‘confident,’ with an additional 10.5% of
students feeling ‘very confident’ responded that they were
‘confident’. Similarly 80% of students felt ‘confident’ or
‘very confident’ (60.0% and 20.0% respectively) about
the delivery of tobacco prevention counseling. When we
combined the categories of ‘confident’ and ‘very confi-
dent,’ a lesser percentage (66.7%) were confident about
their ability to assess and treat nicotine dependence.
The survey also asked students questions pertaining to
their perceptions of UBSDM faculty and staff. Students
were asked how helpful the faculty, staff, and dental assis-
tants are in terms of the TCCP implementation. A supple-
mental question was asked regarding the familiarity with
the TCCP within the faculty. Students in general had over-
all neutral responses to these questions (data not shown).
Elimination of Barriers
Initially, patients were charged a $13 clinic fee for the
TCCP counseling services that was added to the regular
cost of the checkup. When asked if the clinic fee was a fac-
tor in hindering the implementation of the TCCP, 83% of
students agreed and indicated that elimination of the fee
for tobacco cessation counseling would increase patient
acceptance of the TCCP. In an unpublished study by
UBSDM faculty members in 2007, it was found that al-
though many students were performing the TCCP, they
were not adding the service to the patient’s bill.
In addition to identification of barriers to implementa-
tion of the TCCP, students were also asked to rank the use-
fulness (1 through 5, with 5 being the most useful) of 5
tobacco cessation resources to which the school uses or has
access. Students identified the New York State Quit-line
(self-help pamphlets and brochures and coordinated care)
as the most useful resource. Free nicotine replacement ther-
apy was ranked as the second most useful option.
Discussion
Instructing healthcare students in the classroom and
clinics is a vital step in ensuring that, with proper coun-
seling, tobacco-using patients will stop using tobacco
products. It is the goal of a dental professional to help in-
dividuals achieve and maintain maximum oral health
throughout their lives. Given that almost one-third of peo-
ple see a dentist, the dental clinic offers an environment
conducive for tobacco counseling.19
Furthermore, implementation of a TCCP within den-
tal education is gaining importance as universities and

4 Dental Learning / August 2010 Vol. 4, No. 8 (Suppl 1)

 Table 2 Student Skills Assessment.
Survey Question
By virtue of the training you have received at UBSDM, how
confident are you in your ability to …
… assist your patients to quit smoking?
… prevent patients from starting to use tobacco products?
... assess and treat nicotine dependence?
health centers increasingly become tobacco-free environ-
ments. Beginning with the 2009 academic year, the Uni-
versity at Buffalo became a smoke-free campus as part of
the UBreathe Free Initiative. In collaboration with several
state and regional associations, the program will help to-
bacco users by offering cessation tools and support.
At UBSDM the new TCCP includes providing dental stu-
dents with 8 hours of in-class lectures starting in their second
year, which includes information on the effect of tobacco
products on systemic health, oral health, and the epidemiol-
ogy of tobacco-associated diseases. Tobacco components and
the role of nicotine in addiction are also covered. The inte-
gration of the TCCP within multiple disciplines produces a
more comprehensive protocol, fortifying the message to stu-
dents and making it relevant for application.20
At UBSDM, the first “A” in the traditional 5 A’s (“Ask
at every appropriate opportunity”) differs in that the pa-
tient is always asked if he or she is a tobacco user. Students
are required to ask patients if they use tobacco products
when taking patient medical histories. The patient’s smok-
ing status is updated each time his or her medical history
is updated. Unlike many other programs, UBSDM students
do not provide tobacco counseling on determining the pa-
tient’s tobacco-use status (taken from their medical his-
tory), but rather after the dental history is taken, diagnosis
has been established, and the treatment plan formulated.
This has demonstrated to be a beneficial change, as 1 study
described that people are less likely to seek any type of den-
tal care when their self-rated dental health status is lower,
and that when “episodic, problem-driven dental care
users” are more likely to rate themselves at a lower health
status, they are also more likely to use tobacco.21
The UBSDM process ensures that the TCCP will be the
first item in the treatment plan. Doing so allows advice to
be systematic and more effective by relating any dental,
oral, and periodontal findings to tobacco use whenever
Vol. 4, No. 8 (Suppl 1)
Responses (%)
Not Confident Confident Very Confident
21.9 67.6 10.5
19.0 60.0 20.0
33.3 61.9 4.8
appropriate. Following this procedure allows the TCCP
to be more individualized for every tobacco user and gives
patients the convenience of having an assessment, coun-
seling, and individualized treatment (including nicotine re-
placement therapy if indicated) in 1 appointment.
Also, UBSDM helped students implement the TCCP
by developing a quick guide brochure on the 5 A’s along
with a patient sticker that is included in the patient’s chart
(Figure 2). The patient sticker summarizes the patient’s re-
sponse to the counseling and is used as a checklist by den-
tal students to ensure all aspects of counseling are covered.
In addition to using the 5 A’s, students are taught to iden-
tify tobacco dependence as an oral health problem and a
chronic disease; thus the TCCP becomes part of the treat-
ment plan. Through the TCCP, students are able to offer pa-
tients a free 2-week supply of nicotine patches and a quit
guide to help them achieve their goals. If nicotine patches
were contraindicated, students were trained about alternative
nicotine replacement therapies or appropriate medications.
UBSDM teaches the importance of practitioners pro-
viding intervention and prevention counseling. For exam-
ple, tobacco intervention counseling becomes mandatory
any time a patient is identified as a tobacco user. Similarly,
when the patient is not a tobacco user, students are in-
structed to encourage prevention and provide positive
morale for the patient to stay tobacco free. This is critical,
especially among younger patients, to prevent them from
becoming smokers. Each treatment is marked by a special
insurance code—U1322 for Tobacco Counseling Cessa-
tion when the patient is a smoker or U1323 for Tobacco
Prevention when the patient is not a smoker. This ensures
that every patient is asked about his or her tobacco use
and that none of the tobacco users will miss receiving to-
bacco counseling. The students are also given school cred-
its for using the TCCP, to emphasize that it is an integral
part of dental treatment. A survey of third- and fourth-
Dental Learning / August 2010 5
Figure 1 — Perceived barriers for third- and 4th year dental students about the Tobacco Cessation Counseling Program (TCCP). (N=106)
Percent agreement reflects the number of students that ‘agreed’ or ‘strongly agreed’ with the given barrier.
year students sought to evaluate the current TCCP by
means of gathering student opinion on the effectiveness
of the program and their confidence with their own skill
set. In addition, our survey was able to identify barriers
facing implementation so that current protocol could be
improved and adjustments made wherever needed.
Experience demonstrates that including tobacco coun-
seling and training in the dental curriculum was very ef-
fective. We found that 99% of students surveyed agreed
that tobacco cessation counseling is part of the dentist’s
professional role and 81.3% of students that were sur-
veyed felt that good dental care should include the TCCP.
Fried, et al22 reported that 90.6% of dental students be-
lieved that the TCCP was part of a dental professional’s
role. Other studies also concluded that the role of the den-
tal professional should include a TCCP.23, 24 The data also
indicated that more third-year students agreed that stu-
6 Dental Learning / August 2010
dents should be trained in the TCCP and were more con-
fident in the program’s implementation. This is different
from the 2006 Texas study in which 90% were not fa-
miliar with a TCCP.10
Talking with and counseling dental patients may be dif-
ficult and challenging, especially with the presence of patient-
related barriers. Students identified several barriers to
tobacco cessation counseling, including professional fees,
lack of time, and apparent lack of faculty involvement. These
results are consistent with findings of other studies.7, 25, 26
With the high demands of clinical practice and didac-
tic requirements of every dental program, it is under-
standable that students felt that lack of time was a barrier
to providing tobacco counseling. Better time management
during patient appointments may alleviate the stress that
causes dental students to take no action regarding tobacco
cessation counseling. A large number of studies have been
Vol. 4, No. 8 (Suppl 1)
 TOBACCO CESSATION PROTOCOL
DATE: ________________________
ASK THE PATIENT: SMOKING HISTORY
# cigs/day _____ # cigs/wk _____ # yrs smoking _____
# cigars/wk _____ # bowls pipe tobacco/wk _____
# pouches/cans smokeless tobacco/wk _____
ADVISE THE PATIENT: TOBACCO-RELATED
ORAL PROBLEMS NOTED (check all present)
Stain ____ Periodontitis _____ Halitosis _____
Oral Lesion _____ Other _____
ASSESS THE PATIENT:
Patient interest in quitting from 1 to 10 ______
ASSIST THE PATIENT:
Literature given: Yes ____ No____
Quit Date: Now ____ Later ____
Expected quitting date: ___________
Patch Dispensed: Yes ____ No ____
ARRANGE FOR THE PATIENT:
Willing to be called: Yes ____ No ____
Time __________ Number ________________
Referred to Quitline: Yes ___ No___
Figure 2 — TCCP sticker that is inserted in patient chart as part
of comprehensive Tobacco Cessation.
devoted to the idea that dentists can greatly increase to-
bacco cessation rates by simply counseling patients.18, 27
In the US Centers for Disease Control and Prevention’s
Treating Tobacco Use and Dependence: 2008 Update, ex-
perts recommend that 3- to 10-minute counseling sessions
can have dramatic effects on cessation rates.27 The report
states that the more time a dentist can spend with a pa-
tient, the better, but that even low-intensity counseling,
defined as a 3-minute session, can significantly increase
abstinence rates compared with no discussion of tobacco
as an oral health issue. The TCCP program at UBSDM
has implemented 10-minute counseling of patients within
the allotted appointment time.
Also, because students at UBSDM receive credit points
for the TCCP, it would be to their benefit to continue im-
plementing the program with patients. Getting points will
not only give students the message that the TCCP is im-
Vol. 4, No. 8 (Suppl 1)
portant, but will also impress on students that it is as es-
sential as any dental procedure needed for a patient.
Where dentists and dental students are concerned as pro-
fessionals, they must understand the important role they
play as proponents of oral health, prevention, and treat-
ment of oral disease and thus implementation of a TCCP.
Overall, questions pertaining to students’ perceptions
of faculty and staff had overwhelmingly neutral responses.
Neutrality was not synonymous with silence in this study.
Several focus groups were held between students and fac-
ulty, in which concerns about the faculty and staff’s fa-
miliarity, helpfulness, implementation, and barriers of
TCCP were discussed. Several studies identify lack of ed-
ucation among dentists and hygienists as significant bar-
riers to student program implementation.28, 29 To increase
confidence among dental students, it would be beneficial
to have continuing education programs geared toward
faculty, so that they may better help students with imple-
mentation of a TCCP.
With respect to the clinic fee associated with tobacco
cessation, because of the presentation of these findings at
several student/faculty focus groups, the clinic fee has now
been eliminated and the TCCP is provided at no cost to
the patient. This was a necessary step in furthering the re-
solve to help patients, as charging patients for the TCCP
was met with largely negative reviews by dental students,
who believed their patients often became hostile to the
idea that they had to pay for such services, which are typ-
ically not paid for by dental insurance.
Dental students may find tobacco cessation counsel-
ing harder to implement on unwilling patients. This is ev-
idenced by the higher percentages of third-year students
versus fourth-year students who believed that they should
be trained in the TCCP. It is likely the result of several fac-
tors, including the idea that the third-year students are
more optimistic because they have had less experience in
the actual clinic setting. However, to improve student will-
ingness for training, it may be beneficial to include addi-
tional TCCP training throughout the students’ dental
education. A limitation of our study was that we per-
formed no pretest survey of student opinions before they
underwent TCCP training. However, based on past re-
search,11, 14 it is reasonable to expect that students who
have not had training in the TCCP would feel less willing
Dental Learning / August 2010 7
and less prepared to provide tobacco cessation counseling
to patients. Furthermore, the survey elicited helpful ideas
on improving the protocol that did not require a pretest
(ie, identifying barriers, elimination of the clinic fee, added
continuing education courses on the TCCP for faculty).
Conclusion
After adding a TCCP to the dental curriculum, most den-
tal students believe that tobacco cessation counseling is a
dentist’s professional responsibility and that both dental stu-
dents and dental school faculty require additional training.
In summary, based on the findings of this study, den-
tal schools and dentists must do the following to improve
implementation of a TCCP, which should, in turn, help
more patients to quit using tobacco:
• Motivate and educate the faculty and staff about a
TCCP and offer more continuing education programs.
• Include TCCP training throughout the dental curricu-
lum in all years of dental education, not limiting it only
to the first 2 years.
• Make the TCCP services free for patients.
• Provide tobacco cessation counseling after taking both
the medical and dental history, to make the TCCP
more individualized by relating patients’ dental find-
ings to their tobacco use.30,31
• Make a TCCP part of dental practices when treating
smokers. A recent publication by one of the authors
showed significant efficacy of a TCCP on the quitting
rates of smokers.32
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