Background
Oral disease is a significant public health threat which affects millions of people. It includes common oral diseases such as periodontitis and dental caries, and less common oral and pharyngeal cancers. Together these diseases exact a large human toll. Oral disease not only results in unnecessary pain, potential physical disfigurement, and emotional suffering, it puts individuals at greater risk for subsequent morbidity and mortality [
1]. For example, periodontal oral infections are associated with increased risk of cardiovascular disease, stroke, adverse pregnancy outcomes, diabetes, obesity, and non-oral cancers [
1‐
5]. Treating acute disease and preventing the onset of future oral disease are important public health goals.
Tobacco users are at particularly high risk for oral disease compared to people who do not use tobacco [
1,
6]. Unfortunately, many smokers fail to seek routine professional dental care [
6‐
8]. As a result, additional public oral health efforts may be needed to reach smokers and to augment the preventive care provided by dental practitioners. Routine oral hygiene such as daily brushing and flossing, use of fluoride products, and lifestyle changes such as reducing tobacco and alcohol use are critical to preventing disease [
1]. In fact, encouraging proper self-care at home is now an accepted practice of preventive intervention [
9] and can be influenced by behavioral counseling [
10,
11], prompting a recent recommendation that public health officials consider leveraging the existing tobacco quitline infrastructure in the United States to counsel tobacco users about both smoking cessation
and better oral health care [
8].
Tobacco quitlines provide motivational and cognitive behavioral counseling for tobacco cessation, primarily through proactive counseling calls (i.e., calls initiated by the quitline based on a pre-determined call schedule established after one enrolls in the services). Participants typically receive supplemental mailed materials and may also have access to online intervention materials or even text-based messaging support. Tobacco quitlines are ubiquitous in North America. At present, all 50 US states, the District of Washington, Puerto Rico, Guam, and 10 Canadian provinces offer free tobacco quitline programs. Other smokers receive services from the hundreds of commercially-funded quitline programs supported through health insurers, employers, and other private funders. According to data from the North American Quitline Consortium (NAQC), in 2009 alone more than 380,000 tobacco users received services from their quitline members [
12]. The Global Quitline Network includes additional service providers in Europe and Asia. Expanding oral health promotion activities provided through the existing quitline infrastructure could reach a sizable population, nationally and internationally, and be an innovative way to reach individuals who are at particularly high risk for oral disease. It would also take advantage of an existing cadre of trained behavior change professionals, and the preventive care counseling offered could augment the standard care provided by dental care providers and even encourage utilization of their services. That is, in addition to receiving tobacco cessation counseling, quitline callers could be informed about the risks of oral disease and counseled on ways to improve their oral health through lifestyle risk factor modification (e.g., quitting smoking, limiting alcohol use, proper nutrition, fluoride use, brushing and flossing daily, and seeing a dentist regularly).
To assess the feasibility of this strategy in the U.S., we previously surveyed a representative sample of callers to the Washington State Quitline (WAQL; n = 816) [
8]. WAQL provides free tobacco cessation counseling to all eligible callers. Persons are typically eligible if they do not have access to nicotine dependence treatment services through other means (e.g., coverage provided by an employer or through private health insurance) or if they are in a high risk priority group, such as pregnant smokers. The results of this survey demonstrated an important opportunity to promote better oral health among tobacco quitline callers by intervening to prevent future oral disease. Among tobacco users who still had their natural teeth (79.3% of those surveyed), most failed to meet the American Dental Association’s (ADA) recommendations for daily brushing and flossing (83.9%) and most had not visited the dentist in more than a year (52.6%). Although, relatively few people in this sample self-reported a diagnosis of gum disease (21.6%) or dental bone loss (20.4%). If these reports are accurate, it underscores the opportunity for preventative care, to reduce the risk of future disease. If, however, these rates are an underestimation of oral disease in this population, it speaks to the opportunity to better educate smokers about the signs of oral disease and need for regular professional dental screenings. We also found that many tobacco users were open to learning more about ways to improve their oral health (57.4%), were receptive to be counseled by their quitline coach (48.2%), or were open to receiving oral health intervention materials by mail (62.7%) or Internet (50.0%), so there is evidence that many smokers contacted through the quitlines are receptive to oral health promotion efforts.
These data are encouraging, but it is unclear whether the results generalize to smokers recruited through commercially-funded quitlines. In contrast to state-funded quitlines, which reach smokers of lower socio-economic status and are often limited to persons with no private health insurance, commercial quitlines are typically funded by health plans or employers. As such, they reach tobacco users who are of higher socioeconomic status and, therefore, may have different oral health needs, interests and intervention opportunities. The current paper examines self-report oral health indicators, behavioral oral health risk factors, motivation for behavior change, and interest in oral health promotion among medically-insured smokers receiving tobacco quitline services. We sought to replicate the outcomes previously reported among state quitline participants and to extend them by examining additional indicators of oral disease, behavioral risk behaviors, and motivation for change. These findings not only enhance our understanding of smokers’ oral health needs, but will help inform future efforts to design oral health promotion programs that can be integrated into the standard counseling offered to smokers through tobacco quitlines.
Results
Participant characteristics
Participant characteristics are presented in Table
1. Respondents were predominantly non-Hispanic white, middle-aged, females. The majority had at least some college education and two-thirds were employed. More than half had a household income exceeding $40,000/year and three-quarters reported dental insurance coverage.
Table 1
Participant characteristics
Age | 48.3 (13.8) | 46.7 (13.9) |
|
N (%)
|
N (%)
|
Female | 296 (65.1) | 247 (64.3) |
White, non-hispanic | 384 (84.4) | 322 (83.9) |
Married or living as married | 269 (59.1) | 226 (58.9) |
Education | | |
High school or less education | 152 (33.4) | 125 (32.6) |
Some college | 202 (44.4) | 166 (43.2) |
College or post-graduate degree | 101 (22.2) | 93 (24.2) |
Employed | 298 (65.5) | 262 (68.2) |
Household income a
| | |
< $20,000 | 69 (15.2) | 56 (14.6) |
$20-39,999 | 115 (25.3) | 93 (24.2) |
$40,000 – 59,000 | 77 (16.9) | 64 (16.7) |
≥ $60,000 | 153 (33.6) | 135 (35.1) |
Dental insurance (private or government funded) | 358 (78.7) | 309 (80.5) |
Tobacco use | | |
Cigarette smoker b
| 274 (60.2) | 233 (60.7) |
Pipe, cigar, or bidis | 9 (2.0) | 9 (2.3) |
Oral tobacco | 9 (2.0) | 7 (1.8) |
Alcohol user | 329 (74.3) | 263 (76.4) |
Oral health indicators
Oral health indicators are presented in Table
2. Eighty-five percent of respondents had some or all of their natural teeth. Nearly half of these had lost one or more teeth due to disease. Approximately 15% of the total sample had lost all of their natural teeth. One third of dentate respondents reported prior treatment for gum disease, such as scaling or root planing, and a quarter indicated they had been diagnosed with dental bone loss. Based on their current symptoms, 30% believed they may have gum disease.
Table 2
Self-report oral health indicators
Edentulous (lost all natural, permanent teeth)a,b
| 68 (14.9) | n/a |
Self-rated health of teeth & gums as ‘good’ or better a
| 272 (59.8) | 271 (70.6) |
Believe may have gum disease based on current symptoms (e.g., swollen, receding, sore, or infected gums or loose teeth)a
| 116 (25.5) | 116 (30.2) |
One or more permanent teeth removed due to Diseasec
| 231 (50.7) | 175 (45.7) |
Ever received treatment for gum disease (such as scaling or root planing)a
| 136 (29.9) | 136 (35.4) |
Ever had teeth become loose without injury | 73 (16.0) | 73 (19.0) |
Ever diagnosed with dental bone lossa
| 97 (21.3) | 96 (25.0) |
Ever diagnosed with oral cancer | 4 (0.9) | 2 (0.5) |
Oral health self-care
Self-reported oral health self-care behaviors among dentate respondents are presented in Table
3. Two thirds of dentate respondents met the ADA recommendation to brush their teeth daily, but only 27.6% reported daily flossing. The median number of times people flossed per week was 3, as was the median number of days per week they flossed. In total, only 85 people (22.1%) met ADA recommendations for both daily brushing and flossing; 77.9% failed to meet this basic daily hygiene recommendation.
Table 3
Oral health behaviors among dentate respondents
Met ADA recommendation: brush twice daily | 252 (65.6) |
Met ADA recommendation: floss 7 days week | 106 (27.6) |
Met ADA recommendation: brush twice and floss daily | 85 (22.1) |
Visited dentist or dental clinic in last 12 monthsa
| 258 (67.2) |
Had teeth cleaned in last 12 monthsb
| 242 (63.0) |
In terms of professional dental care, approximately two-thirds had their teeth cleaned in the past 12 months and a similar proportion had visited a dentist in the past year.
Other oral health risk behaviors
The oral health survey was conducted up to 8 months after smokers had enrolled in the tobacco quitline program. By the time of this assessment, approximately 40% reported no longer smoking, but most continued to smoke and a small number reported use of other forms of tobacco products (see Table
1). The majority of respondents also reported alcohol use (74.3%) and 63.3% (n = 288) reported daily alcohol consumption. Thirty-four percent of women (n = 100) and 40.3% percent of men (n = 64) had AUDIT-C scores indicative of problem drinking (i.e., scores ≥ 3 for women and 4 for men).
Overall, respondents had moderate to high levels of motivation to take good care of their oral health. Motivation levels by specific oral health self-care behaviors of interest are reported in Table
4.
Table 4
Motivation for oral health care
a
Take good care of my teeth and gums | 5.7 (1.4) | 5.8 (1.2) | 5.6 (1.2) |
Floss my teeth daily | 5.2 (2.0) | 5.5 (1.7) | 5.2 (1.8) |
Brush my tongue daily | 5.9 (1.7) | 5.9 (1.7) | 5.8 (1.7) |
Brush my teeth daily | 6.4 (1.4) | 6.6 (1.0) | 6.5 (1.1) |
See a dentist in the next 6 months | 5.8 (1.8) | 6.1 (1.5) | 6.0 (1.5) |
Moderate interest in future oral health promotion intervention was also observed. Approximately half (n = 198, 43.5%) of all respondents said they were interested in learning more about ways to improve their oral health, with many interested in receiving this information either over the Internet (n = 223, 49.0%) or by mail (n = 213, 46.8%). Fewer were interested in talking with a quit coach about ways to improve their oral health (n = 132, 29.0%), but this may reflect the fact that many participants had completed their quitline counseling program at the time of the survey.
Interest in oral health promotion differed between dentate and edentulate smokers. More dentate smokers were interested in learning how to improve their oral health (47.0% vs. 28.8%, p = .006) and interested in receiving materials by Internet (51.6% vs. 38.8%, p = .054), but fewer dentate respondents were interested in receiving oral health materials by mail (45.2% vs. 59.7%, p = .029). There was no difference in respondents’ interest in talking with a quit coach about their oral health (29.4% [dentate] vs. 29.9% [edentulate], p = .94).
Comparison with state-funded quitline population
Compared to smokers sampled from a state-funded quitline [
8], participants were more likely to be non-Hispanic white (OR = 1.36, 95% CI 1.00 – 1.85; p < .05), to have some college education (OR = 2.12, 95% CI 1.67-2.69; p < 0.001), to have annual household incomes at or above $40,000 (OR = 6.23, 95% CI 4.81-8.06; p < 0.001), and to have dental coverage (OR = 5.94, 95% CI 4.49-7.86; p <0.001). Differences in oral health indicators were also observed. Fewer participants in the current sample had lost all of their natural teeth (OR = 0.70, 95% CI 0.52-0.96; p = .03) and fewer thought they could have gum disease based on their symptoms (OR = 0.58 95% CI 0.44-0.76; p < 0.001), but more reported they had been treated for gum disease in the past (1.62, 95% CI 1.24-2.11; p <0.001). A similar proportion of each group had been diagnosed with oral cancer (0.9% vs. 1.0%, OR = 0.89, 95% CI 0.38-2.10; p = .97).
Finally, differences in oral health behaviors, motivation and interest in oral health promotion services were also observed. A greater proportion of commercial quitline callers met ADA recommendations for brushing (OR = 1.4 95% CI 1.09-1.86; p = .01), flossing (OR = 1.53 95% CI 1.14-2.06; p = 0.005), or daily oral hygiene (combined brushing and flossing) (OR = 1.52 95% CI 1.10-2.10; p = .01); and 20% more participants had visited the dentist last year (OR = 1.96, 95% CI 1.53-2.51; p < .001). Commercial quitline participants were also more motivated to see a dentist (mean score 5.8 vs. 5.3, p < .001) and floss daily (mean score 5.4 vs. 5.0, p = .01), but no more motivated to brush daily (6.3 vs. 6.4, p = .42). They were also less interested in oral health promotion services than were callers to the state quitline program, defined as interest in learning how to improve their oral health (OR = 0.57, 95% CI 0.45-0.72; p < .001), interest in talking with a quitline counselor (OR = 0.44, 95% CI 0.35-0.56; p < .001), or interest in receiving oral health promotion information by mail or Internet (OR = 0.68, 95% CI 0.52-0.88; p = 0.003).
Discussion
While clear differences exist between smokers seeking services through a commercially-funded versus a state-funded tobacco quitline, the survey results indicate that opportunities to promote better oral health do exist among more economically-advantaged smokers calling a tobacco quitline. For one, most smokers still had some or all of their natural teeth, making preventative care and lifestyle risk factor modification important. Additionally, most smokers had dental coverage (85.1%). This was a significant potential barrier to care among state quitline callers, of whom only 42.4% reported dental insurance, including those covered through Medicaid services which have since been eliminated in Washington. That most of the commercial quitline callers have dental insurance increases the possibility that they could follow through on recommendations for routine professional dental care. Two-thirds of participants had visited a dentist in the past year, but one third had not. This proportion is lower than that observed in the general population residing in the same geographic region (76.0%), based on data from the 2010 Washington state BRFSS [
16]. Educating smokers about the importance of routine dental care and providing referrals for treatment could boost uptake rates. Persons who do not have insurance could be referred to more affordable treatment options, such as care provided through local dental schools.
Even in the absence of professional dental care, opportunities exist to improve smokers’ oral hygiene and lifestyle risk factors. Nearly 80% of those surveyed failed to meet basic daily hygiene recommendations (brushing and flossing) and more than 63% reported daily alcohol consumption. Each of these behaviors place smokers at elevated risk for future periodontal disease, cavities, and oral cancer [
17‐
19] and represent important targets for intervention. In fact, a dual counseling focus on smoking cessation and oral health promotion that addresses these behaviors could have a positive synergistic effect on both tobacco cessation
and improved oral health outcomes. This focus could be integrated into a standard cognitive behavioral intervention for nicotine dependence treatment. It is not uncommon to advise smokers preparing to quit to have their teeth cleaned (i.e., to remove tobacco stains and start fresh), to brush their teeth or floss as a way of coping with urges to smoke after quitting, or to limit/avoid alcohol use since it interferes with one’s ability to stop using tobacco. This advice could be extended to include discussion of the interconnection between one’s oral health and their overall health, the importance of proper daily hygiene and use of fluoride products, and the synergistic effects of tobacco and alcohol on oral cancer risk [
18]. Smokers can also be encouraged to chew sugar-free gum. Chewing gum is another common strategy for coping with cravings to smoke, and sugar-free gum can reduce plaque and decrease one’s risk of dental caries [
20‐
22].
A combined oral health promotion-tobacco cessation program would also be responsive to the U.S. Surgeon General’s national call to action to promote oral health [
23]. Our data indicate many smokers would be receptive to this intervention. Most smokers in the current survey endorsed moderately high levels of motivation for taking good care of their teeth and gums and nearly half said they were interesting in learning more about how to improve their oral health. In fact, since many elements of this intervention could be interwoven into a standard smoking cessation program without delineating it as a separate intervention, all smokers could receive this integrated intervention. These efforts could never replace the important preventative and acute care provided by dental health professionals, but this expanded health focus could be an innovative way to augment this care and better meet the multi-factorial health needs of smokers.
Clearly, future research must confirm the effectiveness of the proposed intervention strategy, but data collected from two separate representative tobacco quitline populations now support the need and opportunity to pursue this effort in conjunction with both publically and commercially funded tobacco quitline programs.
The current survey is strengthened by inclusion of a large group of consecutively sampled quitline participants and our ability to compare outcomes across diverse quitline populations. Because all participants were from Washington state, it is possible that the results may not generalize to smokers in other geographic areas, but we are unaware of any reason that callers in Washington would have systematically worse oral health self-care behaviors than smokers in other states. Furthermore, the data suggest that participants’ self-reported oral health indicators (i.e., edentulism, self-rated oral health) are similar to those reported among smokers in other surveys [
6,
15], providing more confidence in the generalizability of these results.
Acknowledgements
We are grateful to the National Institute of Dental and Craniofacial Research (R21 DE19525, J. McClure, PI) and to the Group Health Research Institute for funding this work. The authors also thank Julia Anderson and the Group Health Research Institute’s Survey Research Program for their help with data collection, and Susan Zbikowski, PhD at Alere Wellbeing (a leading US provider of tobacco quitline services) for her collaboration on our earlier study examining outcomes among state-funded quitline providers. Finally, we thank the Washington State Quitline for their assistance with this line of research and Annie Shaffer for her assistance with the manuscript preparation.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
JBM is responsible for developing the research concept, securing research funding, drafting the survey, interpreting the results and drafting the manuscript. KR assisted in drafting the survey content, analyzing the data, and preparing the manuscript. JSJ provided day-to-day project oversight at GHRI, assisted in the survey design, and provided comments on the manuscript. SLC assisted in data interpretation and preparation of the manuscript. All authors read and approved the final manuscript.