Smoking cessation interventions in NHS primary dental care: the ENHANCE-D trial

Smoking is a major contributor to health inequalities and a key risk factor for oral cancer and severe gum disease (periodontitis).
Smoking cessation interventions in NHS primary dental care: the ENHANCE-D trial
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What is the research about?

Our BDJ paper explores patients' and dental professionals' perspectives of smoking cessation interventions including: electronic cigarettes (ECs); nicotine replacement therapy (NRT) and very brief advice (VBA) delivered in NHS primary dental care (high street dental practices). The paper is part of a larger randomised controlled clinical trial known as the 'ENHANCE-D' study: ENHANCing smoking cEssation interventions in Dentistry.  More information about the  ENHANCE-D study can be found on the trial website.

ENHANCE-D logo

Why is this research important?

We believe dental teams are well placed to offer smoking cessation interventions as they  represent one of the few healthcare settings that asymptomatic patients regularly attend. Providing more intensive smoking cessation interventions beyond 'very brief advice' (VBA), may offer patients additional opportunities to quit smoking as well as upholding the 'making every contact count' ethos found elsewhere within the NHS.  Furthermore,  a VBA approach can double a patient's success with quitting smoking (1).

As well as exploring the effectiveness of different smoking cessation interventions and their influences upon health, it's important to know what people think about using these interventions and for us to try to identify facilitators and barriers to their potential future use in an NHS high street dental practice environment.

How were the data collected?

We used interviews with trial participants who were randomised to receive electronic cigarettes, NRT and/or VBA interventions. We additionally explored the views of members of the dental team as well as NHS commissioners.  We interviewed some patients around 1 month following intervention start ('early') and some at approximately 6 months following intervention start ('late'). Fig 1 is taken from our paper.

Flowchart for participant involvement in the ENHANCE-D trial

Fig 1. The qualitative element of the wider ENHANCE-D trial

We used Normalisation Process Theory (NPT) as a framework to guide our analysis. This theory provides a number of 'constructs' to help us to understand how actions and practices become embedded and integrated into their social context (2).  We interviewed 24 patients across the study arms, 13 dental professionals and 3 NHS commissioners. 

What did we find?

Below we present a brief overview of some of our main findings. Please be sure to download our BDJ paper (which is open access) to explore all the themes and sub-themes  which are supported by additional evidence.

  • Motivating factors for smoking cessation interventions (NPT: Coherence)

'Coherence' explained the motivating factors for smoking cessation. These factors were often associated with participants' general and dental health as well as potential financial benefits of quitting and the convenience of using certain interventions.

"Just having the EC is more beneficial and less harmful for my health than having cigarettes" (patient, female, 55+ years, EC, Birmingham)

"It's not obvious [NRT patch]. Slap it on in the morning and you don't have to think about it all day" (patient, female, 35-54 years, NRT, Dundee)

  • Patient demotivators for smoking cessation interventions (NPT: Cognitive participation)

'Cognitive participation' helped to explain patient demotivators towards the interventions (as well as their benefits as we outline in the paper). 

"I think everything's more attractive to people if it's free...people would be less likely to pay out of their own pocket for it [EC]" (patient, female, 35-54 years, EC, Glasgow) 

"...I think anybody you speak to who has smoked, will tell you that they have, when they've given up, they've put on a lot of weight" (patient, female, 55+ years, NRT, Newcastle)

  • Management of smoking cessation in NHS dental practices (NPT: Collective action)

'Collective action' refers to the work that participants do to make an intervention function. A common issue for dental teams  was the limited time to accommodate smoking cessation interventions  as part of routine clinical activities.

"It's not something that we can deliver within clinical time and still stick to time" (dental nurse, Scotland)

"...the more time you spend delivering your intervention, the less time you are earning money...there would need to be some sort of financial incentive to cover the time spent doing that..." (dentist, Northern England)

  • Strategies for viability of smoking cessation in NHS dental practices (NPT: Reflexive Monitoring)

'Reflexive monitoring' refers to participants' reflections of the interventions under study. Areas identified included the supply and logistics of distributing EC and NRT interventions, alongside the training needed to help prepare dental teams to deliver these options.

"...so, the first thing will be training...so you can't just say to them, provide this information...that is a difficult conversation so use like some form of mentorship...so, there's a big training programme behind this" (NHS commissioner, Southern England)

"...there's very basic things like getting the stock out to them and who would do that and, if it was EC's for example, how would they be procured? How would you even choose which one you would use? How would you make sure it was safe and all that kind of stuff?" (NHS commissioner, Scotland).

Who might use our research findings?

We chose the BDJ for our paper as we hope our findings will be read and considered by a large number of dental professionals in the first instance. We have additionally made the paper open access in order to reach the wider dental profession, other interested health care professionals, academics and policy makers both in the UK and internationally. We hope this will help to disseminate our findings more broadly and that our study will contribute to the growing global body of evidence in this important area.

Please feel free to share this blog (using the button above) and the link to our BDJ paper with your colleagues!

Acknowledgements

We'd like to thank all our colleagues working on the ENHANCE-D trial (particularly Anthony Weke and co-authors) and the many patients who volunteered to participate in this additional element of the study.

We acknowledge the support of our funder, the National Institute for Health and Care Research (NIHR) Health Technology Assessment (HTA) programme (Reference No: NIHR129780).  The views expressed in this blog and in the published paper are not necessarily those of the NIHR or the Department of Health and Social Care.

References

(1) Holliday R, Hong B, McColl E, Livingstone-Banks J, Preshaw PM. Interventions for tobacco-cessation delivered by dental professionals. Cochrane Database Syst Rev 2021;2: CD005084.
(2) May C, Finch T. Implementing, Embedding, and Integrating Practices: An Outline of Normalization Process Theory.  Sociology 2009; 43:535-554.
Blog created (offline): 10.09.2024. BDJ paper published: 20.09.2024. Blog published: 30.09.2024

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Go to the profile of Heather Bradbury
about 1 month ago

Thank you both for sharing this summary of your article on this very important topic! The article has also been selected for inclusion in the Research Insights section of an upcoming BDJ issue.

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Dental Public Health
Life Sciences > Health Sciences > Clinical Medicine > Dentistry > Dental Public Health
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Life Sciences > Health Sciences > Clinical Medicine > Dentistry > Dental Business > Dental patient management
Tobacco cessation in dentistry
Life Sciences > Health Sciences > Clinical Medicine > Dentistry > Dental Public Health > Tobacco cessation in dentistry
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