Dental staff and patient attitudes about nicotine replacement therapy samples in dental care: A National Dental Practice Based Research Network study

Abstract

Objectives:

Cigarette smoking negatively affects oral health. Nicotine replacement therapies (NRT; e.g., nicotine patch or lozenge) and brief interventions (e.g., Ask-Advise-Refer; AAR) can improve cessation outcomes but are underutilized. NRT sampling (NRTS) increases NRT utilization by providing patients with samples of NRT as part of routine healthcare. Ask-Advise-Refer is a brief intervention where practitioners: Ask patients about tobacco use, Advise those using tobacco to quit, and Refer to the state quit line. The objective of this qualitative study was to explore dental care practitioners’ and patients’ attitudes and experiences regarding tobacco cessation treatment and perceptions of two brief intervention models, assessed separately: NRTS and AAR.

Methods:

Twenty-four dental care practitioners and nine patients, recruited through the National Dental Practice-Based Research Network, participated in semi-structured telephone interviews. Interviews assessed experiences with tobacco use intervention and attitudes toward NRTS and AAR. Thematic analysis identified emergent themes related to feasibility and acceptability of NRTS and AAR.

Results:

Practitioners varied on how they address tobacco use, from systematically to idiosyncratically. Some practitioners recommend NRT; few had prescribed it. Practitioners had favorable attitudes toward AAR and NRTS, with most believing that both interventions would be acceptable and feasible to implement. Concerns regarding AAR were time and patient resistance to discussing tobacco use. Concerns regarding NRTS were patient resistance to using NRT, side effects or medication interactions, and capacity to provide follow-up. Patients reported that oral health practitioners generally ask about tobacco use but do not provide interventions. Patients were open to discussing their tobacco use with practitioners and had favorable attitudes about NRTS.

Conclusions:

This formative work suggests that NRTS and AAR may be feasible to implement in dental care settings. Future studies are needed to assess the effectiveness and implementation potential of NRTS in dental care settings.

Introduction

Cigarette smoking negatively affects oral health including causing: oral cancer, periodontal disease, tooth loss, and bone loss.¹ Tobacco cessation reduces the incidence and progression of oral health problems.^2,3 Novel approaches for oral health practitioners to encourage use of evidence-based tobacco cessation treatment are needed.

Tobacco cessation interventions by oral health practitioners are effective but rarely delivered. A Cochrane review of tobacco cessation intervention studies conducted in oral healthcare settings found, with moderate certainty, that interventions including nicotine replacement therapy nearly tripled abstinence rates compared to usual care/brief advice.⁴ Despite tobacco cessation treatment in oral healthcare settings being effective, oral healthcare practitioners rarely provide them. In the United States (US), only 31% of people who smoke who visited the dentist in the past year reported that they were advised to quit, and only 4% were advised to use tobacco cessation medication.⁵ The American Dental Hygienists Association (ADHA) recommends that oral health practitioners: Ask about tobacco use, Advise patients using tobacco to quit, and Refer people who use tobacco to state quit lines (Ask-Advise-Refer; AAR).⁶ US dentists and hygienists report high rates of asking (90%) and advising (76%), but only 45% assisted with cessation and only 25% prescribed cessation medication.⁷

People who smoke rarely use validated tobacco cessation treatments.⁸ In the US, during quit attempts, <30% use medication and <10% receive counseling.⁹ Among the 7 FDA-approved tobacco cessation medications, Nicotine Replacement Therapies (NRT) are the most widely used.⁹ In the US three of the five types of NRT (nicotine patch, gum, and lozenge) are available over the counter (OTC). In the US, NRT can be prescribed by anyone with an unrestricted license (e.g., medical doctors, dentists, nurse practitioners, physician assistants) and, in some states, by pharmacists. NRT reduces withdrawal and craving^10,11 and meta-analytic evidence from 100+ trials shows a doubling of long-term abstinence with NRT use.^12,13

One novel strategy for connecting dental patients with tobacco cessation treatment during oral healthcare visits is NRT sampling (NRTS). NRTS refers to providing short, starter packs of NRT, which can be added to existing AAR protocols. NRTS is distinct from a full course of NRT: the intent is to engage people who smoke in the process of quitting, without a requirement or expectation to quit. It is designed to reduce barriers to obtaining and heighten acceptance of NRT, and to enhance motivation and self-efficacy.¹⁴ It is rooted in marketing research, which shows that free samples of products increase positive opinion and use.¹⁵ NRTS can induce quit attempts even in those unmotivated to quit and has been shown in primary care patients to increase long-term abstinence.^16,17

The investigation was part of a study to determine the feasibility and acceptability of procedures planned for a clinical trial about NRTS (NCT05627596). The aim of the current study was to explore key informant (patient and practitioner) perceptions regarding: (1) experiences with tobacco cessation intervention in oral healthcare, (2) attitudes regarding nicotine replacement therapy, (3) attitudes regarding the feasibility and acceptability of AAR and NRTS.

Methods

Recruitment

The investigators used a purposeful (nonprobability) sampling approach¹⁸ to recruit oral healthcare practitioners (dentists, dental therapists, and dental hygienists) within the National Dental Practice-Based Research Network (National Dental PBRN)¹⁹ through engagement with Network members and practitioners. Two dentist champions from the National Dental PBRN recruited their patients. Study staff emailed an invitation to participate in a telephone interview to interested prospective participants. These messages included study information and the study informed consent document.

Participants

Dentists were eligible for interviews if they were a member of the National Dental PBRN and were affiliated with a practice in the Midwest region. Hygienists were employed at a practice affiliated with the National Dental PBRN. National Dental PBRN members are representative of United States dental practices.²⁰

Patient eligibility criteria include people for whom NRT was not contraindicated and who had the technology required to participate in the future clinical trial. Patients were eligible if they were ≥18 years old, smoked at least 1 cigarette per day, and owned a smartphone. Patients were excluded if they were currently pregnant or breastfeeding, had a heart attack or stroke within the last 3 months, or had used NRT or cessation medication in the last week.

Data collection and analysis procedures

For practitioners, informed consent was obtained verbally at the time of the interview. Patients were emailed a REDCap survey link to obtain written informed consent and demographic information. Interviews were conducted by telephone, audio-recorded, and professionally transcribed. Practitioner interviews occurred between March and June of 2021; patient interviews occurred between May 2021 and January 2022. Interviewers were three clinical psychologists and one health services researcher. Practitioner interviews were approximately 60 minutes. Interviews with patients were approximately 30 minutes. Staff members received $50 for completing interviews and patients received $40 for completing interviews and $10 for completing a demographic survey.

The semi-structured interview guides were grounded in the integrated-Promoting Action on Research Implementation in Health Services (i-PARiHS) framework^21,22 and organized by recipient factors (e.g., practitioners’ past experiences with tobacco intervention and recommending NRT to patients; beliefs about NRT safety), context factors (e.g., perceived barriers to intervening with patients during dental appointments), and innovation factors (e.g., attitudes toward and recommendations for implementing NRTS into dental practices). Interview guides focused predominantly on innovation factors. There were also questions related to planned future clinical trial procedures (e.g., feedback on planned participant remuneration; recommendations for electronic toothbrush brands to be used in the study control condition), which addressed distinct research questions and were not included in analyses for the present study. Example interview questions that were included for analysis in the current study are shown in Tables 1 (practitioners) and 2 (patients). Full interview guides are shown in Appendix A.

Table 1.

Content areas addressed in the staff interview protocols

Content Area (corresponding iPARiHS factor[s])	Sample Interview Question(s)
Experiences counseling about tobacco use (recipient, context)	Could you tell me a bit about your experiences with talking to patients about cigarette smoking?
Experience with and attitudes toward recommending or prescribing NRT to patients (recipient, context)	Do you ever recommend that patients use nicotine replacement therapy– that is, medicinal nicotine products like nicotine patch, gum, and lozenge? Why or why not?
Attitudes and beliefs about providing brief AAR tobacco cessation counseling (innovation)	As part of the FreSH study, all participating dental practices will be encouraged to deliver brief (about 1–3 minute) counseling –“Ask, Advise, Refer”– to all patients who smoke cigarettes. This intervention involves asking all patients if they smoke, advising them to quit smoking, and referring them to the state quit line for treatment. Practitioners would receive training in how to provide the Ask, Advise, Refer intervention with smokers prior to study launch. How do you feel about providing “ask, advise, refer” counseling to your patients who smoke cigarettes?
Attitudes and beliefs about NRT sampling (innovation)	In the FreSH study, we will also be testing the effectiveness of Nicotine Replacement Therapy (NRT) Sampling. NRT sampling refers to providing dental patients who smoke with a “starter pack” of NRT consisting of a 2-week supply of both nicotine patches and lozenges in a routine care visit. What thoughts or reactions do you have about NRT sampling? Do you think it would be feasible to implement NRT sampling in dental practices (e.g., as part of a routine care visit)? Why or why not?

Table 2.

Content areas addressed in the dental patient interview protocols

Content Area (corresponding iPARiHS factor[s])	Sample Interview Question(s)
Tobacco treatment and cessation history (recipient)	Have you ever received counseling, medication, or other treatment to help quit smoking?
Previous experiences with and perceptions of NRT (recipient)	Have you ever tried nicotine replacement therapy (NRT), such as nicotine patches, gum, or lozenges? If yes, what was your experience using those products? Would you be open to using NRT to help quit smoking at some point in the future?
Experiences receiving smoking cessation counseling during dental visits (recipient)	When you go to the dentist, what, if anything, does your dentist or hygienist say about your smoking during your dental visits?
Attitudes toward receiving smoking cessation assistance from a dental care practitioner (recipient, context)	Would you be willing to accept smoking cessation help (e.g., advice or strategies to help quit smoking) from your dentist or someone else at your dentist’s office? Why or why not?
Feedback on NRT sampling (innovation)	Would you be willing to accept a free sample of nicotine patches and lozenges from your dentist? Why or why not? How likely are you to use nicotine patches or lozenges if you were to receive a sample from your dentist?

Data analysis

The study team analyzed the participant transcripts using a directed (deductive) and inductive (hybrid) content analysis^23–26 consisting of two phases. This approach was selected for multiple reasons. Because research questions were grounded in a specific implementation framework, i-PARiHS, and focused on specific questions relevant to trial planning, a deductive approach was relevant for organizing and interpreting qualitative data. However, because NRTS is a relatively novel intervention, which has not previously been examined in dental settings, an inductive approach was also important to identify any new categories the emerged from the data and ensure comprehensive understanding of participant feedback.²⁷ Additionally, as noted above, the parent study also involved multiple research questions related to future implementation and study design for which both describing manifest content of and quantifying frequency of specific participant responses were relevant (e.g., number of patients who endorsed prior use of NRT; number of patients who were not willing to accept NRT samples). Note that although some frequency counts are reported for the purpose of describing the sample and providing additional context and detail, the present study focuses on predominantly on describing contextualized latent themes^25,26,28 within pre-specified content areas.

A deductive approach was used for the first phase of analysis, drawing from the elements of the i-PARiHS framework. The study interviewers (MSD, ELV, SJJ, ZP) developed separate preliminary codebooks for practitioners and patients with initial categories and nested subcategories and codes (where relevant) based upon topics in the interview protocols and organized by content areas and i-PARiHS recipient, context, and innovation factors. In the second phase, the team took an inductive approach following joint review and discussion of transcripts in which raters iteratively added or removed codes and sub-codes to sufficiently capture themes that emerged from interview transcripts. Codebooks for patients and providers are shown in Appendix B. Following group discussions (with SJJ) and consensus on codebook structure and code saturation, two PhD-level raters (MSD & ZP) then independently coded a subset of interview transcripts to assess agreement (interrater reliability K=0.92) using Dedoose software.²⁹ MSD and ZP then coded the remaining transcripts,^24,30 reviewed the text assigned each code, and summarized latent themes for interpretation (or, “themes of meaning”)²⁶ by content area in memos. Findings were then synthesized and reviewed with the study team. Interpretive themes are summarized in narrative form below and in Tables 3 and 4.

Table 3.

Summary of findings and illustrative quotes in practitioner interviews by content area

Content area (iPARiHS factor[s] addressed)	Unites (Example quotes)	Category/subcategory/code	Themes
Practitioners’ experiences counseling about tobacco use (recipient, context)	“I think we have an obligation as practitioners to be able to help educate patients so that if they’re not hearing it this time, they’re hearing it next time, and then the following time, not as a lecture but just as informative information so they know that if and when they are interested in quitting smoking, which everybody knows that it is not good for oral health, that there are resources available.” “I have had many people in the practices I’ve been to that smoke or chew tobacco. I always tutor them in a gentle way, stopping smoking, that it causes periodontal disease and heart disease and all these other things and what chewing will do to your gums and it causes cancer along with cigarette smoking. Usually, it’s taken fairly well.” “ It is a question on our medical health history because the condition of the mouth certainly does—there are risk factors for oral health that are attributed to smoking, and so that’s why it’s important for us to ask these questions on our medical health history. “	Experiences counseling patients about tobacco use (category) Systematic tobacco assessment/counseling protocol (subcategory)	Practitioners acknowledged the importance of tobacco cessation for oral health and routinely intervened but approaches to assessing and intervening varied considerably.
	“it’s not something that we talk about all the time, but if we see a lot of staining on somebody’s teeth, we’ll ask them [about tobacco use].” “ I don’t really come down on them too hard. I only coach them when they show interest in quitting. I will coach them how to quit. “	Experiences counseling patients about tobacco use (category) Inconsistent or unsystematic assessment/intervention (subcategory)
	“In my experiences, most of the people I talk to about either smokeless or smoking tobacco have such an addiction that I think it would take more time than I have to try to counsel or treat them on stopping smoking. They’re not going to listen to me on a one-time basis.”	Experiences counseling patients about tobacco use (category) Challenges or concerns with assessing/intervening about tobacco use (subcategory)	Some practitioners identified challenges or concerns surrounding perceived patient resistance to tobacco counseling.
Practitioners’ experience with and attitudes toward recommending or prescribing NRT to patients (recipient, context)	“I don’t… Because I’m not sure exactly what I would recommend… Is it something that I can recommend? Or how it would work? If that patient can use it? If that’s the best option for them to do? I’m not sure.”	Experiences recommending or prescribing NRT (category) Does not recommend NRT to patients (subcategory)	Some practitioners had previously recommended NRT to patients based on perceptions that it is an effective quit aid for some patients, but prescribing NRT was rare (n=1 practitioner).
	“Yes, if they are interested in and are wanting to quit. Most of the time, they tell us no, they’re not. Yeah, if they do show any interest, we do talk to them about [NRT], and don’t have any samples or anything like that to give out to them, but we just talk about it with them in the chair.” “I’ve had some success with prescribing some medications or using gum”	Experiences recommending or prescribing NRT (category) Ever recommend NRT to or discuss NRT with patients (subcategory) Ever prescribed NRT (code)
	“[I’m concerned about] any possible side effects of [NRT]. If it could like bother your stomach or anything. Any questions that a patient might ask me, or if there could be any allergies or anything like that.”	Experiences recommending or prescribing NRT (category) Perspectives on recommending NRT to patients (subcategory) Any identified concerns about recommending NRT to patients (code)	Some practitioners raised concerns about NRT safety for patients with underlying health conditions or contraindications and others were uncertain about what specific products to recommend.
Practitioners’ attitudes and beliefs about providing brief AAR tobacco cessation counseling (innovation)	“I think the dental office is a good setting to do it. I think that there’s a demonstrable impact that smoking has on dental health, and I think that anything that we can do to be a part of a patient’s overall health is beneficial. I think it’d be very positive thing if we had access to that kind of assistance that we can give to patients.”	Reactions to providing AAR (category) Positive reaction/no concerns about AAR (subcategory)	Most practitioners had favorable reactions and no concerns about offering brief AAR counseling in dental practices and felt that this form of brief intervention would align well with their existing practice and workflow.
	“I think in terms of wanting to do it, it’s something I would. [But] I think there might be some pushback from clinical staff. There’s never enough time for a dental appointment, you know?… Adding another thing, even though it may be one to three minutes, could seem cumbersome to them.”	Reactions to providing AAR (category) Concerns about or negative reaction to AAR (subcategory)	Some practitioners voiced concerns about potential additional time and/or burden it would take for practitioners to implement AAR counseling and potential patient resistance to receiving counseling.
Practitioners’ attitudes and beliefs about NRT sampling (innovation)	“I mean, this sounds like a really nice way to get people on board. Because there’s so many smokers or tobacco users that are hesitant, or they don’t want to say they’re currently quitting then feel like they’re going to let me down. I like the idea that I can provide them something and that they can take home with them and contemplate it without any pressure. I like that.” “Actually having the resources readily available to someone is probably the hardest step or part of starting on a process. If you can give them a little jump on nicotine replacement, like actually providing them with samples or providing them with the opportunity to do something […] you’re putting things in their hands. You’re literally giving them stuff, the product that they need to start—jumpstart the quitting process. I think that’s definitely beneficial, versus where, a lot of times, we just give them a sheet of paper and say, “Hey, go and call this number.”	Reactions to NRT sampling (category) No concerns/positive reaction to NRT sampling as a resource (subcategory)	Most practitioners had favorable reactions or no concerns related to NRT sampling and highlighted the importance of providing a tangible cessation resource to patients.
	“I think that’ll vary. I think some people will be open to it, those people that’ve kind of thought about it and just haven’t had the little push to go that way. I think there’ll be other ones that have no interest and might resent the fact that you’re trying to influence them with that, so I think there’ll be a wide range of reactions.” “I guess if I’m doing the sampling and if it’s effective, then am I prescribing the materials or recommending the materials after that sampling period of time? Am I gonna be the healthcare provider in charge of keeping track of them and seeing that they get what they need, I guess, is my question.” “If there was any possible side effects of it. If it could like bother your stomach or anything. Any questions that a patient might ask me, or if there could be any allergies or anything like that.”	Reactions to NRT sampling (category) Concerns about or negative reactions to NRT sampling (subcategory)	Practitioners raised different concerns about NRTS, including patient resistance to accepting NRT samples, concerns about potential negative side effects or appropriateness of NRT for some patients, and considerations surrounding patient management and follow-up.

Note. iPARiHS = integrated-Promoting Action on Research Implementation in Health Services framework, which informed development of study interview guides. AAR = Ask, Advise, Refer counseling. NRT = nicotine replacement therapy. NRTS = nicotine replacement therapy sampling.

Table 4.

Summary of findings and illustrative quotes from patient interviews by content area

Content area (iPARiHS factor[s] addressed)	Units (Example quotes)	Category/subcategory	Themes
Experiences receiving smoking cessation counseling during dental visits (recipient)	“I think [the dentist] has tried to ask me to. ‘You should probably stop smoking and your teeth will look better and feel better,’ and stuff like that, but nothing extreme.” “[the dentist] does occasionally [say]. ‘You ought to quit smoking. Have you tried the patch?’” “No, [the dentist] knows better than to preach to me. You know what I mean? I’m there to get my teeth worked on. Let’s not talk about my overall health. It’s been touched on. Let’s put it that way.”	Experiences receiving smoking cessation assistance during dental visits (category) Provider talks about smoking during a visit (subcategory)	Most patients reported being asked about smoking and advised to quit smoking by a dental care practitioner, although experiences were mixed.
Attitudes toward receiving smoking cessation assistance from a dental care practitioner (recipient, context)	“I’m open for anything that’s gonna make me quit smoking.” “I just think that [dentists are] knowledge-based, and what they see and experience is something that – I would definitely take their advice.” “[I would accept help] because I like [my dentist], and [my dentist] is very kind and fair.”	Willingness to accept smoking cessation help from dental provider (category)	All but one patient indicated that they would be willing to receive brief cessation help from a dental care practitioner during a dental care visit, which some attributed to positive relationships with practitioners and trust in practitioner expertise.
	“I’m very comfortable. I’ve been going to [my dentist] for so long, and [dentist is] one of the sweetest, nicest people to talk with, and very understanding.”	Comfort talking to dentist about quitting smoking (category) Comfortable having a conversation about smoking (subcategory)	Patients generally expressed comfort in talking to their dental practitioner and emphasized brief and supportive, non-judgmental approaches as factors that may increase comfort talking to their dentist about quitting.
	“I would be okay, but if [the dentist is] very persistent, then I feel uncomfortable.” “Mine is a time issue. That’s why all the counseling’s usually like a half hour or whatever. It’s just I’m a very busy guy. I just probably wouldn’t go to the counseling, to be honest with you.” “I don’t think scaring people into [quitting] works. Like saying ‘Oh look at your lungs. Look at this. Look at that.’ I would say the majority of the population probably doesn’t—that scaring them into quitting doesn’t work, what doctors all seem like they’re doing.”	Comfort talking to dentist about quitting smoking (category) What should providers say about smoking/preferred approach (subcategory)
Feedback on NRT sampling (innovation)	“I just think it would be super convenient because you go to the dentist twice a year. How many people realistically do you know go to the doctor? I go to my dentist more often than I go to my doctor.” “[I’m confident that my dentist has] researched it before she would give me something, whereas when I walk into a store, I have no idea.”	Reactions to NRT sampling in dental practices (category) Willing to accept NRT (subcategory)	Nearly all patients expressed willingness to accept NRT samples from a dental care practitioner, largely because samples were free and convenient and the perception of practitioners as trusted experts.
	“I’m not a big smoker. I smoke maybe about 10 cigarettes a day, so there’s the reason too that I haven’t [tried the patch] because I’m afraid that I might get more nicotine than my body’s used to.” “[I would use the NRT sample] as long as [the dentist] tells me it won’t interfere with the medication I’m already taking.”	Reactions to NRT sampling in dental practices (category) Challenges/concerns with NRT sampling (subcategory)	Some patients expressed concerns about NRT safety and had questions about how to use NRT correctly.
	“How will it affect me? From what I understand, basically, it’s just a habit. You’re used to having that cigarette in your hand, cigarette in your mouth, besides the nicotine. If you’re getting the nicotine elsewhere—I really don’t know how to explain it. How would it keep me from not want to actually light one up and put it in my mouth?” “I know there’s different milligrams on it. Since I’m such a high smoker, it needs to be a high—you don’t want them to go, ‘Well, here’s a free sample of a two-milligram or three-milligram.’ What’s that gonna do?”	Reactions to NRT sampling in dental practices (category) Information you would like about NRT (subcategory)

Note. iPARiHS = integrated-Promoting Action on Research Implementation in Health Services framework, which informed development of study interview guides. NRT = nicotine replacement therapy. NRTS = nicotine replacement therapy sampling.

Results

Participants

Study participants included 12 dentists, 12 staff (11 dental hygienists and one dental therapist), and nine patients. Most of the dentists (80%) were male; 67% identified as White (15% Asian, 8% Hispanic/Latino). For staff, the majority were female (91%); 55% identified as White, 27% biracial, 9% Black, and 1% did not disclose race.

Patients were majority (56%) female and identified as of White race (78% identified as White, the rest did not disclose their race). Of note, eight of nine patients came from a single private practice. With regards to smoking history, the majority (89%) had tried to quit smoking in the past, many more than once. Only one had ever used smoking cessation counseling, 56% (5/9) had previously tried NRT.

Practitioner Interviews

Practitioner interview findings are summarized in Table 3, organized by study content area (designated a priori based on interview guides and corresponding iPARiHS implementation factors). Below, we provide a narrative summary of latent themes identified within each content area from the coded interview data.

Practitioners’ experiences counseling patients about tobacco use (recipient and context factors)

Two overarching themes emerged for the content area addressing practitioner experiences with counseling patients about tobacco use. First, practitioners described regularly counseling patients on tobacco use due to perceived importance of tobacco cessation for oral health but approaches varied considerably. All practitioners had some experience talking with patients about smoking. Most practitioners reported comfort counseling patients about tobacco use; only two (one dentist and one hygienist) reported not being confident. No interviewees reported that counseling about tobacco use was not part of their job or that they lacked the knowledge to intervene. Many interviewees underscored the importance of educating patients on tobacco use and helping patients quit as a part of patient care.

Several practitioners reported their practice conducts systematic assessment of smoking status as part of regular visits, often via a medical history form. Some interviewees reported asking about interest in quitting smoking/tobacco use to all patients who indicate they use tobacco. Others reported an inconsistent approach triggered by apparent effects of smoking on oral health or by patient request; one explained,

“it’s not something that we talk about all the time, but if we see a lot of staining on somebody’s teeth, we’ll ask them [about tobacco use].”

[Dentist]

Some practitioners described addressing tobacco by referring to external resources (e.g., quit lines, medical providers). Many staff members reported no formal training in tobacco cessation counseling. Of those with training, most received it while in school, while a few staff members took continuing education courses, trainings from quit lines or as part of other research studies.

Finally, although few interviewees expressed specific challenges or problems with counselling patients about tobacco use, some practitioners acknowledged patient resistance to talking about smoking as a potential issue. One interviewee commented,

“Most people think it’s a medical issue, so when you start talking about it at the dentist, a lot of people don’t really like that aspect of it.”

[Dental hygienist]

One dentist expressed a belief that patients need more intensive intervention than they could provide during a dental visit.

“Most of the people I talk to about either smokeless or smoking tobacco have such an addiction that I think it would take more time than I have to try to counsel or treat them on stopping smoking.”

[Dentist]

Experiences recommending or prescribing NRT to patients (recipient, context)

As shown in Table 3, two overarching themes emerged with respect to practitioners’ experiences with recommending NRT to patients. First, although some recommended NRT due to perceptions of its effectiveness, prescribing NRT was uncommon. Most respondents reported having recommended NRT to at least some of their patients who smoke, but only one dentist had prescribed it. Several interviewees reported no concerns about recommending NRT, usually citing patients’ successful quit attempts using NRT and beliefs about its efficacy for smoking cessation. A few interviewees reported that they never recommended NRT.

Second, some providers expressed concerns about recommending NRT, which included being unsure what to recommend, perceived patient resistance, concerns about side effects and contraindications, and being unable to provide follow-up care for tobacco cessation. Some perceived evaluation of contraindications, side effect management and follow-up care to be the purview of medical providers.

Attitudes and beliefs about providing brief AAR tobacco cessation counseling (innovation)

Two overarching themes emerged in this content are. First, practitioners had largely favorable reactions toward AAR and felt that it aligned well with practice workflow. Several indicated that these practices aligned with their scope of practice and professional values, and that the proposed interventions had potential to improve their patients’ oral health. Other interviewees emphasized the value of AAR intervention trainings to practitioners and its potential to standardize their approach to patients who use tobacco. For example,

“If I’m trained or I have some more specific ways to do it, I could see doing it more than I do now. Having a very specific [plan] laid out, a one- to three-minute presentation and someplace to refer them to would make it easier to do, I believe.”

[Dentist]

Second, although most practitioners had no concerns about offering AAR and felt that this brief intervention would align well with their workflow, some interviewees expressed concerns including patient resistance and the anticipated additional time and/or burden needed to provide AAR counseling. As expressed by one interviewee,

“I think there might be some pushback from clinical staff. There’s never enough time for a dental appointment, you know?… Adding another thing, even though it may be one to three minutes, could seem cumbersome to them”

[Dentist]

Attitudes and beliefs about NRT sampling (innovation)

Similar themes emerged from practitioner feedback in the NRT sampling content area, such that 1) most interviewees expressed favorable reactions and 2) practitioners voiced some minor concerns surrounding provision of NRT samples – most related to patient resistance and considerations for patient safety and management. Most interviewees reacted favorably to NRTS and thought it would be feasible to implement. Several interviewees indicated that patients may be open to receiving NRT samples primarily because, as described by one dentist,

“[offering samples] would be helpful for people to experiment and have familiarity with them before they actually engage with a counseling program.”

[Dentist]

In discussing potential benefits of NRTS for patients, several practitioners emphasized the non-judgmental approach of offering NRT samples to all patients who smoke cigarettes. They also acknowledged ease of fitting NRTS into existing workflows because if samples are given to all patients who smoke the practitioner does not need decide to whom to distribute them.

As noted above, another theme related to practitioners’ concerns related to offering NRT samples. Some practitioners expressed concerns about NRTS. The most prominent concern was patient resistance to discussing smoking cessation. Other concerns included management of NRT side effects and the appropriateness of NRT for some patients (e.g., those with psychiatric disorders or other chronic health conditions). Interviewees also raised other concerns, although these tended to be minor and only expressed by one or two individuals. For example, some interviewees raised concerns about the time it would take to integrate NRTS into workflows, questioned whether the dental practice would be responsible for managing any future NRT the patient wanted, and cited concerns about sustainability and potential costs to patients for NRT following the samples as potential challenges to implementation.

Patient Interviews

Patient interview findings by content area are summarized in Table 4. As above, the following section provides a narrative summary of findings focusing on themes within each content area.

Receipt of smoking cessation counseling as part of dental care (recipient)

With respect to patient experiences with smoking cessation counseling in dental care, the dominant theme was as follows: most patients reported being advised to quit by a dental care practitioner at some point, although experiences varied considerably. The majority of patients reported talking to their dentist about quitting smoking. Most patients described these conversations as pertaining to tobacco use being detrimental to oral health. As described by one patient,

“I think [the dentist] has tried to ask me to [quit]. ‘You should probably stop smoking and your teeth will look better and feel better,’ and stuff like that, but nothing extreme.”

[Patient]

Only two patients reported ever having a dentist discuss cessation medications, but none had been specifically referred to resources or prescribed these medications. Another interviewee indicated that their dentist asked about smoking but did not routinely provide cessation advice or counseling. This patient attributed the dentist’s non-intervention to understanding that the patient was not interested in discussing overall health:

“No, [the dentist] knows better than to preach to me. You know what I mean? I’m there to get my teeth worked on. Let’s not talk about my overall health. It’s been touched on. Let’s put it that way.”

[Patient]

Attitudes toward receiving smoking cessation assistance from a dental practitioner (recipient, context)

Two dominant themes emerged from patient responses in the content area assessing attitudes toward receiving smoking cessation assistance in dental care. First, all but one of the patient interviewees indicated that they would be willing to receive brief cessation help from a dental care practitioner. Patients were also open to cessation help from others in the dentist’s office, such as hygienists and receptionists. Reasons for their willingness to receive brief counseling from a dentist or hygienist included perceived expertise of the dentist. For example,

“I just think that [dentists are] knowledge-based, and what they see and experience is something that – I would definitely take their advice”

[Patient]

Others said their positive relationship with the dentist would make them willing to accept help. As noted by one patient,

“[I would accept help] because I like [my dentist], and [my dentist] is very kind and fair.”

[Patient]

Second, although most patients expressed comfort in discussing quitting with their dentist, and most did not have opinions about how the dental practitioners should approach these conversations, some interviewees emphasized that brief and non-judgmental approaches to intervening and avoiding fear-based approaches may increase their comfort. For example, as noted by one interviewee

“I don’t think scaring people into [quitting] works. Like saying ‘Oh look at your lungs. Look at this. Look at that.’ I would say the majority of the population probably doesn’t—that scaring them into quitting doesn’t work, what doctors all seem like they’re doing.”

[Patient]

Feedback on NRT sampling (innovation)

In the content domain related to patient feedback on NRT sampling, two themes were evident. First, nearly all patients expressed willingness to accept NRT samples from their dentist’s office, which was often attributed to convenience and trust in their dentist. Patients reported several potential benefits with getting NRT from a dentist; some were glad the NRT would be provided for free and thought it would be convenient in that it would save them a trip to the doctor, with one stating

“I go to my dentist more often than I go to my doctor.”

[Patient]

Patients differed in responses when asked specifically about how they would use NRT samples. One said they would use it to try it and see if they liked it, a few were not sure how or if they would use it, and several said they would use it to make a quit attempt.

The second overarching theme in this content area related to NRT safety concerns and uncertainty surrounding appropriate use. Several patients had concerns about the safety or side effects of NRT. Concerns included interactions with other medications, side effects, and using the correct dose. To address these concerns, patients mentioned information that would be useful to provide with the samples. Several asked for explanations of the side effects of NRT or for the dentist to confirm that NRT does not interact with their other medications, others asked for length of medication course and dose. One patient also specifically noted that it might be difficult to get refills from the dentist if needed.

Discussion

Dentists, staff at dental practices and patients were interviewed about their attitudes towards addressing smoking in dental practices and about two potential interventions to be provided in dental practices: AAR and NRTS. In general, oral health practitioners believed they should be addressing smoking, patients felt that addressing smoking in dental practices was expected and welcome, and there was enthusiasm among patients and practitioners about AAR and NRTS.

Consistent with population survey data,⁷ practitioners in our sample reported that they assess smoking status but inconsistently intervene due to lack on knowledge of cessation treatments and fear of patient resistance. Patients reported similar experiences, saying smoking is assessed but they rarely receive concrete help despite being open to it. More work needs to be done to bridge the gap between patient willingness to have smoking addressed,³¹ and practitioner perceptions that patients are unwilling. Practitioners requested training about smoking cessation treatment, including management of side effects. Patients wanted practitioners to address smoking non-judgmentally and to provide information and resources.

AAR was acceptable to practitioners because it was short, protocolized and fit within existing workflows. The US Preventive Health Services Clinical Practice Guideline for Treating Tobacco Use and Dependence found brief interventions increase long term abstinence by 30%.¹² The effectiveness of interventions increases when counseling is combined with medication. Interventions in the dental setting that include NRT increase abstinence nearly three-fold compared to usual care.⁴ Another concern among practitioners was billing for interventions that are provided. If settings can bill medical codes, practitioners can be reimbursed for counseling about tobacco use (CPT codes 99406 <10 minutes and 99407 >10 minutes).

Both practitioners and patients liked NRTS. Practitioners felt that patients would like samples and it would be simple to include samples in current workflows if they are given to all people who smoke regardless of interest in quitting. Practitioners felt samples would make it easier to discuss smoking because the purpose would be to give patients something helpful instead of shaming them. Patients thought samples would be convenient. Patients were interested in using samples to try the product and potentially to support a quit attempt. Both patients and practitioners had concerns about the safety of NRT, in particular as it relates to interactions with other medications and side effects. Medication interactions with NRT that cause increased risk to the patient are rare.³² The active ingredient in NRT is nicotine, which all patients would already be ingesting by smoking so there should be no additional risk of drug interactions with NRT. Over the counter designations for many NRT products should reassure practitioners and patients that side effects are mild. In fact, in a study of NRTS conducted in primary care practices, there was not a single serious adverse event due to NRTS.¹⁶ Nonetheless, if NRT sampling becomes common, practitioners will need education to address patient questions about the products.

Findings of this study should be interpreted in the context of limitations. This is a qualitative study and is intended to be hypothesis generating, not a representation of the population of dental patients and practitioners. This study only sampled practitioners and staff from the Midwestern United States, and most patients came from one dental practice. Attitudes regarding addressing tobacco were similar globally to those expressed in the current study. In a systematic review of dental professional behavior internationally, across studies, oral health professionals were found to believe tobacco use should be addressed in oral healthcare but few followed clinical practice guidelines to address tobacco use among their patients and knowledge of NRT was low.³³ At present, there is not a clear path for paying for NRT samples through insurance United States reimbursement structures, although, if effective, NRTS may be cost-saving for countries with socialized medicine. In primary care, NRTS cost $75 and was associated with a lifetime reduction of healthcare expenditures of $1065.³⁴ Evidence that NRTS is effective in oral healthcare could be used to advocate for policies to allow healthcare settings to provide point of care medication samples.

In conclusion, both oral health practitioners and patients feel smoking should be addressed in oral healthcare. Protocolized treatments such as AAR are acceptable to oral health practitioners due to fitting well into existing workflows. NRTS is also acceptable to patients and practitioners because it is perceived as convenient, simple to administer, and may motivate more conversations between patients and practitioners about tobacco use as well as more use of tobacco cessation medication by patients. A future clinical trial is planned to test the effectiveness of AAR + NRT sampling in dental practices (NCT05627596).

Data Availability Statement

Research data are not shared due to concerns about identifiability of the research participants from the qualitative interview data.