Can Tobacco Cessation Quitlines Improve the Use of Dental Health Care?

In this issue of AJPH, McClure et al. (p. 689) describe the use of a stratified semipragmatic trial design to evaluate the effectiveness of the Oral Health 4 Life (OH4L) program offered in conjunction with a quitline smoking cessation program. The oral health component included oral health messaging, scripted oral health counseling, and online or mailed oral health materials. Messages included benefits of good oral health and recommendations for managing tobacco cravings through use of good oral hygiene behaviors. Participants also received a toothbrush, floss, and sugar-free gum. Referral information to local dental providers was provided. The aims of the study were to determine whether the intervention would increase smoking cessation and, at the same time, increase utilization of professional dental care. Authors report that integrating the OH4L program into the quitline infrastructure was not an effective strategy for increasing the use of professional dental care among callers.

REVIEW OF THE METHODOLOGY

Before diving into the results of this study, a brief review of the methodology is warranted. Some readers may struggle with what the authors described as a randomized “semipragmatic” trial for evaluating the intervention. Pragmatic randomized trials attempt to help determine effects of an intervention under usual conditions purporting the results can better help with making health resource allocation decisions.¹

Two design limitations included no operational definition for a socioeconomically low-resource community and no initial baseline of the population. Assuming smoking cessation strategies would automatically translate into increased professional dental care utilization, such as connecting smokers with low-cost treatment resources in their local community, was flawed. Dental care can be quite expensive, even with some forms of dental insurance. And for many, the ability to afford either a dental plan or low-cost dental services has far-reaching repercussions for dental health. Financial barriers to preventive dental care is reported more often than with any other type of health care, regardless of age, income level, or type of insurance.²

Culture, region, economics, access, and other social determinants of health often make knowledge irrelevant as people sort out personal dental concerns unique to their own situations. Although oral health education is positively associated with improved knowledge and attitudes toward oral care, it has not been found to be sufficient in increasing dental care utilization, especially in socioeconomically disadvantaged communities.³ The authors report that provider stipulations did not allow for any additional changes to the existing quitline infrastructure other than including messaging, scripted counseling, and referrals. If health promotion activities known to empower individuals and the community to achieve meaningful and improved oral health outcomes were included, it would have likely brought about a higher quantum of utilization to the targeted communities.

EFFECTIVENESS OF QUITLINES

Although the results of this study were highly confounded, they do lead us to rethink the types of programs that produce behavior change in patients with poor health. Although quitlines have been found by some researchers to be effective, the authors should also point out that there are studies that contradict that claim, even when the programs were delivered in a real-world setting (pragmatic approach).^4,5 Those researchers who contradict that claim report that participants with chronic diseases and young adults were less likely to quit after participating in a quitline.^4,5 Knowing more about the population is critical to developing effective interventions, and this was not readily evident in the authors’ reported limitations of this study.

Although the authors concluded that integrating an intervention such as the OH4L was not an effective strategy for increasing the use of professional dental care among quitline callers, this study does represent an important first step forward in developing innovative approaches to improving the oral health of Americans. Oral health disparities, poverty, and minority race appear to be primary predictors of unmet oral health care needs and barriers to achieving good oral health.⁶ Many strategies for preventing and improving poor oral health are dependent on successful behavioral, lifestyle, and community-level social changes; however, what type, where to implement, and how to target resources for these approaches remains somewhat uncertain.⁶

FINANCIAL BARRIERS TO DENTAL CARE

Because many report financial barriers among the top underlying forces to dental care, adults, particularly low-income adults, are turning toward settings such as emergency departments or simply avoiding or delaying care altogether.⁷ The question to be asked is, “Can programs such as OH4L be leveraged to reverse this trend?” The authors could have investigated partnerships with public health dental hygiene or similar providers within the community to offer no-cost frontline services, such as free oral screenings, to quitline callers. In addition, collaborative efforts could have produced innovative efforts to help grow the pipeline for free expanded dental services within the community, such as tapping into existing free dental clinics provided by dental schools or community health centers, organizing and optimizing the dental profession’s participation in charitable events, and nonmedical emergency transportation.⁶ These approaches would have more likely produced an increase in dental care utilization without additional cost to the study or changes within the quitline infrastructure.⁶

This study does emphasize how stakeholders have long attempted to apply existing practices to novel health promotion programs with little to no success. By remaining steadfast and not open-minded to innovative approaches known to improve oral health dental utilization (e.g., free screenings, transportation, and treatment vouchers), the likelihood of a successful outcome in this study was slim to none from the start. These reported results can be attributed to many factors, among which include the lack of strategies found in the literature to help improve dental utilization. Although sustainability is critical to any program, the problem with a bottom-line approach toward sustainability is that stakeholders only include elements that are visible and produce quick financial payoffs. They do not go beyond and search for novel practices and policies that might not readily appear to fit into the current infrastructure but could ultimately ensure positive outcomes while safeguarding sustainability.

This is a critical moment for oral health in the United States, and a time when profound change in the practice environment could bring about unprecedented opportunities. Therefore, the time has come to explore the questions outlined in this study and in this editorial. Can programs such as OH4L chart the course for change in the future and enable quitlines to provide the grass roots, innovative alternative that makes it possible to deliver necessary oral health care education, coupled with active partnerships within the communities, to improve dental care utilization through innovative oral health promotion programs? I believe they can if, and only if, stakeholders will think outside the box and allow collaborative partnerships that put into place proper enabling conditions to attract dental providers to participate in low-cost or free services. These efforts could change the oral health landscape and address the main critical driver why adults report not intending to visit a dentist. I believe that the decline in dental care utilization warrants significant attention and it is important to uncover the critical implications for decreased dental care utilization. The time is now to act to expand access to dental care for adults and open up the avenues that have been found to be effective in increasing dental utilization.