By engaging dental professionals in formative research, we successfully identified a wide variety of issues that providers believed would facilitate the delivery of tobacco control in dental practice. As organized by our expert panel, the information solicited from providers suggests that interventions focused outside the practice to change policies and reimbursements related to tobacco control were also felt to be important by providers. Both providers and patients are appropriate and necessary targets for interventions.
Provider education was strongly endorsed as an important facilitator across panels of dental providers. Strategies involving training and education represented over 40% of the possible weighted votes in these 2 sessions. This finding is consistent with prior research, as surveys of dental providers have noted gaps in training.33
Providers who received tobacco cessation counseling training are likely to perceive fewer barriers to tobacco cessation counseling and are more likely to engage in counseling activities (i.e., asking and advising). Knowledge of approaches and development of skills for tobacco counseling are likely necessary, although not necessarily sufficient to increasing tobacco control in dental practice.
Dentists and hygienists also frequently requested tools to further support their efforts, including patient materials (patient handouts, models, videos) and practice materials (history forms). The providers also suggested standard protocols (e.g., “Assign tobacco screening/counseling to hygienist”). Practice reorganization strategies such as developing standard protocols are likely to be effective based on prior research in quality improvement.
Some recommended strategies may not be easily implemented. For example, a strategy to “cue dentists about the legal consequences of failing to screen” is more complex than some of the other issues. We could not find specific legal cases in which dentists were sued for lack of tobacco cessation counseling. Thus, this is more of a theoretical concern. In considering how to implement these strategies in an intervention, quality-improvement engineers should consider these comments within the context of what is feasible and practical in dental practice.
Our cognitive mapping also suggested that forces external to the practice are also critical to tobacco control in dental practice, representing one extreme of the 2-dimensional model. Reimbursements and certification issues represented 2of the 4 clusters identified. These results suggest that dental providers believe that outside regulation, monitoring, and funding are needed to move tobacco cessation activities forward in dental practices. In deciding to counsel smokers, dentists still must consider that many of their patients are self-pay. Thus, dentists may be more reluctant to provide sensitive counseling because they fear that patients will be dissatisfied. Although evidence suggests that dental patients value receiving tobacco cessation counseling, this may not be well known in practice. 34
In considering the decisional balance of dental providers, additional external supports (e.g., funding) may thus be needed to increase tobacco control.
Our formative assessment has several limitations. We purposefully recruited dentists and hygienists into our sample, but the number of providers participating in our nominal group technique meetings was limited, and their opinions, although valuable, may not be representative of all providers. Although there was some overlap, each meeting included unique strategies. Thus, theme saturation was not completely achieved, and the strategies proposed are not likely to be a comprehensive list.
A strength of the present study is the combination of perspectives. We have incorporated the views of 2 key informant groups: providers and experts in tobacco control and health services research by combining formative research methods. This framework offers a common basis for designing components of an intervention. Our approach and sample size did allow for an understanding of variations in opinions. Further research could include quantitative evaluations of provider characteristics that might influence dental-provider opinions regarding tobacco cessation counseling. In addition, similar research should be undertaken to identify patient- level perspectives of tobacco cessation counseling strategies. Patient-level data reflecting patients' views regarding what they perceived effective or ineffective intervention components would likely allow for developing a more comprehensive/integrated intervention approach to facilitate tobacco cessation counseling in dental practice.
We have used the results to create an Internet-delivered intervention for dental providers that includes a series of educational cases and a robust toolbox of downloadable tools for the practice. Ultimately, we will use the cognitive map derived from this formative research to test the impact of the various intervention strategies on the outcome of interest: increasing tobacco cessation advice by dental providers.