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Public Health Aspects of Tobacco Control: Setting the Agenda for Action by Oral Health Richard G. Watta/Habib Benzianb/Viv Binniec/Christine Gafnerd/ Marjoljin Hoviuse/Tim J. Newtonf/Robert E. Mecklenburgg Abstract: Tobacco use is a significant public health problem across Europe. Each year over half a million Europeans die pre-maturely due to a smoking-related disease. Tobacco use is a primary cause of many oral diseases and adverse oral condi-tions. The prevalence of tobacco use varies considerably across Europe, although in many countries overall rates of usehave declined in recent years. However, tobacco use among women and young people is rising in several European coun-tries. Tobacco behaviour is influenced by an array of factors, and quitting is a major challenge for many tobacco users. To-bacco use is now considered a chronic progressive relapsing condition requiring very specific support and assistance.
To reduce tobacco use across Europe, a range of complementary actions and policies are required at an international, na-tional and local level. The WHO Framework Convention on Tobacco Control (FCTC) outlines an array of evidence-based poli-cies that can be implemented to prevent tobacco use and promote cessation. National dental associations and professionalgroups across Europe have an important role to play in supporting the ratification and implementation of the FCTC.
The aim of this paper is to outline the public health aspects of tobacco control and highlight how the oral health professionsacross Europe can become actively engaged in this important and relevant area of prevention.
Key words: public health, tobacco control, oral health professions Oral Health Prev Dent 2006; 4: 19-26. Submitted for publication: 01.12.05; accepted for publication: 09.01.06. Tobacco use is one of the greatest global public high amongst the poorer and socially isolated sec- health challenges. Worldwide it is estimated that tions of many developed societies, thereby contribut- over 4.9 million people will die prematurely due to to- ing significantly to health inequalities (WHO, 2002).
bacco-related diseases (WHO, 2002). Although rates In many parts of the developing world tobacco sales of tobacco use have declined steadily in many devel- have risen steadily in recent years, and the global oped countries over the past 30 years, rates remain death toll inflicted by tobacco will therefore increasedramatically in the coming years.
The damaging effects of tobacco use on oral health are well established. The most significant effects on a Department of Epidemiology and Public Health, University College the oral cavity are oral cancers and potentially malig- nant lesions, increased severity and extent of peri- b FDI World Dental Federation, Ferney-Voltaire, France. odontal diseases, as well as poor wound healing fol- c Department of Dental Public Health, University of Glasgow Dental lowing surgery (EU Working Group, 1998; Winn, 2001).
Tobacco-induced oral diseases contribute significant- Progef, Neufeldr. Bern, Switzerland. ly to the global oral disease burden (WHO, 2005). The e InHolland University of Professional Education, School of Hygiene, oral health professions across Europe have a profes- f Department of Dental Public Health, Kings College London, UK. sional and ethical duty to become actively engaged in efforts to combat tobacco use. Gillon (1995) identifies four key ethical principles by which health interven- Reprint requests: Prof. Richard G. Watt, Department of Epidemiologyand Public Health, University College London, 1-19 Torrington Place, tions should be appraised: beneficence, non-malfea- London WC1E 6BT, UK. E-mail: [email protected] sance, equity and scope. These ethical principles are Alle R Copyright
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Table 1 Smoking prevalence across EU and Switzerland 2002-03 applicable to tobacco control and the duty of oral rope and globally. The oral health professions across Europe are in a unique position to help their patients Although some progress has been made, a great stop using tobacco. Ways of supporting cessation ac- deal more could be achieved if oral health profes- tivities delivered by oral health professionals will be sionals became more actively involved in tobacco outlined. High-quality targeted education and train- control, and in particular provided cessation support ing that develop the dental teams’ knowledge and to their patients who use tobacco. Increasingly pa- skills in cessation are urgently needed. Training op- tients expect oral health professionals to provide portunities exist at both undergraduate and postgrad- support and advice on tobacco cessation (Campbell uate levels. Finally, the role of dental professional et al, 1999; Rikard-Bell et al, 2003). It is now time organisations in tobacco control will be highlighted.
oral health personnel as health professionals taketheir responsibility in providing cessation support totheir patients.
The aim of this paper is to outline the public health aspects of tobacco control and cessation. The Tobacco use is a major public health problem across oral health professions across Europe have an im- the world. The global death toll from tobacco con- portant role to play in tackling the tobacco epidemic.
sumption is now 4.9 million people per year and is This chapter will summarise the epidemiology of estimated to reach 10 million by 2020 (WHO, 2002).
tobacco use across the European Union (EU) and In the European Union (EU) prior to enlargement it Switzerland. The need to understand the nature and was estimated that tobacco use was responsible for characteristics of tobacco use behaviour will be high- more than half a million deaths each year (Ryan, lighted. As a chronic relapsing condition it is essen- 2000). In addition to the recognised impact on gen- tial that effective actions are implemented to prevent eral health, tobacco use is a primary cause of many the uptake of tobacco use, particularly amongst oral diseases and adverse oral conditions (WHO, young people. An overview of the broader tobacco control agenda will be outlined to illustrate the im- The prevalence of smoking across the EU varies portance of implementing a comprehensive range of considerably, from 17% in Sweden to 45% in Greece, policies to combat the activities of vested interest with an overall average of 29% (Joossens, 2004) groups engaged in promoting tobacco use across Eu- Alle R Copyright
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Overall rates of tobacco use have declined in most nicotine dependence (Jarvis and Wardle, 1 nt
European countries over the past 30 years. For exam- tine and t en
ple, in Iceland, Norway, Sweden and Slovenia there fore find quitting more difficult. When people stop us- has been more than a 25% reduction in smoking rates ing tobacco they experience severe cravings and a between 1985-2003 (Joossens, 2004). The reduction range of unpleasant physical and psychological side- in smoking has been most marked amongst men, effects. Most smokers make repeated attempts to quit whereas rates of smoking amongst women have actu- before eventually succeeding. Indeed, tobacco depen- ally increased in several countries. For example, in dence can be considered as a chronic relapsing con- Greece, Lithuania, Finland, Hungary and Austria sig- dition. This recognises the long-term nature of quitting nificant increases in smoking levels amongst women and the fact that periods of relapse and remission are have been reported between 1985-2003 (Joossens, common. Such an approach has important implica- 2004). Another area of concern is the rate of smoking tions on how best to support tobacco users to quit suc- amongst young people across Europe. In many coun- cessfully. Whether or not smokers are successful in tries smoking rates are notably higher amongst girls their quit attempts depends on the balance between than boys. It has been reported that over 30% of 15- that individual's motivation to stop tobacco use, their year-old girls smoke at least once a week in Austria, degree of dependence on tobacco and the social sup- Czech Republic, Finland, Germany, Slovenia and Spain In many European countries smoking levels are sig- nificantly higher amongst socially disadvantaged groups and is therefore a major contributory factor increating health inequalities. In addition, the rates of Clinical and public health interventions need to be quitting smoking are significantly lower amongst based upon sound scientific evidence. A significant adults from lower socio-economic groups (Judge et al, amount of high quality research has been published 2005). The differences in quit rates between social in the tobacco cessation field. Many of the studies groups is not merely a reflection of different levels of were randomised controlled trials enabling meta- motivation. Evidence clearly indicates that smokers' analysis to be undertaken of the pooled results.
level of nicotine dependence increases systematically Based upon the available evidence, consensus guide- with deprivation. Poorer smokers are essentially more lines on professional practice have been published addicted than more affluent smokers (Jarvis and War- (Fiore et al, 2000; West et al, 2000). These guide- dle, 1999). The prevalence of smoking is also higher lines highlight the role of health professionals in to- amongst a range of vulnerable groups, including peo- bacco cessation and outline the steps involved in ple with mental illness, the homeless and certain eth- assessment, support, treatment and referral. The nic minority groups. In addition to smoking, the use of quality of evidence in relation to oral health profes- smokeless tobacco is a major concern in relation to sionals’ involvement in tobacco use cessation is less oral pathology (Gupta and Warnakulasuriya, 2002).
robust, with few well designed randomised controlled Smokeless tobacco use is common amongst certain trials undertaken. However, the available eviden- ethnic minority groups and in countries such as Swe- ce suggests that dentists and their teams are as successful in providing cessation support as otherhealth professionals (Fiore et al, 2000; Warnakula-suriya, 2002). Major gaps remain in the evidence base for the primary prevention of tobacco use.
To be able to develop effective preventive strategiesand treatments, it is important to consider the complex nature of tobacco use behaviour. The majority of smok-ers start in their teenage years when a variety of fac- In order to effectively reduce tobacco use across Eu- tors such as fashion, peer pressure and advertising rope, a range of complementary actions and policies are particularly influential on behaviour. Once depen- are required at an international, national and local dence is established, smoking soon becomes an en- level. Examples of such interventions are given in trenched routine linked to a range of aspects of daily living and coping with pressures and stresses. Howev- Effective smoke-free policies in the workplace and er, the most powerful determinant of tobacco use is public spaces will reduce passive smoking, encourage Alle R Copyright
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• Smoke-free policies in public spaces and workplace Greater restriction on the point of sale of tobacco products is important, particularly where young peo- ple may be able to access tobacco products - for ex- • Controls on tobacco promotion (advertising, product ample, vending machines provide a point of access that is largely unsupervised. Tobacco products contain thousands of compounds aside from nicotine, many of which are harmful, if not highly toxic. There is a need for greater regulation of the contents of tobacco products, comparable to the legislation covering food, • Provision of effective and accessible cessation services drugs and other consumer products (Jamrozik, 2004).
In an expert review of tobacco control policy across 28 European countries the relative value of differentpolicy options were considered and ranked (Joossens,2004). Out of a possible maximum score of 100 the fol- cessation and hence lower consumption, and de- crease the number of negative role models availableto children. In some countries, such as Ireland, Scot- land and Italy, legislation on restricting smoking in pub- • Workplace/public space smoking bans (22 points) lic spaces has already been passed. Workplace smok- • Overall tobacco control budget (15 points) ing bans lead, on average, to 4% of smokers quitting, and reductions in smoking among continuing smokers • Tobacco dependence treatment (10 points).
Regular increases in the cost of tobacco products in real terms (and increased taxation) have a direct ef- The five countries with the highest scores for their fect on consumption, particularly amongst adoles- tobacco control policies were Iceland, UK, Norway, Ire- cents. An increase in the price of tobacco products of 10% has been shown to lead to a fall in smoking of4% in adults and 6% in children (Jha and Cha-loupka,1999). However, increased prices may lead to in- WHO Framework Convention on Tobacco Control creased smuggling of tobacco products, which should be addressed through appropriate mechanisms to de-tect and deter this criminal activity. Between 1990 At the World Health Assembly in May 2003 a ground- and 1997 world-wide the smuggling of tobacco prod- breaking global public health treaty was agreed. The ucts increased by more than 110% (ASH, 2005).
WHO Framework Convention on Tobacco Control There is some evidence that public education pro- (FCTC) outlines the following actions (WHO, 2003): grammes, which are sustained and delivered in concert with other aspects of the tobacco control The core demand reduction provisions include: agenda, can be effective in reducing the prevalenceof smoking. On 1 January 2004, one million people • Price and tax measures to reduce the demand for in Holland stopped smoking as part of a mass media campaign to encourage smoking cessation. At one • Non-price measures to reduce the demand for to- year follow-up, 239,000 individuals (23.9%) were still not smoking (Kalkman, 2004). Increasingly countriesare seeking to exercise greater control over the ad- - Protection from exposure to tobacco smoke vertising and promotion of tobacco products both di- - Regulation of the contents of tobacco products rectly and indirectly through product placement and sports sponsorship. In 1975 the Norwegian govern- - Packaging and labelling of tobacco products ment announced a ban on the advertising of smok- - Education, communication, training and public ing, which was associated with tobacco consumption reaching a plateau against a trend of increasing use - Tobacco advertising, promotion and sponsor over 20 years (Royal College of Physicians, 1983). An Alle R Copyright
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Table 3 Perceived barriers limiting progr - Demand reduction measures concerning to- The core supply reduction provisions include: • Doubts about effectiveness of advice• Lack of time ñ cost concerns • Fear of affecting patient/dentist relationship • Provision of support for economically viable alter- • Assume responsibility of other health professionals• Outdated concepts of prevention and behaviour change Pressure is now being placed on governments Sources: Chestnut and Binnie, 1995; John et al, 1997; across the world to ratify and enact the convention.
Other examples of policy approaches to tobacco con-trol are the European Union Directive on Tobacco Ad-vertising and a range of other EU directives.
Developing the dental team’s knowledge and skills to deliver effective cessation support is essential.
Training covering all relevant aspects of cessation A key element in tobacco control most relevant to should be provided at both undergraduate and post- health service settings is the provision of evidence- graduate levels. At the undergraduate level tobacco-re- based cessation services and support. Significant lated topics can be integrated into a range of subjects progress across Europe has been made in engaging such as dental public health, behavioural sciences, the oral health professions in cessation activity. How- communication skills, oral pathology, oral diagnosis ever, major barriers have been identified that need to and periodontology. A useful incentive to encourage be addressed to move this agenda forward (Table 3).
oral health professionals' attendance at cessation The diverse nature and range of barriers that limit courses is to have the programmes accredited for con- oral health professionals’ active engagement in ces- tinuing professional development (CPD) points. In the sation activities means that a multifaceted approach UK, uptake of a cessation training resource was sig- is required to facilitate progress in this important area nificant, in part due to the CPD points awarded for of preventive practice. Evidence-based guidelines reading the guide (Beaglehole and Watt, 2004). De- have been published, which summarise the research tails of professional training are covered below and in on the effectiveness of cessation services (Fiore et al, 2000; West et al, 2000). These need to be dissemi- Evidence indicates that cessation rates double when nated to oral health professionals in a format that is pharmacological products such as nicotine replace- relevant, accessible and applicable in clinical dental ment therapy (NRT) or bupropion (Zyban) are used settings to address practitioners' concerns over the ef- (Fiore et al, 2000; West et al, 2000). However, in many fectiveness of cessation support. A fundamental bar- European countries neither of these products can be rier is the perceived time it takes to provide cessation prescribed by dentists at present. Reform of the pre- support and the absence of any direct funding to re- scription guidelines is urgently needed to enable den- imburse oral health practitioners for their efforts. Re- tists to prescribe these useful products. On a more forming reimbursement systems to encourage pre- practical level, tailored cessation resources for use in ventive care is a significant challenge. Where fee-per- clinical dental settings are needed to enable cessation item systems operate, cessation activity should be in- advice to become routinely incorporated into clinical corporated as a recognised item of preventive care. It dental practice. For example, medical history forms has been estimated that cessation advice delivered in should contain standardised questions to assess pa- dental settings takes under seven minutes per patient tients' smoking patterns. In addition, information on lo- (Cohen et al, 1989). If the whole dental team becomes cal helplines and cessation services could be displayed actively engaged in smoking cessation, the amount of time dentists are directly involved will be reduced fur-ther. In addition it is important to recognise the valueof other direct and indirect compensation systems.
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Professional education, training and capacity ole of dental associations and professional Appropriate education and training is required at both National and international dental associations and pro- undergraduate and post-qualification (graduate) levels fessional groups have an important role to play in to- to enable all members of the oral health professions bacco control. However, a recent survey of National across Europe to engage effectively in tobacco pre- Dental Associations (NDAs) across OECD countries re- vention and cessation. Regarding certain public health vealed that only 50% of NDAs had a written policy on to- aspects, the professional education and training bacco control (Beaglehole et al, 2005). The FDI and WHO have recently published a useful guide that out-lines a range of actions NDAs can perform in relation to • Knowledge of the local epidemiology of tobacco tobacco control (FDI/WHO, 2005). Key recommenda- use and inequalities in tobacco use across social tions in the FDI Code of Practice on tobacco control for groups. Information on the groups with the highest oral health professional organisations include (FDI, prevalence of smoking provides important infor- mation on the priorities for the development ofservices and targeting of health promotion.
• Actively support governments in the process lead- • A thorough understanding of the infrastructure for ing to signature, ratification and implementation the delivery of healthcare (both general health of the WHO Framework Convention on Tobacco and oral health) within the individual country, par- ticularly in relation to tobacco cessation services.
• Support and endorse the tobacco control activi- • An understanding of contemporary theories of be- ties of other health networks and professional haviour change and health promotion, in particu- lar the range of factors and processes influencing • Support campaigns for tobacco-free public places • Actively participate in World No Tobacco Day every • Knowledge of the nature and levels of tobacco de- 31 May and in other global and countrywide pub- pendence and nicotine addiction, and its impact on oral health and dental practice. Contemporary • Include tobacco control in the agenda of all rele- research has revealed much important informa- tion on the nature of nicotine addiction and de- • Influence training institutions and educational set- pendence, which has important implications for tings to include tobacco control in their oral health the development of cessation services.
professionals' curricula at undergraduate, continu- • An understanding of behaviour and specifically be- • Advise all, their members to deliver evidence- • Instilling positive attitudes towards the undertak- based cessation support to their patients ing of smoking cessation activities among dentalhealthcare professionals, including the provision In addition, professional groups and associations of professional role models in smoking cessation could support their membership by publishing and for members of the dental healthcare team.
disseminating cessation guidelines and resources • Knowledge of the available treatment options and designed for use in clinical dental settings. Lobbying governments to reform dental health care systems to • The development of skills required to support sus- facilitate an expansion of preventive practice is an- tained behaviour change in smoking cessation, other important advocacy role that can be perform- including communication skills and pre- and post- ed. For example, in many countries dentists are not able to prescribe nicotine replacement therapies • Where relevant, the ability to work in a team ap- (Beaglehole et al, 2005). Reforms of prescribing poli- proach, supporting other members of the dental cies are therefore urgently required.
• Where relevant within the healthcare setting, the importance of and mechanisms for referring pa- tients to specialist services for support.
A wealth of high quality international research hasbeen undertaken specifically in relation to the evalu- Alle R Copyright
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