Difficult conversations part 3: Talking to patients about smoking

This article was first published in the ADA's News Bulletin, May 2022

As healthcare professionals, we know that our remit goes way beyond a patient’s oral well-being and appearance. We are part of a suite of care for our patients that can include doctors, surgeons, psychologists, carers and more, depending on the needs of each individual. So when we are checking out a patient’s oral health and find telltale signs of abuse, serious illness or so many other possible problems, we know it’s our duty not to ignore it.

However these can be deep waters indeed, especially for those of us less predisposed to the psychological part of our service and profession. We owe it to our patients not to shy away from these difficult conversations, though, as in many cases we can be the first ‘frontline’ response to assist patients in finding safety, wellbeing and support.

Dr Sarah White was appointed Director of Quit in 2014 and is the leading national spokesperson for smoking cessation. Dr White oversees the delivery of the Victorian, NT, SA and WA Quitline, and has expertise in areas including smoking cessation practice change models in health system settings, and the impact of smoking on health, particularly for priority populations such as people with mental illness or substance use disorders.

Dental professionals have an important role to play in talking to patients about their smoking. Studies show most people who smoke want their health professional to offer advice about quitting and that one in five people who are unmotivated to quit will take steps to do so when advised by a health professional. Dental health professionals are highly respected, and that time in the dental chair provides a perfect teachable moment to build motivation to quit.

Quit has actually developed online training especially for dental professionals together with Dental Health Services Victoria and ADA Victoria, to equip dental professionals with the skills and confidence to chat with patients about their smoking.
 

The most helpful thing to say

Very few people who smoke know the impacts of smoking on oral health. A good way to broach the subject, therefore, is to simply say out loud, during examination, that there is evidence of damage from smoking and explain in a non-judgmental and matter-of-fact way how the damage occurs. Fundamentally, smoking is a clinical risk factor, so dental professionals should use the same educative tone and approach as they would when speaking about any other clinical risk factor. What tone would you use if you see evidence of decay and wanted to educate the patient about the importance of brushing their teeth? That’s the tone to use when discussing smoking.

The worst thing to do is to talk to the patient as if their smoking is a 'lifestyle choice' that they can be lectured out of making. Remember that – with very few exceptions – people who smoke started as a child and became addicted to a product marketed by a very devious industry. Adding a touch of empathy to any conversation will go a long way to helping the patient feel supported.

Supporting a patient to quit smoking starts with planting a seed in their mind. A sensitive and non-judgemental way to start the conversation is by using the fast, simple and effective brief advice model: Ask, Advise, Help (AAH). The model helps health professionals to connect patients with best practice nicotine dependence treatment – multi-session behavioural intervention through a specialist counselling program like Quitline and pharmacotherapy, if clinically appropriate. Brief advice takes as little as 3-5 minutes and is recommended by the Royal Australian College of General Practitioners:

- Ask all patients about smoking status (current or former smoker) and document this in their case file;

- Advise all patients who smoke about the best way to quit (counselling plus pharmacotherapy to help manage cravings) and why this is important for their oral health; and

- Help by offering a referral to Quitline’s specialist behavioural counselling program and help patients access smoking cessation pharmacotherapy, if clinically appropriate and possible. Patients are 13 times more likely to engage with smoking cessation treatment if a health professional refers them directly to Quitline rather than advising the patient to call 13 7848 themselves. It is simple and fast to connect patients with Quitline; refer by fax to 1800 931 739 or online (a dental assistant or receptionist can fill in the minimal referral details on discharge). If it’s not possible to provide a script for pharmacotherapy then and there, encourage the patient to see their GP.
 

Start them on the journey

It’s critical to normalise the idea that quitting is a journey and that quitting smoking for good can take several attempts. "It costs nothing to try and not succeed" and "If you try and don't succeed, you’ve still gained something" are good phrases to use. You can explain that every quit attempt is an opportunity to develop and practise their quitting skills; each time they try, they learn about what trips them up and can develop strategies to take them another step closer to achieving their goal.

Most people struggle to quit smoking because they don’t have the knowledge and support they need. Explain that the Quitline service will help them recognise and address their habits and triggers around smoking and that nicotine replacement therapy or stop smoking medications can help manage cravings. Evidence shows that combining these two aspects of treatment gives someone the best chance of success at quitting, but this isn’t well known.

It used to be that dental (and other) professionals were asked to assess 'readiness to change' before providing any advice on smoking. However, research has now shown that 'readiness to change' can itself change multiple times throughout a day. The approach now is to provide clinical information and an offer of help, in effect before resistance to quitting can even be expressed.
 
You might also be interested in:

"Difficult conversations part 1: Talking to angry/frustrated patients"; and

"Difficult conversations part 2: Discussing suspected domestic violence"