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  Table of Contents  
Year : 2022  |  Volume : 59  |  Issue : 1  |  Page : 12-17

Toolkit for delivering the 3Es and 6As tobacco interventions in dental care

1 Department of Oral Medicine and Radiology, Faculty of Dental Sciences, Ramaiah University of Applied Sciences, Bengaluru, Karnataka, India
2 Department of Oral Medicine and Radiology, D.A. Pandu Memorial RV Dental College, Bengaluru, Karnataka, India
3 Department of Community Medicine, M S Ramaiah Medical College, Bengaluru, Karnataka, India
4 Department of Community Dentistry, Vokkaligara Sangha Dental College, Bengaluru, Karnataka, India
5 Department of Oral Medicine and Radiology, Saveetha Dental College, Chennai, Tamil Nadu, India

Date of Submission07-Feb-2020
Date of Decision12-Feb-2020
Date of Acceptance21-Jun-2020
Date of Web Publication19-May-2022

Correspondence Address:
S Sujatha
Department of Oral Medicine and Radiology, Faculty of Dental Sciences, Ramaiah University of Applied Sciences, Bengaluru, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijc.IJC_104_20

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 » Abstract 

Tobacco use is one of the major public health problems in India and also the single most important remediable public health problem. Tobacco cessation is the need of the hour. The dentists have a unique opportunity and professional obligation to be a positive influence in reducing the economic and social burden inflicted by tobacco use on dental and general health. However, dentists, in general, have not widely embraced tobacco cessation in practice. In this article, an evidence-based model (an adaptation of the World Health Organization “5As” tobacco cessation model) is presented for the dentist to help patients avoid tobacco initiation, to encourage and assist patients in tobacco cessation.

Keywords: 3Es and 6As model, behavioral counseling, dental clinic, dentists, moderate intervention, pharmacotherapy, tobacco cessation tool kit

How to cite this article:
Sujatha S, Iyengar A, Pruthvish S, Radhaprashanth, Nagi R. Toolkit for delivering the 3Es and 6As tobacco interventions in dental care. Indian J Cancer 2022;59:12-7

How to cite this URL:
Sujatha S, Iyengar A, Pruthvish S, Radhaprashanth, Nagi R. Toolkit for delivering the 3Es and 6As tobacco interventions in dental care. Indian J Cancer [serial online] 2022 [cited 2022 Dec 4];59:12-7. Available from:

 » Introduction Top

According to the World Health Organization (WHO), tobacco-related disease is the single leading preventable cause of death worldwide.[1] India is the second largest consumer of tobacco, with 250 million consumers; it is sitting on the verge of an unparalleled health crisis.[2] Though several antitobacco policies are being implemented at the national level, these efforts may not directly benefit the current tobacco user; as nicotine is highly addictive, this makes quitting challenging.[3] The dental office is an ideal setting for tobacco cessation services since preventive treatment services, oral screening, and patient education have always been a large part of the dental practice. Although dental office-based tobacco cessation interventions are efficacious, adoption into practice has been slow.[4] The most significant barrier remains lack of education on tobacco cessation activities and lack of time among the others. In order to increase tobacco intervention effectiveness, a stepped care approach should be adopted by dentists to offer routine care to their patients.

Successful intervention begins with identifying users and appropriate interventions based upon the patient's willingness to quit. Various studies suggested that patients showed greater reduction in smoking consumption when advice to quit smoking was combined with dental health instructions.[5],[6],[7],[8],[9] This paper presents an evidence-based tobacco cessation model (an adaptation of the WHO “5As” tobacco cessation model)[10] for the dentists to encourage and assist patients in tobacco cessation. It is suggested that dentists should limit themselves to brief-to-moderate counseling sessions with patients and they should familiarize themselves with the barriers to quitting and effective coping strategies.

Interventions for tobacco cessation

In relation to tobacco cessation, 6As pertain to ask, associate, advice, assess, assist, and arrange at each follow-up visit. Two pieces of information are important: (i) whether the person uses tobacco (smoking/smokeless tobacco [ST]/both) currently, and (ii) if so, whether the individual is interested at present in quitting. Three types of interventions are suggested depending on time and available resources—brief, moderate, and severe intervention. It is suggested that dentists should limit themselves to brief-to-moderate counseling sessions with patients.[11]

Brief intervention (“2Es and 3As” model)

Recommended for busy dentists: Ensure Every patient at Every clinic visit, Ask, Advise and Act (provide information about pharmacotherapy and self-help materials). It takes about 2–3 minutes and every patient who uses tobacco should be offered at least brief intervention [Figure 1].
Figure 1: 2Es and 3As tobacco cessation model for brief intervention

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Moderate intervention (3Es and 6As model)

Recommended for dentists as a “tool for practice” for the treatment of tobacco dependence in the dental office. It includes several steps and takes about 25–27 minutes. All staff postgraduate students and paramedical staff of the department should be trained to ensure that tobacco intervention strategies are standardized and that patients get the same message from all personnel [Figure 2].
Figure 2: 3Es and 6As tobacco cessation model for moderate intervention

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3Es emphasize on screening that is E1- each and every patient for tobacco use, E2-at every visit support every tobacco user to quit and every patient who is not tobacco user to avoid exposure to secondhand smoke and E3- ensure documentation to avoid missing out on tobacco users. Brief, repetitive, consistent, and positive reminders to quit at every visit from multiple providers (reinforcement) may double the success rate.

The 6As emphasize on Ask about tobacco use, Associate with existing oral/medical diseases, Advise to quit in a strong personalized manner, Assess willingness to quit and the level of nicotine addiction, Assist to quit through a tailor made cessation plan, and Arrange for long term follow-up. The additional “A” as compared to 5A model stands for association of tobacco use with existing oral/medical diseases and it may significantly affect the cessation and treatment outcome.

A1. Ask—Ask every patient about tobacco use/exposure to secondhand smoke at each visit. Tobacco use status stickers can be added on all patient charts/electronic medical records as reminders, 'Ask' component should be performed on all patients starting at age 12 at each visit, and document status to capture uptake and relapses as compared with asking only new patients or at annual examinations. Tobacco use should be asked in a friendly and simple way that enhances rapport and provides a safe environment for people to consider the possibility of change.

A2. Associate—Associate the tobacco use to current oral symptoms and other health concerns, for example, dental caries, periodontitis, abscess formation, implant failure, oral soft tissue lesions. etc., its adverse effects on both noninvasive and surgical procedures, and warn them that continuing to use tobacco will worsen the problem.

A3. Advice—Advice all tobacco users that they need to quit, it should be clear, strong, and personalized, for example, quitting is the best thing you can do for your health and well-being; tobacco use takes away not just the health but wealth also. Benefits of tobacco-cessation and the cessation process along with the possible withdrawal symptoms should be explained to the patient. The clinician may use a strategy called “paradoxical intentional” to motivate the tobacco user. Under this strategy, the clinician should ask the tobacco user to choose between continuing to take numerous medications for the primary illness and quitting using tobacco.

If the patient is ready to go ahead with a quit attempt, you can move on to A4–A6 strategies, that is, assess, assist, and arrange steps.

A4. Assess—If the tobacco user is either contemplating to quit/willing to quit/prepared to quit in the next 30 days. If the patient is willing to quit, assess the level of nicotine addiction via measuring scales, for example, Fagerstrom test for nicotine dependence (FTND) scale/carbon monoxide (CO) monitor, and/or biochemical validation through chair-side salivary cotinine kits that quantify as high, moderate, and minimal dependence. This can be used for immediate and personalized feedback to improve patient compliance, quit rates, and reinforces tobacco cessation.

A5. Assist—The type of intervention that is provided will vary depending on the assess component, as well as the clinical setting and time available. Support the patient to quit by personalized counseling based on set guidelines and complement with pharmacological therapy, if necessary. [Table 1] illustrates therapy recommended depending on the level of addiction.
Table 1: Therapy recommended depending on the level of addiction

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  1. Help the patient with a tailor-made quit plan.
  2. Set a quit date ideally within next 2 weeks (preferably a date of personal relevance, birthday, anniversary, etc.).
  3. Discuss various reasons for tobacco use.
  4. Ask to make certain changes in his/her routine to adjust with the “new life” without tobacco, known as lifestyle modification.
  5. Encourage self-monitoring (e.g., tobacco dairy) and help the patient identify events or activities that increase the risk of tobacco use or relapse.
  6. Inform family, friends, and colleagues about quitting and encourage for support.
  7. Advise to remove tobacco products, ash tray, etc. from the patient's environment and make home tobacco-free.
  8. Help the patient to practice cognitive and behavioral coping skills.
  9. Provide supplementary materials, including information on quit lines and other referral resources.
  10. Use approved medication if needed except where contraindicated or with specific populations (i.e., pregnant women).
  11. Advise to exercise, as it helps to deal with both the physical and psychological aspects of nicotine addiction, and to eat right (avoid fat diets), drink lots of water, sleep well, and to involve in physical activity, socializing, meditation, to enjoy music, nature, and all that which eliminates stress.
  12. Advise to avoid or limit alcohol intake.
  13. Educate about the financial aspects of tobacco use—costs involved in purchase of tobacco products, and medical cost incurred toward tobacco-induced illness.

Approximate tobacco use cost estimator

Number of packs/sachets you use per year × Number of years used × Average price = Money spent on tobacco during your lifetime

A6. Arrange—Regular follow-ups are important for long-term abstinence. During the first session itself, preferably first week, the patient should be informed about the need for regular follow-up for maintaining a tobacco-free life. A second follow-up contact is recommended at the end of first month after the quit date. Follow-ups should be regular at least for the initial 6 months and ideally should continue for a year [Figure 3]. Use practical methods such as telephone, SMS, personal visit, email, or dedicated telephone quit lines to do the follow-up. During follow-up, assess medication use; for patients who are abstinent from tobacco, congratulate them on their success; for patients who have used tobacco again (relapse), remind them to view relapse as a learning experience; and to make a fresh quit attempt again, review circumstances and elicit recommitment and refer the patient to specialist if support needed. Rigorous interventions are necessary to improve the tobacco user's participation and efficacy.[12]
Figure 3: Follow-up chart

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Severe intervention

Heavy smokers, particularly those with serious emotional and social problems, will require intensive behavioral intervention and should be referred to psychologists, psychiatrists, or specialists of programs to quit tobacco use. Tobacco users who are significantly dependent, nicotine replacement or drug therapy should be given to help them quit. Signs of severe dependence include use of tobacco (cigarettes/ST) more than 10 per day, tobacco use within 10 minutes of waking up, tobacco use even while sick/hospitalized, waking up at night to use tobacco, using tobacco to ease the withdrawal symptoms.[12],[13]

Pharmacotherapy for tobacco cessation

They are effective at treating tobacco addiction and alleviating withdrawal symptoms. First-line pharmacotherapy, nicotine replacement therapies (NRT), bupropion, and varenicline (non-NRT) are three effective tobacco cessation medications that are readily available. Clonidine and nortriptyline have been proposed as second-line pharmacotherapies.[14] When used correctly, medications can double and triple quit rates. Whenever possible, all individuals making a quit attempt should be encouraged to use both medication and counseling as combination of both is more effective than either alone [Table 2].
Table 2: Pharmacotherapy for tobacco cessation

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Nicotine replacement therapies

Nicotine gums and lozenges

Nicotine gums and lozenges are substitutes that can be put into the mouth to help keep cravings under better control. For nicotine gums, the dose can be self-titrated and, thus, time-adjusted according to the patient's needs. It provides substitute oral activity during tobacco abstinence (especially ST users) but may stick to dentures or dental restorations making it hard to chew before “parking”. Nicotine gums and lozenges are generally sugar-free and safe for diabetics.

Nicotine lozenge delivers 25% more nicotine than nicotine gum, because some amount of nicotine is retained in the gum and is dissolved completely. The lozenge may have better patient acceptability, especially in those who cannot use the gum because of dentures, temporomandibular joint pain, or for those who do not prefer chewing gum.[14],[15]

Nicotine patches

Nicotine patches offer a continuous release of nicotine over 16 or 24 hours, are easy to administer, and require less frequent dosing, with fewer adverse effects and better patient compliance. With the nicotine patch, nicotine is absorbed slowly, with peak levels reaching 4–8 hours after application and nicotine levels are about half as those obtained through smoking. The disadvantage of the patch is the lack of acute (rescue) dosing for craving episodes. Combination of nicotine patches with shorter acting products, like the gum, lozenge, nasal spray, or inhaler, is found to be beneficial when there are strong cravings or in treatment-resistant cases.[14],[16]

Nicotine nasal sprays and inhalers

Nicotine inhalers work very quickly and allow mimicking the use of cigarettes by puffing and holding the inhaler, providing the comfort of the hand-to-mouth ritual—so deliver psychological/behavioral benefit.

NRT is meant to be used for a limited period of time and use should be tapered down before it is stopped. They should not be used in pregnant woman or a nursing mother and individuals below 18 years of age. Persons with heart disease, recent myocardial infarction, hypertension, gastric ulcer, and on antidepressant drugs should consult a physician prior to use. Nicotine inhalers, nasal sprays, and patches require a doctor's prescription as some people may not be able to use them because of allergies or other conditions.[14]

Non-nicotine replacement therapies

Varenicline is an anxiolytic drug that has shown to have a significant impact in reducing smoking, in long-term relapse prevention, and treatment of ST dependence, and also has a high cost–benefit ratio.[17] Varenicline maintains a moderate level of dopamine release, which reduces craving and withdrawal symptoms during abstinence, and blocks the reinforcing effects of nicotine obtained from cigarette smoke in case of relapse. Recommended treatment begins 1–2 weeks before the quit date. Neuropsychiatric adverse effects have been reported such as depressed mood, agitation, aggression, hostility, changes in behavior, suicide-related events, and worsening of preexisting psychiatric disorder.[17]

Bupropion hydrochloride, an antidepressant, is one of two non-nicotine-based medications and could be a better choice in the smokers with the history of depression. This therapy is inexpensive, helps in overcoming the dependence, and reduces the associated craving. Treatment is started while the patient is still using tobacco and a target date to stop is fixed within two weeks of onset of therapy. This is done to allow the time for plasma levels of bupropion to reach steady state and, hence, for the drug to start working effectively. However, current reviews suggest that use of bupropion by itself (without additional therapy such as NRT) is unlikely to achieve significant clinical results. Like other antidepressants, bupropion should not be used in those with history of seizure disorder, serious head trauma, eating disorders (bulimia or anorexia nervosa), and in those who receive other medications that may lower seizure threshold. Furthermore, bupropion SR should not be administered while patients are undergoing abrupt withdrawal from alcohol or benzodiazepines, as it carries a risk of seizures. The most common adverse effects, insomnia and dry mouth, are generally transient and often resolve quickly without therapeutic intervention.[14],[18]

Choosing the right pharmacotherapy

As for the decision to choose a suitable therapy, it would be based on patient-specific factors such as presence of any contraindications and side effects, previous experiences with the medications, the patient's preference, type of tobacco used, level of nicotine addiction, dosing frequency, and medication cost. Early exposure of 1 week to NRT, in advance of a designated quit date, is beneficial as it allows the users to adjust dosage, acclimate to any effects, familiarize themselves with product, gain confidence as the quit date approaches, and reduce reinforcing properties of tobacco by providing some/all nicotine intake separately. To provide additional efficacy, NRT can be advised beyond the suggested 12-week treatment period by ±8 weeks. Educate patients about the rationale for treatment and possible side effects and reinforce the importance of treatment adherence.[19] Whatever type of pharmacotherapy is used, it should be taken at the recommended dose for the recommended period for successful outcome.

Relapse prevention

Despite the relative efficacy of these treatments, many tobacco users relapse after a quit attempt, and alternative pharmacotherapies are needed to increase cessation rates and to prevent relapses. Tobacco addiction, like other addictions, is a complex process involving the interplay of pharmacology, conditioned factors, personality, and social setting. Therefore, the ideal treatment involves a comprehensive approach, behavioral counseling to enhance motivation, and to support quit attempts and pharmacological intervention to reduce nicotine reinforcement and withdrawal symptoms.[6],[9] Maintenance therapy is recommended as an effective strategy for relapse prevention in tobacco users who are initially unsuccessful at quitting and to achieve long-term abstinence.[10],[14]

For tobacco users not willing to quit—5 Rs

If a patient is not willing to quit, the clinician can motivate them to consider a quit attempt with the “5Rs”: relevance (personnel relevance of quitting), risks (associated with continued usage), rewards (benefits of quitting), roadblocks (identify barriers of quitting), and repetition (repeat the message at every visit). Encourage patients to seek support when they are ready.[20]

 » Conclusion Top

To conclude, dentists should adopt brief-to-moderate counseling sessions with patients; heavy smokers require both behavioral and appropriate pharmacological intervention to achieve long-term abstinence. However, in order to reverse the tobacco epidemic, concerted efforts are desirable from all health professionals to prevent and treat tobacco dependence. Therefore, it is important to familiarize with the challenges and barriers to quitting and effective coping strategies and skills.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2]


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