Oral disease is a significant public health threat which affects millions of people. It includes common oral diseases such as periodontitis and dental caries, and less common oral and pharyngeal cancers. Together these diseases exact a large human toll. Oral disease not only results in unnecessary pain, potential physical disfigurement, and emotional suffering, it puts individuals at greater risk for subsequent morbidity and mortality . For example, periodontal oral infections are associated with increased risk of cardiovascular disease, stroke, adverse pregnancy outcomes, diabetes, obesity, and non-oral cancers [1–5]. Treating acute disease and preventing the onset of future oral disease are important public health goals.
Tobacco users are at particularly high risk for oral disease compared to people who do not use tobacco [1, 6]. Unfortunately, many smokers fail to seek routine professional dental care [6–8]. As a result, additional public oral health efforts may be needed to reach smokers and to augment the preventive care provided by dental practitioners. Routine oral hygiene such as daily brushing and flossing, use of fluoride products, and lifestyle changes such as reducing tobacco and alcohol use are critical to preventing disease . In fact, encouraging proper self-care at home is now an accepted practice of preventive intervention  and can be influenced by behavioral counseling [10, 11], prompting a recent recommendation that public health officials consider leveraging the existing tobacco quitline infrastructure in the United States to counsel tobacco users about both smoking cessation and better oral health care .
Tobacco quitlines provide motivational and cognitive behavioral counseling for tobacco cessation, primarily through proactive counseling calls (i.e., calls initiated by the quitline based on a pre-determined call schedule established after one enrolls in the services). Participants typically receive supplemental mailed materials and may also have access to online intervention materials or even text-based messaging support. Tobacco quitlines are ubiquitous in North America. At present, all 50 US states, the District of Washington, Puerto Rico, Guam, and 10 Canadian provinces offer free tobacco quitline programs. Other smokers receive services from the hundreds of commercially-funded quitline programs supported through health insurers, employers, and other private funders. According to data from the North American Quitline Consortium (NAQC), in 2009 alone more than 380,000 tobacco users received services from their quitline members . The Global Quitline Network includes additional service providers in Europe and Asia. Expanding oral health promotion activities provided through the existing quitline infrastructure could reach a sizable population, nationally and internationally, and be an innovative way to reach individuals who are at particularly high risk for oral disease. It would also take advantage of an existing cadre of trained behavior change professionals, and the preventive care counseling offered could augment the standard care provided by dental care providers and even encourage utilization of their services. That is, in addition to receiving tobacco cessation counseling, quitline callers could be informed about the risks of oral disease and counseled on ways to improve their oral health through lifestyle risk factor modification (e.g., quitting smoking, limiting alcohol use, proper nutrition, fluoride use, brushing and flossing daily, and seeing a dentist regularly).
To assess the feasibility of this strategy in the U.S., we previously surveyed a representative sample of callers to the Washington State Quitline (WAQL; n = 816) . WAQL provides free tobacco cessation counseling to all eligible callers. Persons are typically eligible if they do not have access to nicotine dependence treatment services through other means (e.g., coverage provided by an employer or through private health insurance) or if they are in a high risk priority group, such as pregnant smokers. The results of this survey demonstrated an important opportunity to promote better oral health among tobacco quitline callers by intervening to prevent future oral disease. Among tobacco users who still had their natural teeth (79.3% of those surveyed), most failed to meet the American Dental Association’s (ADA) recommendations for daily brushing and flossing (83.9%) and most had not visited the dentist in more than a year (52.6%). Although, relatively few people in this sample self-reported a diagnosis of gum disease (21.6%) or dental bone loss (20.4%). If these reports are accurate, it underscores the opportunity for preventative care, to reduce the risk of future disease. If, however, these rates are an underestimation of oral disease in this population, it speaks to the opportunity to better educate smokers about the signs of oral disease and need for regular professional dental screenings. We also found that many tobacco users were open to learning more about ways to improve their oral health (57.4%), were receptive to be counseled by their quitline coach (48.2%), or were open to receiving oral health intervention materials by mail (62.7%) or Internet (50.0%), so there is evidence that many smokers contacted through the quitlines are receptive to oral health promotion efforts.
These data are encouraging, but it is unclear whether the results generalize to smokers recruited through commercially-funded quitlines. In contrast to state-funded quitlines, which reach smokers of lower socio-economic status and are often limited to persons with no private health insurance, commercial quitlines are typically funded by health plans or employers. As such, they reach tobacco users who are of higher socioeconomic status and, therefore, may have different oral health needs, interests and intervention opportunities. The current paper examines self-report oral health indicators, behavioral oral health risk factors, motivation for behavior change, and interest in oral health promotion among medically-insured smokers receiving tobacco quitline services. We sought to replicate the outcomes previously reported among state quitline participants and to extend them by examining additional indicators of oral disease, behavioral risk behaviors, and motivation for change. These findings not only enhance our understanding of smokers’ oral health needs, but will help inform future efforts to design oral health promotion programs that can be integrated into the standard counseling offered to smokers through tobacco quitlines.