Public Health Service Guidelines Research Articles

Systems change to improve tobacco use identification and referral in the chiropractic setting: a pilot study

BackgroundTobacco use remains a leading cause of death and disability in the United States. Health professionals need to address the use of tobacco products by their patients, but chiropractic clinical systems often remain unsupported and underappreciated in their role to facilitate tobacco use cessation.MethodsThis pilot study tested an intervention to assist a chiropractic community to implement sustainable health systems changes for tobacco use based on U.S. Public Health Service guidelines. Chiropractors were educated on the Ask, Advise, Refer (AAR) approach, provided with ongoing guidance, and followed for six months to assess systems change. The study was conducted from March 2016 to July 2017.ResultsEvidence of a systematic process in place to conduct AAR was present in all clinics by the end of the fourth month of the intervention period. Although no clinic had sustained health system change for full AAR, all six of the clinics made progress in the individual AAR components. Furthermore, five clinics achieved sustained system change for the Ask component, as after systems change was achieved, the rate of tobacco user identifications did not drop below 50%. For the Advise component, five clinics succeeded in having individual months of ≥50% of tobacco users being advised, and three clinics achieved the formal definition of systems change. For the Refer component, no clinic achieved system change, although four had individual months of ≥50% of tobacco users being referred. The patient quit rate was 13.3% (n = 15) for the 30-day follow-up and 16.7% (n = 6) for the three-month follow-up.ConclusionsThis study demonstrates the feasibility of implementing a health systems change in the chiropractic setting to identify tobacco users, to advise them to quit, and to refer users for cessation services.

Implementation of Recommended Tobacco Cessation Systems in Dental Practices: A Qualitative Exploration in Northeastern North Carolina.

Every year, cigarettes and other tobacco products cause nearly one in five deaths in the U.S., but many smokers report not being advised to quit by their health care providers. Dentists have an important role to play in tobacco cessation, but more research is needed about the extent of and barriers to implementation in dental practices. The aims of this study were to assess the extent to which dental practices in northeastern North Carolina were implementing the recommended U.S. Public Health Service (PHS) Clinical Practice Guideline, to understand policies about smoking in dental practice settings, and to identify barriers to implementation of recommended systems. In the 252 telephone area code, which covers northeastern North Carolina, 75 general dentists were identified from the American Dental Association website and purposely selected for geographic, gender, race, and practice size diversity from the sampling frame. The 11 dentists who agreed to participate (seven male, four female) took part in 15-minute semi-structured interviews by phone in January-March 2017. The interview transcripts were thematically coded for adherence to the PHS guideline. The results showed that full implementation of the guideline and the 5As was limited, although asking, advising, and assessing about tobacco use was consistently present in these dental practices. Other recommendations, particularly designation of a staff member as coordinator, were not implemented. In terms of barriers, interviewees reported very limited past or present training for themselves or their staff members. This study found meaningful levels of adherence to the tobacco cessation guideline in this area with high smoking prevalence; but the results suggest room for improvement in training through both dental curricula and continuing education.

Effect of training program regarding smoking cessation counseling for primary health care physicians in Port Said City, Egypt

Smoking is a major risk factor for death-related diseases. Not all healthcare professionals are following evidence-based guidelines for smoking cessation counseling in primary care settings. The WHO, Framework Convention on Tobacco Control (FCTC), and United States Public Health Service (USPHS) guidelines recommend that all healthcare professionals, including students in healthcare training programs, receive education in the management of tobacco use and dependence. To evaluate the effect of training programs for primary healthcare physicians on the knowledge, attitude, and practice of smoking cessation counseling. This was a pre-post intervention study. The study included 74 primary care physicians working in primary healthcare centers affiliated with the Ministry of Health and Suez Canal University Hospitals in Port Said City. The study was conducted between June 2015 and March 2016 using a structured questionnaire and observation checklist to assess counseling of patients willing to quit smoking. There were highly statistically significant improvements in the physicians’ median scores of knowledge (30%–80%), attitude (65% -100%), and practice (20%–70%) (p < 0.001) pre-post intervention. The most frequent correct knowledge was consequences of smoking (73%–87.3%) (p < 0.001) pre-post intervention. The most favorable attitude was the importance of smoking cessation (70.3%–100%) (p < 0.001) pre-post intervention. The best observed correct practice was asking about smoking (70.3%–100%) (p < 0.001) pre-post intervention. Knowledge, attitude, and practice skills regarding smoking cessation counseling among primary healthcare physicians were markedly improved after implementation of the education program.

A Bridge to Understanding Smoking among Women in Rural Central Appalachia: Qualitative Interviews with Local Nurses

The rural Central Appalachian area of Southeast Ohio has a persistently higher rate of tobacco-related women’s health issues, low birth weight, and preterm birth than other parts of the state and the nation. Nurses from Appalachia can provide a bridge for health care providers who are not from the region to understand the perspectives of people who reside in Central Appalachian counties. The purpose of this study was to learn more about the influences and the special needs in Central Appalachia to inform women’s health promotion and smoking cessation interventions. Method : Semi-structured small focus group and individual interviews were conducted with 15 nurses working with women in rural Central Appalachia. Participants were asked about smoking and smoking cessation in relation to their knowledge and experience of women in their home county. Findings : Major themes discovered included reasons for smoking, reasons for quitting, barriers to quitting, and perceptions of current interventions. The influence of the rural social environment on smoking, such as smokers in the social network and ambivalence toward the dangers of smoking, were particularly emphasized. Conclusions : The particularly strong influence of the social environment is a force for change that must be considered in women’s health promotion activities in this area. Tips for quitting smoking in Public Health Service guidelines may be more discouraging than helpful for women in the region according to study participants. Using the information gathered, smoking cessation interventions for rural women in this region should incorporate salient issues such as the social environment, smokers in the household, and the desire for gradual smoking cessation. The data suggests that the social context of smoking may dramatically affect smoking cessation efforts in this region. Keywords: Smoking cessation, Women’s health, Appalachia DOI: http://dx.doi.org/10.14574/ojrnhc.v18i1.505

Organ Donation in the Era of the Opioid Crisis

Organ Donation in the Era of the Opioid Crisis

Color stability of ceramic laminate veneers cemented with light-polymerizing and dual-polymerizing luting agent: A split-mouth randomized clinical trial

Statement of problemThe color stability of luting agents influences the esthetics of ceramic laminate veneers. Clinical studies that have evaluated the color changes of veneers cemented to enamel with light- and dual-polymerizing resin cement are lacking. PurposeThe purpose of this split-mouth randomized clinical trial was to evaluate the color change and marginal discoloration of dual- and light-polymerizing cement used for cementation of ceramic laminate veneers. Material and methodsIn 10 participants, 0.3-mm-thick ceramic laminate veneers were cemented on the buccal surface of the second premolars without tooth preparation. A randomized application of light-polymerized cement was used on one side and a dual-polymerized cement on the contralateral side. The operator and participants were blinded to the activation mode. Color was evaluated by a blinded evaluator with a spectrophotometer at 24 hours and at 2, 6, 12, and 24 months after cementation. The CIELab (ΔE*ab) and CIEDE2000 (ΔE*00) formulas were used to quantify color alteration, and Δa*, Δb*, and ΔL* were calculated between the first and subsequent measurements. US Public Health Service guidelines were used to evaluate the marginal discoloration. ResultsWilcoxon tests did not show a statistical difference in ΔE*ab and ΔE*00 between the groups (P>.05). At 24 months, the median ΔE*ab was 2.31 (interquartile ranges [IQR]: 3.34) for the light-polymerizing mode and 1.57 (IQR: 0.41) for the dual-polymerizing mode, while the median ΔE*00 was 1.65 for the light-polymerizing mode (IQR: 2.34) and 1.18 for the dual-polymerizing mode (IQR: 0.25). The thresholds for clinically acceptable color changes ΔE*ab>3.46 and ΔE*00>2.25 were found for both curing modes. Marginal discoloration was observed from the 2-year assessment. ConclusionsThe color stability of ceramic laminate veneers was similar for both of the polymerizing modes for all evaluated periods. Marginal discoloration increased over a 2-year period for both the light- and the dual-polymerizing modes.

Pharmacotherapy of Tobacco Use Disorder

Pharmacotherapy of Tobacco Use Disorder

Abstract: Seroconversion Rates Among Healthcare Workers Exposed to Human Immunodeficiency Virus and Hepatitis C-Contaminated Body Fluids: The University of Pittsburgh Experience

BACKGROUND: Human Immunodeficiency Virus (HIV) and hepatitis C virus (HCV) transmission to healthcare personnel (HCP) following percutaneous exposure to the blood of a source patient, has been reported to occur at an average rate of 0.3% (0.2–0.5%) 1 and 1.8% (range 0–10%),1,2 respectively. Most of this data is either outdated or was from predominantly non-US centers. We aimed to determine the seroconversion rate after exposure to HIV or HCV-contaminated body fluid at a major academic medical center in the US. METHODS: A longitudinal analysis of a prospectively maintained database of reported occupational injuries occurring between 2002 and 2015 at the University of Pittsburgh Medical Center was performed. Inclusion criteria included HCP who sustained needlestick, laceration, or splash injuries from known HIV or HCV-positive patients. Exclusion criteria included missing data (on the type of injury and fluids), and a positive HIV or HCV status of the HCP. Data collected included the type of injury, injured body part, type of fluid, contamination of sharps, and patients’ HIV and HCV status. Univariate and bivariate statistical analyses were performed using SPSS statistical software (version 19.0; SPSS Inc., Chicago, IL, USA). RESULTS: 1,627 cases (HIV=266, HCV=1,361) were included in the study. The majority of the cases were due to percutaneous injuries (HIV=52.6%, HCV=65.0%) as opposed to mucocutaneous injuries (HIV=43.2%, HCV=33.7%), and the majority of injuries occurred in the hand (HIV=52.6%, HCV=63.3%). Blood exposure accounted for 64.3% (HIV) and 72.7% (HCV) of cases, saliva for 5.6% (HIV) and 3.4% (HCV), and other fluids for 13.6% (HIV) and 11% (HCV). The seroconversion rate was calculated at 0% after a mucocutaneous exposure to either HIV- or HCV-contaminated body fluid, but was 0% (n=0) for HIV and 0.2% (n=2) for HCV, after a percutaneous exposure. The two seroconverted cases were secondary to blood exposure via percutaneous injuries. CONCLUSION: This study provides the most recent data from a major US academic medical center. The seroconversion rates among HCP exposed to HIV and HCV-contaminated body fluids (0% and 0.2% respectively), were found to be lower than most of the data found in the literature. HIV and HCV do not seem to be easily transmitted by needlestick, laceration, or splash injuries. However, further large-scale studies are needed for a more accurate estimation of the risk of transmission. DISCLOSURE:The authors have no financial interest to declare in relation to the content of this article. REFERENCES: 1. CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR 2001;50 (No. RR-11):1–52. 2. Mitsui T, Iwano K, Masuko K, Yamazaki C, Okamoto H, Tsuda F, Tanaka T, et al. Hepatitis C virus infection in medical personnel after needlestick accident. HEPATOLOGY 1992;16:1109–1114.

Changing the US Public Health Service Guideline for Reducing Viral Transmission Through Organ Transplantation

In response to several inadvertent transmissions of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) through organ transplantation, the US Public Health Services issued guidelines to prevent the transmission of HIV through transplantation of human tissue and organs in 1994. Despite significant changes in the epidemiology of HIV in the USA and advances in screening assays for detecting latent infection, the guidelines remained generally unchanged for nearly 20 years. Although the 1994 guidelines identified risk factors in donors that placed them at increased risk of HIV transmission, compliance with the recommendations was highly variable at US transplant centers. After the cotransmission of HIV and HCV from one donor to four transplant recipients, the OPTN policies were amended to incorporate the definitions of donors at increased risk for HIV and required transplant centers to obtain specific informed consent and follow-up when such donor organs were utilized. With renewed attention, it became obvious that the guidelines needed to be revised and expanded to include HBV and HCV. A revised US PHS Guideline was developed over a several year period, and final recommendations were published in 2013. Despite the revisions, definitions of donors at increased risk of disease transmission require further review and revision. This article will attempt to review the revision process of the US PHS Guideline and make suggestions for next steps in further refining the guideline.

Diffusion of Newer HIV Prevention Innovations: Variable Practices of Frontline Infectious Diseases Physicians.

US Public Health Service guidelines recommend early initiation of antiretroviral treatment (ART) for human immunodeficiency virus infection (HIV)-infected patients and preexposure prophylaxis (PrEP) as a prevention option for persons at risk for HIV acquisition. Before issuance of these guidelines, few clinicians reported prescribing early ART or PrEP. The Emerging Infections Network, a national network of infectious diseases physicians in the United States and Canada, was surveyed in September 2014 to assess practices of adult HIV-care providers with early ART, PrEP, and other guideline-recommended HIV prevention methods. Almost half of the 1191 active members invited (48.1%) participated; 415 (72.4%) were HIV-care providers. Most providers (86.5%) indicated that they typically recommended ART initiation at diagnosis, irrespective of CD4(+) cell count. However, for patients with a CD4(+) cell count >500/µL, clinicians would defer ART if patients did not feel ready to initiate ART (94.7%) or had uncontrolled substance abuse (66.0%). Many providers had counseled HIV-infected patients about PrEP for partners (59.0%) or offered visits for partners to discuss PrEP (40.7%), and 31.8% had prescribed PrEP. Clinicians who deferred ART were less likely to endorse and engage in aspects of PrEP provision. Concordant with guidelines, most infectious diseases physicians recommend early ART, and many have experience with aspects of PrEP provision, suggesting recent evolution of clinician practices. Providers who defer ART are also cautious about PrEP. Interventions that help physicians motivate patients to initiate ART and identify missed opportunities to provide PrEP could enhance HIV prevention.

Gaining momentum: Pharmacists recognized for health care contributions

Gaining momentum: Pharmacists recognized for health care contributions

Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis

This report updates US Public Health Service recommendations for the management of healthcare personnel (HCP) who experience occupational exposure to blood and/or other body fluids that might contain human immunodeficiency virus (HIV). Although the principles of exposure management remain unchanged, recommended HIV postexposure prophylaxis (PEP) regimens and the duration of HIV follow-up testing for exposed personnel have been updated. This report emphasizes the importance of primary prevention strategies, the prompt reporting and management of occupational exposures, adherence to recommended HIV PEP regimens when indicated for an exposure, expert consultation in management of exposures, follow-up of exposed HCP to improve adherence to PEP, and careful monitoring for adverse events related to treatment, as well as for virologic, immunologic, and serologic signs of infection. To ensure timely postexposure management and administration of HIV PEP, clinicians should consider occupational exposures as urgent medical concerns, and institutions should take steps to ensure that staff are aware of both the importance of and the institutional mechanisms available for reporting and seeking care for such exposures. The following is a summary of recommendations: (1) PEP is recommended when occupational exposures to HIV occur; (2) the HIV status of the exposure source patient should be determined, if possible, to guide need for HIV PEP; (3) PEP medication regimens should be started as soon as possible after occupational exposure to HIV, and they should be continued for a 4-week duration; (4) new recommendation-PEP medication regimens should contain 3 (or more) antiretroviral drugs (listed in Appendix A ) for all occupational exposures to HIV; (5) expert consultation is recommended for any occupational exposures to HIV and at a minimum for situations described in Box 1 ; (6) close follow-up for exposed personnel ( Box 2 ) should be provided that includes counseling, baseline and follow-up HIV testing, and monitoring for drug toxicity; follow-up appointments should begin within 72 hours of an HIV exposure; and (7) new recommendation-if a newer fourth-generation combination HIV p24 antigen-HIV antibody test is utilized for follow-up HIV testing of exposed HCP, HIV testing may be concluded 4 months after exposure ( Box 2 ); if a newer testing platform is not available, follow-up HIV testing is typically concluded 6 months after an HIV exposure.

The Effect of Systematic Clinical Interventions with Cigarette Smokers on Quit Status and the Rates of Smoking-Related Primary Care Office Visits

BackgroundThe United States Public Health Service (USPHS) Guideline for Treating Tobacco Use and Dependence includes ten key recommendations regarding the identification and the treatment of tobacco users seen in all health care settings. To our knowledge, the impact of system-wide brief interventions with cigarette smokers on smoking prevalence and health care utilization has not been examined using patient population-based data.Methods and FindingsData on clinical interventions with cigarette smokers were examined for primary care office visits of 104,639 patients at 17 Harvard Vanguard Medical Associates (HVMA) sites. An operational definition of “systems change” was developed. It included thresholds for intervention frequency and sustainability. Twelve sites met the criteria. Five did not. Decreases in self-reported smoking prevalence were 40% greater at sites that achieved systems change (13.6% vs. 9.7%, p<.01). On average, the likelihood of quitting increased by 2.6% (p<0.05, 95% CI: 0.1%–4.6%) per occurrence of brief intervention. For patients with a recent history of current smoking whose home site experienced systems change, the likelihood of an office visit for smoking-related diagnoses decreased by 4.3% on an annualized basis after systems change occurred (p<0.05, 95% CI: 0.5%–8.1%). There was no change in the likelihood of an office visit for smoking-related diagnoses following systems change among non-smokers.ConclusionsThe clinical practice data from HVMA suggest that a systems approach can lead to significant reductions in smoking prevalence and the rate of office visits for smoking-related diseases. Most comprehensive tobacco intervention strategies focus on the provider or the tobacco user, but these results argue that health systems should be included as an integral component of a comprehensive tobacco intervention strategy. The HVMA results also give us an indication of the potential health impacts when meaningful use core tobacco measures are widely adopted.

Integrating Evidence-Based Tobacco Cessation Interventions in Free Medical Clinics

Free medical clinics serve a critical role in health care delivery of America's uninsured population, who are less likely to receive tobacco cessation counseling and 1½ times more likely than the general population to use tobacco. The authors evaluate the opportunities for and challenges to implementing the U.S. Public Health Service Guidelines for tobacco cessation in free clinics. Six free clinics participated in this pilot study. Five objectives were targeted: implementation of a tobacco user identification system, education of all clinic staff and volunteers, dedication of a program champion, use of evidence-based treatment, and creation of a supportive environment that reinforces provider behavior. Key informant interviews and focus group data were used to describe the opportunities and barriers of implementing the Public Health Service Guidelines. All clinics adopted a user identification system, dedicated a program champion, adopted evidence-based counseling, and created an environment conducive for cessation. Common challenges included getting volunteers to attend on-site training programs, accessing nicotine replacement therapy, and promoting Quit Line usage, all of which are part of evidence-based treatment. With more than 1,200 free clinics nationwide, it is very important to understand the opportunities and barriers of implementing tobacco cessation services and systems in free clinics.

Donor Disease Transmission

Donor Disease Transmission

Outcomes of a consultation service to emergency medicine clinicians for postexposure management of occupational bloodborne pathogen exposures

Potential bloodborne pathogen exposures, many of which occur after hours and are evaluated by emergency medicine physicians, are an important occupational hazard. Emergency medicine physicians might not be as conversant with the latest US Public Health Service guidelines as occupational medicine physicians. This research presents an efficient model in which a single expert occupational medicine physician provides guidance to many emergency medicine clinicians. Outcomes evaluation indicates that the service was widely utilized and highly rated.

Oncology healthcare providers’ implementation of the 5A's model of brief intervention for smoking cessation: Patients’ perceptions

ObjectiveHealth care providers (HCPs) can play an important role in promoting smoking cessation and preventing relapse. Public Health Service guidelines recommend the “5A's” model of brief intervention. The goal of the current study was to examine cancer patients’ perceptions of 5A's model implementation by their oncology HCPs. MethodsThis study included 81 thoracic and 87 head and neck cancer patients at a large NCI-designated comprehensive cancer center. Patients completed questionnaires assessing perceptions of their oncology HCPs’ implementation of the 5A's model of brief intervention. ResultsResults indicate partial implementation of the 5A's model. The majority of patients reported that their providers had asked about smoking and advised them to quit, however; only half reported that their interest in quitting had been assessed, and few reported assistance in quitting or follow-up. Delivery of the 5A's was greater among patients who requested cessation advice from their HCPs. ConclusionThe current findings suggest a need to increase adherence to the 5A's in the oncology setting. Practical implicationsEfforts to increase smoking cessation treatment provision by HCPs may improve the rate of cessation among cancer patients, and ultimately translate into better long-term cancer treatment outcomes.

Evaluation of the United States Public Health Service Guidelines for Discontinuation of Anticytomegalovirus Therapy After Immune Recovery in Patients With Cytomegalovirus Retinitis

To evaluate United States Public Health Service (USPHS) guidelines for discontinuing anticytomegalovirus (CMV) therapy in patients with AIDS who have immune recovery and quiescent retinitis after initiating highly active antiretroviral therapy. Cohort study of patients with CMV retinitis (Longitudinal Study of Ocular Complications of AIDS). Participants had CMV retinitis and CD4+ T-cell counts of 50 cells/μL or fewer enrolled from 1998 through 2009 who demonstrated sustained immune recovery (2 consecutive CD4+ T-cell counts of 100 cells/μL or more at least 6 months apart) and inactive retinitis. Participants were classified into 2 groups according to anti-CMV treatment after immune recover: (1) continued anti-CMV therapy and (2) discontinued therapy. We evaluated survival, visual acuity, and CMV retinitis activity; we used propensity scores to adjust for confounding factors for these analyses. Of 152 participants reviewed, 71 demonstrated immune recovery, 37 of whom discontinued therapy and 34 of whom continued therapy. At immune recovery, participants continuing therapy tended to be older (44 vs 40 years; P = .09), have bilateral retinitis (53% vs 32%; P = .10), and have lower CD4+ T-cell counts (148 vs 207 cells/μL; P < .001). There were no statistical differences in any of the clinical outcomes (death, retinitis progress, visual acuity, or incidence of bilateral retinitis). Both groups lost visual acuity during follow-up, on average 1.2 letters per year (P < .01). Discontinuation of anti-CMV therapy after immune recovery did not increase the risk of poor outcomes. These results support the current guidelines for discontinuation of anti-CMV therapy after achievement of sustained immune recovery.

Estimating long-term survival of densely sintered alumina crowns: A cohort study over 10 years

Alumina-core crowns have become a standard treatment option in contemporary dental practice. The short-term survival of alumina crowns has been well documented. However, there is still a paucity of long-term survival data. The purpose of this prospective cohort study was to estimate long-term survival of alumina crowns in anterior and posterior areas over an observation period of up to 10 years. Between 1997 and 2005, 155 alumina crowns were placed in 50 subjects. Clinical and technical parameters were assessed at baseline. In 2005 and 2008, the crowns were clinically assessed using modified U.S. Public Health Service (USPHS) guidelines. Treatment failure was defined as crown or tooth loss and separated into technical or biological failures. Survival probabilities were estimated using the Kaplan-Meier method. In 2008, 29 subjects with 112 alumina crowns, including 86 (77%) posterior and 26 (23%) anterior crowns, were available for clinical assessment. The average observation period for these subjects was 7.8 years, with a range from 3 to 10.7 years. In total, 3 technical and 8 biological failures were observed. The estimated survival probability considering technical failures only was 95% (95% Confidence Interval (CI), 89% to 100%). The estimated overall survival probability after 10 years was 84% (95% CI, 74% to 95%). There was no significant difference in treatment failures in posterior as compared to anterior crowns (all failures: P=.713; technical failures: P=.352). The results suggest that the expected 10-year survival rate of alumina crowns due to technical failures is 95% (95% CI, 89% to 100%).

Implementing Tobacco Use Treatment Guidelines in Public Health Dental Clinics in New York City

In this study we evaluated the effect of a multicomponent intervention to implement the Public Health Service (PHS) guideline Treating Tobacco Use and Dependence in six randomly selected dental clinics in New York University's College of Dentistry. The main outcome measure-provider adherence to tobacco use treatment guidelines-was assessed by auditing a random selection of patient charts pre (698) and post (641) intervention. The intervention components included a chart reminder and referral system, free nicotine replacement therapy (NRT), and provider training and feedback. The results showed that rates of screening for tobacco use did not change between pre and post test chart audits. However, providers were significantly more likely to offer advice (28.4 percent pre, 49 percent post), assess readiness to quit (17.8 percent pre, 29.9 percent post), and offer assistance (6.5 percent pre and 15.6 percent post) in the post test period. Increases in NRT distribution were associated with booster training sessions but declined in the time periods between those trainings. Research is needed to further define sustainable strategies for implementing tobacco use treatment in dental clinics. The results of this study suggest the feasibility and effectiveness of using a tailored multicomponent approach to implement tobacco use treatment guidelines in dental clinics.