PERFIL DE PACIENTES FUMANTES E O PAPEL DO CIRURGIÃO

UNIVERSIDADE FEDERAL DE SANTA MARIA
CENTRO DE CIÊNCIAS DA SAÚDE
CURSO DE ODONTOLOGIA
PERFIL DE PACIENTES FUMANTES E O PAPEL DO
CIRURGIÃO-DENTISTA NA CESSAÇÃO DO
TABAGISMO: UM ESTUDO TRANSVERSAL NO SUL
DO BRASIL
TRABALHO DE CONCLUSÃO DE CURSO
Carolina Dummel
Santa Maria, RS, Brasil
2015
1
PERFIL DE PACIENTES FUMANTES E O PAPEL DO
CIRURGIÃO-DENTISTA NA CESSAÇÃO DO TABAGISMO:
UM ESTUDO TRANSVERSAL NO SUL DO BRASIL.
Carolina Dummel
Trabalho de Conclusão de Curso apresentado ao Curso de Odontologia
da Universidade Federal de Santa Maria como requisito parcial para
obtenção do grau de
Cirurgião-Dentista
Orientador: Prof. Dr. Sílvia Ataide Pithan
Santa Maria, RS, Brasil
2015
2
Universidade Federal de Santa Maria
Centro de Ciências da Saúde
Curso de Odontologia
A Comissão Examinadora, abaixo assinada,
aprova o Trabalho de Conclusão de Curso
PERFIL DE PACIENTES FUMANTES E O PAPEL DO CIRURGIÃODENTISTA NA CESSAÇÃO DO TABAGISMO: UM ESTUDO
TRANSVERSAL NO SUL DO BRASIL.
elaborado por
Carolina Dummel
como requisito parcial para obtenção do grau de
Cirurgião-Dentista
COMISSÃO EXAMINADORA:
______________________________________
Prof. Dr. Sílvia Ataide Pithan
(Presidente/Orientador)
______________________________________
Prof. Dr. Rachel de Oliveira Rocha (UFSM)
____________________________________
Prof. Dr. Thiago Machado Ardenghi (UFSM)
Santa Maria, 16 de junho de 2015.
3
O presente trabalho, intitulado
PERFIL DE PACIENTES FUMANTES E O PAPEL DO CIRURGIÃODENTISTA NA CESSAÇÃO DO TABAGISMO: UM ESTUDO
TRANSVERSAL NO SUL DO BRASIL.
será submetido para publicação no periódico
JOURNAL OF PUBLIC HEALTH DENTISTRY
sob o título
PROFILE OF SMOKERS AND THE ROLE OF DENTISTS IN
TOBACCO USE CESSATION: A CROSS-SECTIONAL STUDY IN
SOUTHERN BRAZIL.
4
AGRADECIMENTOS
Aos meus pais, Valdir e Izolete, pelo amor, cuidado e apoio incondicional.
Obrigada pela oportunidade de estudar e pela confiança e incentivo constantes.
Obrigada, pai, por me mostrar a admiração pela nossa profissão. Obrigada, mãe, por
me ensinar o amor pela saúde pública e por buscar incansavelmente uma sociedade
mais justa e igual para todos.
As minhas irmãs Juliana e Claudia, pelo amor e companheirismo. À Juliana, por
ser meu grande exemplo e inspiração. À Claudia, pelo exemplo de esforço,
humildade e motivação.
Aos meus sobrinhos Angelina, Mateus e Miguel, por serem a luz e a alegria dos
meus dias e por me mostrarem o amor mais puro e verdadeiro.
A minha orientadora Sílvia Pithan, pelo suporte, auxílio e motivação nessa
caminhada. Obrigada pela inspiração em promover a saúde de forma universal,
integral e igualitária.
À professora Ângela Dullius, pelo auxílio na estatística do nosso trabalho.
Aos colegas e amigos Caroline, Patrícia e Renan pela ajuda na pesquisa desde
o seu início, sem nunca desanimar frente às dificuldades encontradas.
Ao Renan, pelo amor e parceria diários, e por dividir comigo o sonho de tornar
nossa sociedade um lugar melhor para todos, sem preconceitos e opressões.
À Paula, Laura e Carine, obrigada pela amizade, parceria, pelo aprendizado
diário e pela oportunidade de conviver com pessoas de corações tão grandes e
solidários.
As minhas amigas Priscila Campeol, Priscila Kist, Bárbara, Silvana e Vanessa,
obrigada pela amizade nesses seis anos (e nos próximos que virão), pelo apoio em
incontáveis momentos e por serem minha família em Santa Maria.
A todos os professores, colegas e amigos que ao longo desses seis anos
contribuíram para a minha formação acadêmica e pessoal. Sou eternamente grata a
todos vocês!
À Universidade Federal de Santa Maria pela formação de alto nível e por todas
as oportunidades de atividades de ensino, pesquisa e extensão.
Ao programa Ciência sem Fronteiras e a De Montfort University pela
oportunidade de estudar um ano em uma universidade de excelência na Inglaterra,
5
vendo a saúde pública de outra perspectiva e aprendendo com um sistema de saúde
reconhecido internacionalmente.
A todas as pessoas que eu conheci nessa
aventura, que me ajudaram a abrir meus olhos para outras culturas e realidades e a
vencer muitas barreiras e preconceitos.
À cidade de Santa Maria e suas pessoas de todas as cores e credos, obrigada
por me formar para a vida.
“Um sonho que se sonha só é só um sonho que se sonha só, mas sonho que se
sonha junto é realidade.”
Raul Seixas
6
“Se você trata a doença, você ganha ou perde. Se você trata a pessoa, você sempre
ganha – independentemente do resultado.”
Patch Adams
7
RESUMO
Trabalho de Conclusão de Curso
Curso de Odontologia
Universidade Federal de Santa Maria
PERFIL DE PACIENTES FUMANTES E O PAPEL DO CIRURGIÃO-DENTISTA NA
CESSAÇÃO DO TABAGISMO: UM ESTUDO TRANSVERSAL NO SUL DO
BRASIL.
Autor: Carolina Dummel
Orientador: Sílvia Ataide Pithan
Local e Data da Defesa: Santa Maria, 16 de junho de 2015.
O objetivo deste estudo foi avaliar o perfil dos pacientes fumantes que
frequentam as clínicas de um Curso de Odontologia no sul do Brasil e a opinião dos
mesmos sobre o papel do cirurgião-dentista na cessação do tabagismo. Trata-se de
um estudo transversal analítico, onde os dados foram coletados por meio de um
questionário contendo questões fechadas e abertas. A amostra compreendeu 442
pacientes e os dados foram analisados por meio de estatística descritiva e do teste
Qui-quadrado com nível de significância de 5%. A idade média foi de 48,5 anos e 93
pacientes (21,04%) eram fumantes, a maioria do sexo feminino (52,7%). Verificou-se
associação significativa entre fumo, escolaridade e renda, sendo que quanto menor
a escolaridade, maior a frequência de fumantes (p=0,026), e a frequência de não
fumantes esteve associada a uma maior renda (p=0,021). Dos fumantes
entrevistados, 95,7% gostariam de abandonar o hábito, 81,7% já tentaram parar e
apenas 23,7% têm conhecimento de grupos de apoio à cessação. Em relação ao
papel do cirurgião-dentista na cessação do hábito de fumar, 97,8% dos fumantes
acredita que este deve dar orientações sobre os danos provocados pelo cigarro,
mas 36,6% não receberam informações ou conselhos do dentista. A identificação do
perfil dos pacientes tabagistas permite um melhor planejamento de estratégias em
saúde pública e é imprescindível que todos os profissionais de saúde trabalhem
juntos para ajudar seus pacientes a pararem de fumar. Neste contexto, o papel do
cirurgião-dentista é fundamental, pois seus pacientes esperam receber informações
e conselhos para a cessação.
Palavras-Chave: Tabaco, Abandono do Uso de Tabaco, Odontólogos.
8
ABSTRACT
Trabalho de Conclusão de Curso
Curso de Odontologia
Universidade Federal de Santa Maria
PROFILE OF SMOKERS AND THE ROLE OF DENTISTS IN TOBACCO USE
CESSATION: A CROSS-SECTIONAL STUDY IN SOUTHERN BRAZIL.
Autor: Carolina Dummel
Orientador: Sílvia Ataide Pithan
Local e Data da Defesa: Santa Maria, 16 de junho de 2015.
The aim of this study was to investigate the profile of smokers in a dental clinic
of a university in southern Brazil and their views about the role of dentists in smoking
cessation. A cross-sectional study was carried out with the patients of the Dental
School, who answered a face-to-face interview containing closed and open
questions. The sample was formed by 442 patients and data was analysed using
descriptive statistics and Chi Square test with a significance level of 5%. The mean
age was 48.5 years old and 93 patients (21.04%) were smokers, most of them
women (52.7%). A significant association was found between smoking and
schooling, as well as between smoking and income. The lower the level of schooling,
the higher the frequency of smokers was (p=0.026), and the frequency of nonsmokers was associated with a higher income (p=0.021). Among tobacco users,
95.7% would like to quit smoking, 81.7% had tried at least once to stop and only
23.7% have knowledge of counselling groups for cessation. Regarding the role of
dentists in tobacco use cessation, 97.8% of smokers believe that the dentist should
give information and advice about the damage caused by smoking, but 36.6% did not
receive any advice from dentists. Evaluating the profile of smokers allows a better
planning of strategies of cessation and it is imperative that all health professionals
work together to help their patients quit smoking. In this context, the role of dentists is
essential, as patients expect them to offer information and advice for cessation.
Key Words: Tobacco, Tobacco Use Cessation, Dentists.
9
LISTA DE TABELAS
Tabela 1 – Demographic data....................................................................................19
Tabela 2 – Socioeconomic characteristics……………………………………..............19
Tabela 3 – Patterns of smoking………………………………………………….............20
Tabela 4 – Nicotine dependence - Fagerström Tolerance Questionnaire.................21
10
SUMÁRIO
INTRODUÇÃO…………………………………………………………........................11
ARTIGO – PROFILE OF SMOKERS AND THE ROLE OF DENTISTS IN
TOBACCO USE CESSATION: A CROSS-SECTIONAL STUDY IN
SOUTHERN BRAZIL…………………………………………………………............15
Abstract………..……………………………………………………………………………16
Introduction……………………………………………………………………...…………17
Methods……………………………………………………………………………………..18
Results………………………………………………………………………………………19
Discussion………………………………………………………………………………….21
References………………………………………………………………………………….25
CONSIDERAÇÕES FINAIS…………………………………………………………28
REFERÊNCIAS………………………………………………………………………....29
ANEXOS…………………………………………………………………………………..31
Anexo 1 – PARECER FINAL DO COMITÊ DE ÉTICA EM PESQUISA DA UFSM:
Levantamento epidemiológico e perfil dos pacientes tabagistas das Clínicas de
Odontologia da Universidade Federal de Santa Maria..............................................31
Anexo 2 – PARECER FINAL DO COMITÊ DE ÉTICA EM PESQUISA DA UFSM:
Avaliação do Grau de Dependência Nicotínica por meio do Questionário de
Tolerância de Fagerström nas clínicas do Curso de Odontologia da Universidade
Federal de Santa Maria..............................................................................................34
Anexo 3 – QUESTIONÁRIO: LEVANTAMENTO EPIDEMIOLÓGICO E PERFIL DOS
PACIENTES
TABAGISTAS
DAS
CLÍNICAS
DE
ODONTOLOGIA
DA
UNIVERSIDADE FEDERAL DE SANTA MARIA........................................................36
Anexo 4 – QUESTIONÁRIO DE TOLERÂNCIA DE FAGERSTRÖM........................37
Anexo
5
–
NORMAS
DA
REVISTA:
JOURNAL
OF
PUBLIC
HEALTH
DENTISTRY...............................................................................................................38
Anexo 6 – PLANILHA DE CÓDIGOS – PROFISSÕES.............................................47
11
INTRODUÇÃO
O tabagismo ainda constitui um dos principais problemas de saúde pública em
todo o mundo. A mortalidade e a morbidade atribuídas ao tabagismo constituem um
problema crescente, principalmente nos países em desenvolvimento, principal alvo
das indústrias de tabaco na atualidade. Além disso, o fumo gera um impacto
significativo para a economia dos países, representado pelos custos da assistência
médica para o sistema de saúde e pela perda de produtividade devido à morte
precoce e morbidade. O custo total atribuível ao tabagismo para o sistema de saúde
no Brasil em um ano foi de R$ 20,69 bilhões, sem estimar os custos do tabagismo
passivo (ALDERETE, 2014; ALIANÇA DE CONTROLE AO TABAGISMO, 2011).
Atualmente, 29% da população mundial é fumante (FDI/WHO, 2005), e o
cigarro é responsável por quase seis milhões de mortes todos os anos (WHO, 2011).
No Brasil, a prevalência do uso de cigarro é de 17,2% (IBGE, 2009) e o hábito é a
causa de 13% de todas as mortes no país (ALIANÇA DE CONTROLE AO
TABAGISMO, 2011), excedendo a soma das mortes por alcoolismo, AIDS, acidentes
de trânsito, homicídios e suicídios (INCA, 2007). O cigarro contém mais de 4000
substâncias tóxicas, das quais pelo menos 50 são comprovadamente carcinogênicas
(WHO, 2011). Ele é fator causal de quase 50 doenças incapacitantes e fatais (INCA,
2007) e tem impacto na saúde oral e geral, sendo fator de risco para o câncer
(principalmente quando associado ao consumo de álcool), lesões potencialmente
malignas como a leucoplasia, doenças periodontais, halitose, perda de implantes,
candidíase oral e língua pilosa (REIBEL, 2003; FERREIRA ANTUNES, 2013;
BUSENLECHNER, 2014; JOHNSON & SLACH, 2001).
A idade média de iniciação ao fumo é 15 anos, transformando o tabagismo em
um problema pediátrico (INCA, 2007). O consumo de tabaco é aprendido e
tipicamente iniciado durante a adolescência, quando a necessidade de adquirir
aceitação adaptando-se aos grupos sociais é particularmente forte (CHRISTEN et
al., 2001). Entre os fatores que influenciam a iniciação ao tabagismo na
adolescência pode-se destacar a influência dos amigos, morar com alguém que
fuma e a crença de que o cigarro tem um efeito calmante e é eficaz em controlar o
peso (BERNAT, KLEIN & FORSTER, 2012). A presença de pais e irmãos fumantes
também é um fator de influência, além das mensagens disseminadas pela mídia,
11
atualmente por meio de filmes e séries (CHRISTEN et al., 2001).
Entender o mecanismo da dependência nicotínica e como ela influencia as
tentativas de cessação é essencial para a elaboração de estratégias de suporte aos
tabagistas. A nicotina é encontrada na folha do tabaco e após ser inalada e entrar na
corrente sanguínea, atinge o cérebro em 7 a 10 segundos. Ela promove o
relaxamento muscular, aumento da frequência cardíaca e respiratória e aumento da
pressão arterial, sendo utilizada com o objetivo de melhorar a concentração e a
energia e pelo seu suposto efeito calmante. Assim como ocorre com outras
substâncias viciantes, os fumantes desenvolvem uma tolerância após um tempo de
uso, passando a exigir maiores quantidades de tabaco para alcançar os mesmos
efeitos (CHRISTEN et al., 2012). Além disso, a dependência à nicotina está
conectada a dois outros fatores: a dependência psicológica e fatores socioculturais
(CHRISTEN et al., 2001).
Com o objetivo de combater a epidemia do tabagismo, políticas de saúde
pública têm sido criadas nos últimos anos. O Brasil foi um dos 180 países que
ratificaram a Convenção-Quadro para o Controle do Tabaco da Organização
Mundial de Saúde (CQCT), que articula ações multissetoriais para proteger as
gerações presentes e futuras das consequências sociais, sanitárias, ambientais e
econômicas ocasionadas pelo uso e pela exposição à fumaça do tabaco. Ela
também tem o intuito de proteger as políticas públicas dos interesses da indústria do
tabaco (INCA, 2007; ALDERETE, 2014). Entre as principais leis e medidas de
controle ao tabagismo implementadas no Brasil, destaca-se a proibição de
publicidade de produtos de tabaco nos pontos de venda, aumento dos impostos
sobre os cigarros, proibição do fumo em todos os ambientes coletivos totais ou
parcialmente fechados, privados ou públicos e a obrigatoriedade de inclusão de
advertências sanitárias em 100% de um dos lados do maço de cigarros. A partir de
2016 serão adicionadas advertências também em 30% da face frontal da
embalagem (BRASIL. Lei nº 12.546, de 14 de dezembro de 2011; BRASIL. Decreto
nº 8.262, de 31 de maio de 2014.).
Apesar dos constantes esforços dos Estados em garantir a saúde acima de
qualquer interesse particular, a indústria do tabaco cria obstáculos à implementação
da legislação e articula estratégias contra as políticas de controle do tabagismo. No
Brasil, por exemplo, a Agência Nacional de Vigilância Sanitária realizou uma
12
consulta pública em 2010 que resultou em uma resolução proibindo o uso de
aditivos como mentol, cravo e outros aromatizantes nos cigarros, usados para tornálos mais palatáveis e atrativos, principalmente para os jovens. No entanto, a
indústria do tabaco conseguiu impedir a aplicação da resolução através de uma
liminar concedida pelo Supremo Tribunal Federal em 2013, disseminando a ideia de
que tais medidas causariam um impacto negativo sobre a economia brasileira,
gerando o desemprego dos produtores de fumo e estimulando o contrabando
(ALDERETE, 2014). A indústria tem focado sua expansão no público jovem dos
países em desenvolvimento, e por isso busca atrativos para promover a iniciação ao
fumo. O Brasil é o segundo maior produtor e o maior exportador de tabaco e
milhares de famílias de pequenos agricultores inseridas nessa cadeia produtiva
encontram-se em situação de vulnerabilidade social, econômica e sanitária. Estes
produtores estão expostos ao risco de intoxicações por agrotóxicos usados no
cultivo do fumo e ao desenvolvimento da doença da folha verde do tabaco, causada
pela absorção de nicotina na colheita da folha do tabaco (INCA, 2007; RIQUINHO;
HENNINGTON, 2014).
Vários desafios ainda precisam ser enfrentados para a redução do consumo
de tabaco e de seu impacto na sociedade. Os cigarros brasileiros estão entre um
dos mais baratos do mundo, facilitando a iniciação entre os jovens. Há também um
aumento na prevalência de fumantes entre as mulheres, e uma maior concentração
de tabagistas na população de menor escolaridade e renda. Logo, esforços devem
ser concentrados para combater essas desigualdades. Além disso, o acesso ao
tratamento para cessação do tabagismo no SUS ainda é incipiente, com apenas
6,8% dos municípios brasileiros oferecendo o serviço à população. Os cursos de
graduação da área da saúde ainda não inserem o controle do tabagismo na grade
curricular, formando profissionais com pouca ou nenhuma capacitação para atuar na
prevenção e cessação do tabagismo (INCA, 2007).
Cirurgiões-dentistas, assim como outros profissionais da área da saúde, têm a
obrigação ética de fornecer informações aos seus pacientes sobre os danos
provocados pelo cigarro e de motivar os tabagistas a pararem de fumar (CHRISTEN
et al., 2012). Quando doenças orais causadas pelo fumo são diagnosticadas, o
aconselhamento e suporte à cessação torna-se uma parte essencial do tratamento
13
odontológico e não podem ser ignorados. Atualmente 266.530 cirurgiões-dentistas
estão em atividade no Brasil (CONSELHO FEDERAL DE ODONTOLOGIA, 2015), e
aproximadamente 9.000 novos dentistas se formam anualmente no país (MORITA,
HADDAD & ARAÚJO, 2010). A grande frequência de visitas de pacientes nos
consultórios dentários possibilita repetidas intervenções para a cessação do
tabagismo, resultando em um ganho significativo para a saúde e na redução da
prevalência de uso de tabaco (FDI/WHO, 2005). O suporte à cessação do tabagismo
continua sendo uma das mais importantes estratégias no combate ao fumo, e todos
os profissionais de saúde devem estar conscientes da sua responsabilidade no
apoio aos fumantes.
14
ARTIGO
Profile of smokers and the role of dentists in tobacco use cessation: a crosssectional study in southern Brazil.
Carolina Dummel¹, Caroline Francieli Weber², Angela Isabel dos Santos Dullius3,
Sílvia Ataide Pithan4.
¹ Dental student of Federal University of Santa Maria, Santa Maria, RS, Brazil;
² Dental student of Federal University of Santa Maria, Santa Maria, RS, Brazil;
3 Professor
in the Department of Statistics in Federal University of Santa Maria, Santa Maria, RS,
Brazil;
4 Professor
in the Department of Stomatology in Federal University of Santa Maria, Santa Maria, RS,
Brazil.
Correspondence
Prof. Dr. Sílvia Ataide Pithan
Federal University of Santa Maria, Department of Stomatology.
Rua Floriano Peixoto, 1184, Prédio da Antiga Reitoria – Sala 116.
Bairro Centro - Santa Maria, Rio Grande do Sul, Brazil.
Telephone: +55 55 32209269
Email: [email protected]
15
Abstract
The aim of this study was to investigate the profile of smokers in a dental clinic
of a university in southern Brazil and their views about the role of dentists in smoking
cessation. A cross-sectional study was carried out with the patients of the Dental
School, who answered a face-to-face interview containing closed and open
questions. The sample was formed by 442 patients and data was analysed using
descriptive statistics and Chi Square test with a significance level of 5%. The mean
age was 48.5 years old and 93 patients (21.04%) were smokers, most of them
women (52.7%). A significant association was found between smoking and schooling
and between smoking and income. The lower the level of schooling, the higher the
frequency of smokers was (p=0.026), and the frequency of non-smokers was
associated with a higher income (p=0.021). Among tobacco users, 95.7% would like
to quit smoking, 81.7% had tried at least once to stop and only 23.7% have
knowledge of counselling groups. Regarding the role of dentists in tobacco use
cessation, 97.8% of smokers believe that the dentist should give information and
advice about the damage caused by smoking, but 36.6% did not receive any advice
from dentists. Evaluating the profile of smokers allows a better planning of strategies
of cessation and it is imperative that all health professionals work together to help
their patients quit smoking. In this context, the role of dentists is essential, as patients
expect them to offer information and advice for cessation.
Key Words: Tobacco, Tobacco Use Cessation, Dentists.
16
Introduction
Smoking remains one of the greatest public health concerns worldwide.
Currently, there are an estimated 1.3 billion smokers in the world, which represents
29% of the global population (1). Almost six million people die from tobacco use
every year, both from direct tobacco use and second-hand smoke (2). Smoking
prevalence among Brazilian adults is 17.2% (3) and the habit is responsible for 13%
of all deaths in this country (4). Tobacco consumption also produces a significant
burden for the economy. A 2010 report showed that R$ 20,69 billion (approximately
U$7 billion) was spent in that year in Brazil to treat tobacco-related diseases, such as
cardiovascular and respiratory diseases and some types of cancer (4).
Smoking tobacco contains over 4000 chemicals, of which at least 50 are
carcinogenic (2). It has many harmful effects both on the oral and overall health. It is
a risk factor for cancer (especially when combined with alcohol consumption),
premalignant lesions such as leukoplakia, periodontal diseases, halitosis, oral
candidosis and hairy tongue. Continued smoking is extremely detrimental to the
success of periodontal therapy and can be the cause of implant failure (5-8).
To tackle tobacco epidemic, public policies have been created in the past
years, such as restrictions on tobacco advertisements and public campaigns
promoting smoking prevention and cessation. Laws establishing smoke-free
environments, including pubs and restaurants, were adopted aiming to protect all the
population from passive smoking, and to motivate smokers to quit (9). Increasing
cigarette prices is also an effective measure to reduce tobacco use, mainly among
adolescents (10).
Offering assistance in quitting is one of the most effective strategies to control
tobacco use. Quit rates are significantly higher when the individual has support
(11,12). Tobacco cessation treatment is a cost-effective intervention whose positive
outcomes also include the early detection of oral cancer - which is decisive to the
success of the treatment – and the opportunity to teach patients how to do an oral
self-examination (13). Identifying the patterns of smoking and the level of nicotine
addiction is important to guide strategies for cessation.
17
Despite the damage caused by smoking, many health professionals do not
provide any treatment or information to tobacco users, or even referral into smoking
cessation services, in part because of a lack of knowledge and skills (14). Dentists
could significantly contribute to tobacco cessation, informing and advising their
patients and intervening at individual and community levels (15). Patients visit their
dentist more than once in a year, giving an excellent opportunity for dentists to
contribute to tobacco prevention and cessation.
The aim of this study was to evaluate the profile of tobacco users, their interest
in quitting and dental patients’ views about the role of dentists in smoking cessation.
Methods
This cross-sectional study was carried out in the Dental School of Federal
University of Santa Maria, in Santa Maria, southern Brazil. The project was approved
by the Local Ethical Committee.
A convenience sample was used with patients of the dental clinics who were
18 years of age or older. Data collection occurred between 2013 and 2014, when
patients of different clinics, smokers and non-smokers, were approached before or
after their dental appointment in the waiting room. The researcher assessed eligibility
to participate, read a plain language statement describing the project to each
potential participant and written informed consent was obtained before proceeding
with data collection. Patients were asked to answer a face-to-face interview with
twelve closed and open questions assessing the profile of tobacco users, their
interest in quitting smoking and patients’ opinions on the role of dentists in tobacco
use cessation. Smokers who answered the first interview were invited to participate in
a second interview containing six questions evaluating the level of nicotine
dependence through Fagerström Tolerance Questionnaire.
The statistical analysis was performed with Statistical Package for Social
Science (SPSS), version 17. Data was analysed by descriptive statistics and Chi
Square test was applied. T-test was used to test the difference between the age’s
averages. The level of statistical significance was set at p≤0.05.
18
Results
A total of 442 patients answered the first interview assessing the profile of
smokers and patients’ views about the role of dentists in smoking cessation. Among
the participants, 146 were men (33%) and 296 were women (67%). Ninety-three (93)
smokers answered the second interview evaluating their level of nicotine addiction.
Demographic results are outlined in Table 1. The mean age was 48.5 years old and
93 patients (21.04%) were smokers, most of them women (52.7%). There is a higher
frequency of smokers among men (0.001).
Table 1 – Demographic data.
Variable
Category
Total (n=442)
Smokers (n=93)
Non-smokers (n=349)
Age (Years)
Mean ±SD*
Minimum
Maximum
48.5 ±14.14*
18
87
48.09 ±12.68
19
71
48.63 ± 14.43
18
87
Male
Female
146 (33%)
296 (67%)
44 (47%)
49 (52%)
102 (29.2%)
247 (70.8%)
Gender
p
0.718
0.001
*Standard Deviation.
A significant association was found between smoking and schooling, as well
as between smoking and income. The lower the level of schooling, the higher the
frequency of smokers was (p=0.026), and the frequency of non-smokers was
associated with a higher income (p=0.021). Socioeconomics characteristics are
shown in Table 2. Among tobacco users, 95.7% would like to quit smoking and
81.7% had tried at least once to stop, with an average of 185 days without smoking
before relapsing. Only 23.7% smokers have knowledge of counselling groups for
cessation.
Table 2 – Socioeconomic characteristics.
Variable
Total (n=442)
Smokers (n=93)
Non-smokers
p
(n=349)
Schooling
Incomplete Elementary School
Complete Elementary School
Complete High School
Undergraduate degree/Postgraduate
175 (39.6%)
96 (21.7%)
127 (28.7%)
44 (9.9%)
48 (51.6%)
19 (20.4%)
22 (23.7%)
4 (4.3%)
127 (36.4%)
77 (22.1%)
105 (30.1%)
40 (11.4%)
0.026
19
course
Occupation
1 – Retired
2 – Student
3 – Technicians
4 – Administrative professionals
5 – Public administration professionals and
businessman
6 – Scientific and intellectual professions
7 – Farmer
8 – Production workers
9 – Sellers and other services/Not
informed
68 (15.4%)
25 (5.7%)
9 (2.0%)
15 (3.4%)
12 (2.7%)
12 (12.9%)
3 (3.2%)
3 (2.2%)
2 (2.2%)
2 (2.2%)
50 (16.6%)
22 (6.3%)
6 (1.7%)
13 (3.7%)
10 (2.9%)
10 (2.3%)
28 (6.3%)
13 (2.9%)
262 (59.2%)
8 (8.6%)
4 (4.3%)
59 (63.4%)
10 (2.9%)
20 (5.7%)
9 (2.6%)
203 (58.1%)
28 (6.3%)
191 (43.2%)
152 (34.4%)
71 (16.1%)
6 (6.5%)
53 (57%)
24 (25.8%)
10(10.8%)
22 (6.3%)
138 (39.5%)
128 (36.7%)
61 (17.5%)
0.479
Family income (Reais)
Less than 500
Between 500 and 1000
Between 1001 and 2000
Between 2001 and 3000/More than 3000
0.021
Regarding the role of dentists in tobacco use cessation, 97.8% of smokers
believe that dentists should give information and advice about the damage caused by
smoking, but 36.6% did not receive any advice from them. The majority of
participants of this study (99.3% of all participants and 98.9% of smokers) agree with
the law establishing smoke-free environments, including pubs and restaurants.
Table 3 – Patterns of smoking.
Variable
Do you smoke?
Yes
No
How long have you been smoking (in years)?
Média ±SD
How many cigarettes do you smoke per day?
Mean ±SD
Have you ever tried to quit smoking?
Yes
No
If yes, how many days did you stay free of
smoking?
Mean ±SE
Would you like to quit smoking?
Yes
No
Do you believe that oral health problems are
related to smoking?
Yes
No
Do you believe that oral health can improve if
the person stops smoking?
Total (n=442)
Smokers (n=93)
93 (21.04%)
349 (78.96%)
Non-smokers (n=349)
--
--
--
27.49
13.82*
--
--
15.33
8.66*
--
--
76 (81.7%)
17 (18.3%)
--
--
185
63**
--
--
89 (95.7%)
4 (4.3%)
--
411 (93.0%)
13 (7.0%)
84 (90.3%)
9 ( 9.7%)
327 (93.7%)
22 (6.3%)
20
Yes
No
Do you think dentists should inform and advise
their patients about the damage caused by
smoking?
Yes
No
Have you ever received any information or
advice about the harms of smoking from a
dentist?
Yes
No
Do you know couselling groups for cessation in
the city of Santa Maria?
Yes
No
Do you agree with the law establishing smokefree environments, including pubs and
restaurants?
Yes
No
429 (97.1%)
13 (2.9%)
91 (97.8%)
2 (2.2%)
338 (96.8%)
11 (3.2%)
433 (98.0%)
9 (2%)
91 (97.8%)
2 (2.2%)
342 (98.0%)
7 (2.0%)
199 (45.1%)
242 (54.9%)
59 (63.4%)
34 (36.6%)
140 (40.2%)
208 (59.8%)
115 (26%)
327 (74%)
22 (23.7%)
71 (76.3%)
93 (26.6%)
256 (73.4%)
439 (99.3%)
3 (0.7%)
92 (98.9%)
1 (1.1%)
347 (99.4%)
2 (0.6%)
*Standard Deviation. **Standard Error.
Using Fagerström Tolerance Questionnaire, 51.6% were classified as very low
and low dependent, 11.8% as medium and 36.6 % were classified as high and very
high dependent of nicotine. No association was found among level of dependence
and income (p=0.883), schooling and gender (p=0.356).
Table 4 – Level of nicotine dependence: Fagerström Tolerance Questionnaire
Variable
Smokers (n=93)
Level of dependence (points)
Mean ±SD
Level of dependence
Very low
Low
Medium
High
Very high
10.26 ±1.88
23 (24.7%)
25 (26.9%)
11 (11.8%)
22 (23.7%)
12 (12.9%)
Discussion
Identifying the profile of tobacco users and their level of nicotine dependence
is essential for planning cessation strategies. The pattern of smoking varies
according to the countries and their culture, but previous studies have shown that
generally the frequency of smoking is highest amongst people of low income and
educational background (1), which is consistent with the findings of the current study.
Reducing inequalities in smoking is a key public health priority and tobacco
prevention and cessation policies should be focused on this target audience (16).
21
The majority of women found in our sample, even among smokers, can be explained
by the fact that women are generally more concerned than men with their oral health
and search more for dental services. Participants of this study, including smokers,
have positive attitudes towards the law establishing smoke-free environments,
showing that the population is getting more conscious of the damage of smoking in
society.
Findings from our study have shown that the greatest majority of smokers
were willing to quit and had attempted at least once to stop smoking, but most of
them did not succeed. Besides, a few people were aware of community resources to
help them, indicating gaps in advertising counselling groups in the city. Difficulties
experienced during quit attempts include irritability, aggression, urge to smoke,
restlessness, increased appetite, nighttime awakenings and depression (11).
A
significant number of participants of this study have a high or very high level of
nicotine
dependence,
which
indicates
they
will
need
counselling
and
pharmacotherapy to help them quit smoking. Tobacco use cessation therapies, such
as individual or group-based counselling (12), nicotine replacement therapy (17) and
other pharmacotherapies (18) can enhance treatment outcomes, improving the odds
of quitting. The combination of counselling and medication can significantly improve
cessation rates (19) and providing follow-up can produce additional benefit (12).
Several medications are currently available for helping tobacco users to quit.
Nicotine replacement therapy (NRT) temporarily replaces the nicotine from cigarettes
to reduce nicotine withdrawal symptoms and acute cravings, facilitating the transition
from smoking to complete abstinence. This therapy increases the rate of long-term
quitting by approximately 50 to 70% and is commercially available in a variety of
forms, such as gum, transdermal patch, nasal spray and inhaler (17). Other
medications have been proved to help people to quit, such as bupropion and
varenicline. Bupropion is an antidepressant which works by blocking nicotine effects,
relieving withdrawal or reducing depressed mood. The comparison between
bupropion and NRT suggests no advantage for either therapy (18). Varenicline is a
nicotine receptor partial agonist and it is suggested that it is more effective than NRT
and bupropion to help quit smoking. It more than doubled the odds of quitting
compared with placebo (18). Adapting interventions to match smokers’ needs and
22
expectations may improve treatment outcomes. Health professionals should consider
the experiences of smokers in past quit attempts – such as difficulties, side effects of
smoking
cessation
medications
-
and
consider
their
preferences
before
recommending a cessation therapy (11).
Dentists can easily identify smokers and the impact of tobacco use in the
mouth, but their role in smoking cessation is not clear yet. Currently, there are
266,530 dentists (20) in Brazil and approximately 9,000 new dentists graduate
annually in the country (21). Dentists are in a unique position to contribute to tobacco
control. They have regular contact with patients and can easily identify the impact of
tobacco use in the mouth in a routine exam (1). First of all, dentists have an ethical
responsibility to advise all smokers to quit (13). Moreover, studies have shown that a
brief intervention for smoking cessation performed by the dentist will often result in
significant health gain, reducing the prevalence of smoking (1). When oral diseases
caused by tobacco use are diagnosed, cessation counselling is an essential part of
the treatment and cannot be neglected.
Oral professionals can intervene at individual and community levels to
contribute to the decrease of tobacco consumption. Individual approach occurs at
chair side, where the dentist spends a few minutes at every visit encouraging their
patients to quit smoking by highlighting the damage caused by tobacco use to oral
tissues and to general health and emphasizing the health benefits of quitting, always
offering support (15). For a basic intervention, dentists can use a protocol known as
the “Five As”, where they should ASK patients about their tobacco use at every
appropriate opportunity, ADVISE all smokers to quit, ASSESS their willingness to
make a quit attempt, ASSIST them in stopping and ARRANGE for supportive followup procedures (22). Community intervention includes spreading information and
educational material through mass media and community events, participating in
counselling groups for cessation and acting as a role model by not using tobacco
(15).
Although dentists have the opportunity to inform and motivate their patients to
stop smoking, this is not a routine in the dental care. The findings of the current study
are consistent with the findings of previous work (23,24), showing that patients
expect dentists to give information and advice about smoking, but many people did
23
not receive any information about the damage caused by tobacco use. Major barriers
identified by dentists to smoking cessation in the dental setting are lack of
reimbursement, time constraints, not knowing where to refer, lack of training and
knowledge, and not feeling well prepared and confident of doing so (25,26,27).
Dentists have generally positive attitudes toward the effectiveness of providing
tobacco cessation services in the dental settings, thus engaging dental professionals
in effective training and providing resources could address a number of the outlined
barriers, such as lack of knowledge, training and confidence (27). The health
department of Brazilian government offers a free training of tobacco cessation for
health professionals who work in the public service. Online training programs are
also available for health professionals, but attention is needed for the quality of these
courses (14).
The implementation of tobacco cessation programs into dental universities is
another way of involving future dentists in the duty of smoking cessation and there is
evidence of the effectiveness of this action (13,22). The Indiana University tobacco
cessation program has been successfully employed in the School of Dentistry for
more than twenty years, with the one-month quit rate of 58 percent and the one-year
quit rate of 33 percent (22). Generally, dental school curriculum concentrates on
tobacco effects in the oral cavity, but does not focus on cessation techniques.
Including tobacco cessation treatment programs into dental school curriculum would
capacitate dental students to help their patients on quit attempts and prescribe
medications when necessary. Moreover, it would make them aware of their
professional responsibility and important contribution to tackle tobacco consumption.
The use of a convenient sample is a limitation of the current study, which
allows only an internal validity of the results. As with any such research, bias may be
present, considering that all participants were patients of a dental service and most of
them were positive about the role of dentists in tobacco control. This study raises
important questions associated with the challenge of cessation faced by smokers and
health professionals. Further research is required to gain a clearer understanding of
the role of dentists in smoking cessation and prevention, including the opinion of
dental professionals, practical experiences and barriers related to tobacco cessation
programs in the dental setting.
24
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26
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27
CONSIDERAÇÕES FINAIS
Este trabalho possibilitou a identificação do perfil dos pacientes fumantes do
Curso de Odontologia da Universidade Federal de Santa Maria, incluindo seu nível
de dependência nicotínica. Além disso, avaliou o papel do cirurgião-dentista no
auxílio à cessação do tabagismo, colaborando para o desenvolvimento da pesquisa
científica. Pôde-se observar que ainda há dificuldades no encaminhamento de
pacientes para grupos de apoio à cessação em Santa Maria, pois só há um grupo
em atividade que não suporta toda a demanda da região. Qualquer profissional das
Unidades Básicas de Saúde ou Estratégias de Saúde da Família pode criar um
grupo de apoio ao abandono do tabagismo e prescrever a terapia de reposição de
nicotina. A prescrição de antidepressivos também é oferecida pelo Sistema Único de
Saúde para fumantes com dependência elevada à nicotina. Para a capacitação dos
profissionais das equipes, o Ministério da Saúde oferece um treinamento gratuito
que ensina as técnicas e abordagens mais adequadas no tratamento dos fumantes,
assim como a prescrição dos medicamentos que auxiliam a cessação.
O tratamento para cessação do tabagismo pode ser realizado por qualquer
profissional da saúde e o cirurgião-dentista deve colaborar mais ativamente no
combate ao fumo, orientando seus pacientes e oferecendo suporte em todo o
tratamento.
28
REFERÊNCIAS
ALDERETE, M. A saúde não é negociável: a sociedade civil ante as estratégias da
indústria do tabaco na América Latina. Casos de estudo 2014. 2. ed. Ciudad
Autónoma de Buenos Aires : Fundación Interamericana del Corazón Argentina,
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ALIANÇA DE CONTROLE DO TABAGISMO. Carga das doenças tabacorelacionadas para o Brasil – Relatório Final. Rio de Janeiro, 2011.
BERNAT, D. H.; KLEIN, E. G.; FORSTER, J. L. Smoking Initiation During Young
Adulthood: A Longitudinal Study of a Population-Based Cohort. J Adolesc Health, v.
51, n. 5, p. 497-502, Nov. 2012.
BRASIL. Lei nº 12.546, de 14 de dezembro de 2011. Institui o Regime Especial de
Reintegração de Valores Tributários para as Empresas Exportadoras (Reintegra) e
dá outras providências. Diário Oficial [da] República Federativa do Brasil,
Brasília,
DF,
14
dez.
2011.
Disponível
em:
<http://www.planalto.gov.br/ccivil_03/_ato2011-2014/2011/lei/l12546.htm>. Acesso
em: 25 mai. 2015.
BRASIL. Decreto nº 8.262, de 31 de maio de 2014. Altera o Decreto nº 2.018, de
1º de outubro de 1996, que regulamenta a Lei nº 9.294, de 15 de julho de 1996.
Diário Oficial [da República Federativa do Brasil], Brasília, DF, 31 mai. 2014.
Disponível
em:
<http://www.planalto.gov.br/ccivil_03/_Ato20112014/2014/Decreto/D8262.htm> Acesso em: 25 mai. 2015.
BUSENLECHNER, D. et al. Long-term implant success at the Academy for Oral
Implantology: 8-year follow-up and risk factor analysis. J Periodontal Implant Sci, v.
44, n. 3, p. 102-108, May 2014.
CHRISTEN, A. G. Tobacco Cessation, the Dental Profession, and the Role of Dental
Education. Journal of Dental Education, v. 65, n. 4, p. 368-374, Apr 2001.
CHRISTEN, A. G. et al. Understanding Nicotine Addiction and Tobacco Intervention
Techniques for the Dental Professional. Crest® Oral-B® at dentalcare.com
Continuing Education Course, Revised January 6, 2012.
CONSELHO FEDERAL DE ODONTOLOGIA. Dados estatísticos. CFO, 2015.
Disponível
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<http://cfo.org.br/servicos-e-consultas/Dadosestatisticos/?elemento=profissionais&categoria=CD&cro=Todos&municipio=>.
Acesso em: 3 jun. 2015.
FDI/WHO. Tobacco or oral health: an advocacy guide for oral health professionals.
FDI World Dental Federation, Ferney Voltaire, France / World Dental Press,
Lowestoft, UK: 2005.
29
FERREIRA ANTUNES, J. L. et al. Joint and independent effects of alcohol drinking
and tobacco smoking on oral cancer: a large case-control study. PLoS ONE, v. 8, n.
7, e68132, Jul 2013.
IBGE. Pesquisa Nacional por Amostra de Domicílios: Tabagismo – 2008. Rio de
Janeiro: Instituto Brasileiro de Geografia e Estatística, 2009.
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30
Anexo 1
31
32
33
Anexo 2
34
35
Anexo 3
QUESTIONÁRIO
TÍTULO DA PESQUISA: LEVANTAMENTO EPIDEMIOLÓGICO E PERFIL DOS PACIENTES
TABAGISTAS DAS CLÍNICAS DE ODONTOLOGIA DA UNIVERSIDADE FEDERAL DE SANTA
MARIA
NOME: ___________________________________________ IDADE: __________________ SEXO:
( )M( )F
PROFISSÃO: ____________________________________________ ENDEREÇO:
__________________________________ TELEFONE: __________________ BAIRRO:
___________________________ CEP: __________ CIDADE: ________________
NÍVEL DE ESCOLARIDADE:
( ) Ensino fundamental incompleto
( ) Ensino fundamental completo
( ) Ensino médio completo
( ) Curso superior
( ) Pós-Graduação
RENDA MENSAL DA FAMÍLIA:
( ) Menos de R$ 500,0
( ) Entre R$ 500,0 e R$ 1.000,0
( ) Entre R$ 1001 e R$ 2.000,0
( ) Entre R$ 2001 e R$ 3.000,0
( ) Mais de R$ 3.000,0
DATA: ___/___/___
1. Você é fumante? ( ) Sim
( ) Não
2. Há quanto tempo fuma? _________________________________________
3. Quantos cigarros fuma diariamente?________________________________
4. Já tentou parar de fumar? ( ) Sim
( ) Não
5. Se sim, por quanto tempo ficou sem fumar?__________________________
6. Gostaria de parar de fumar? ( ) Sim
( ) Não
7. Você acredita que algum problema de saúde bucal possa ter relação com o hábito de fumar ou ter
fumado? ( ) Sim
( ) Não
8. Você acredita que a saúde bucal pode ser beneficiada se o indivíduo parar de fumar?
Sim
( ) Não
( )
9. Você acredita que o dentista deve dar orientações aos pacientes fumantes sobre os danos
provocados pelo cigarro?
( )Sim ( )Não
10. Você já foi orientado por cirurgiões-dentistas sobre os malefícios provocados pelo tabaco?
(
)Sim ( )Não
11. Você tem conhecimento de grupos de apoio para cessação do tabagismo na cidade de Santa
Maria?
( )Sim ( )Não
12. Você concorda com a Lei que proíbe o fumo em todos os ambientes fechados inclusive bares e
36
restaurantes?
( )Sim ( )Não
Anexo 4
QUESTIONÁRIO DE TOLERÂNCIA DE FAGERSTRÖM
NOME: ______________________________________________________________
IDADE: ____________________________TELEFONE: ________________________
ENDEREÇO: __________________________________________________________
BAIRRO: ___________________________ CEP: _____________________________
CIDADE: _____________________________________________________________
DATA: ___/___/___
CLÍNICA: __________________________________
Pergunta nº 1: Quanto tempo após acordar você fuma seu primeiro cigarro?
( ) Dentro de 5 minutos - 3 pontos
( ) Entre 6 e 30 minutos - 2 pontos
( ) Entre 31 e 60 minutos - 1 ponto
( ) Após 60 minutos - 0 pontos
Pergunta nº 2: Você acha difícil não fumar em locais onde o fumo é proibido (como igrejas,
bibliotecas, etc.)?
( ) Sim - 1 ponto
( ) Não - 0 pontos
Pergunta nº 3: Qual o cigarro do dia que traz mais satisfação (ou que mais detestaria deixar de
fumar)?
( ) O primeiro da manhã - 1 ponto
( ) Outros - 0 pontos
Pergunta nº 4: Quantos cigarros você fuma por dia?
( ) 10 ou menos - 0 pontos
( ) 11 a 20 - 1 ponto
( ) 21 a 30 - 2 pontos
( ) 31 ou mais - 3 pontos
Pergunta nº 5: Você fuma mais frequentemente pela manhã (ou nas 1as horas do dia) que no resto
do dia?
( ) Sim - 1 ponto
( ) Não - 0 pontos
Pergunta nº 6: Você fuma mesmo quando está tão doente que precisa ficar de cama a maior parte
do tempo?
( ) Sim - 1 ponto
( ) Não - 0 pontos
Análise dos resultados:
De acordo com a soma de pontos obtidos com as respostas referentes às perguntas, classifica-se a
dependência nicotínica em cinco graus:
- muito baixa (0-2 pontos)
- elevada (6-7)
37
- baixa (3-4)
- muito elevada (8-10)
- média (5)
Anexo 5
NORMAS DA REVISTA: JOURNAL OF PUBLIC HEALTH DENTISTRY
Journal of Public Health Dentistry
Instructions for Contributors
The Journal of Public Health Dentistry (JPHD) is devoted to the advancement of
public health dentistry through the publication of related research, practice, and
policy developments. We publish, after peer review and/or editorial consideration,
original research articles, brief reports, systematic reviews, articles addressing new
research methods, community action reports, special issues, guest editorials and
commentaries, letters to the editor, and book reviews.
Regular-length scientific articles should be between 2,500 and 3,500 words in length,
with no more than six tables or figures and fewer than 30 references (estimated to be
a total of 21 or fewer double-space pages).
Systematic reviews are similar in length but with different expectations regarding
references and tables, based on the results of the review. Authors are strongly
encouraged to discuss systematic reviews with the editor prior to initiating the review
to ensure that they are carried out in accordance with best practices (e.g., QUORUM
guidelines) and their length can be accommodated by the Journal.
Brief Communications are 1,000–1,500 words, no more than two tables or figures, an
abstract of 150 words or less, and 10 or fewer references. Brief Communications,
commentaries, and systematic reviews undergo peer review similar to regular
scientific manuscripts.
Community Action Reports, highlighting practice-based programs or policy initiatives,
commentaries, and guest editorials of widespread interest to the dental public health
community are 1,000–1,500 words.
Special Issues and Supplements to regular issues may be published, the full cost
being paid by the authors or sponsoring agency. Contact the editor for further in
formation.
Preparation of Manuscripts
Submissions must be in English and conform to the Uniform Requirements for
Manuscripts Submitted to Biomedical Journals. The complete document appears in
Ann
Intern
Med
1997;126(1):36-47;
or
online
at http://www.acponline.org/journals/resource/unifreqr.htm.
38
If you feel that your paper could benefit from English language polishing, we
recommend that you have your paper professionally edited for English language by a
service such as Wiley's athttp://wileyeditingservices.com. Please note that while this
service (which is paid for by the author) will greatly improve the readability of your
paper, it does not guarantee acceptance or preference of your paper by the journal.
Submission of Manuscripts
Manuscripts should be submitted through the ScholarOne Manuscripts site
at:http://mc.manuscriptcentral.com/jphd. Authors will be directed through the
submission process at the Website.
Use double-spacing throughout, including title pages, abstract, text,
acknowledgments, references. Begin each of the following sections on separate
pages: title page, abstract and key words, text, acknowledgments, references, and
individual tables and figures. Number pages consecutively in the upper right-hand
corner of each page, beginning with the title page. Our reference book is MerriamWebster Collegiate Dictionary, 11th edition (Springfield, MA: Merriam-Webster,
2003).
Format and Style of Scientific Articles
Title Page. To facilitate the masked review process, include a title page giving only
the title of the manuscript and not identifying authorship. Authors’ names should not
appear on any manuscript page.
Abstract. The second page should carry an abstract of no more than 250 words (150
for Brief Communications) consisting of four paragraphs, labeled Objectives,
Methods, Results, and Conclusions. These sections should describe the problem
being addressed in the study, how the study was performed, the salient results
(without statistical tests), and what the authors conclude from the results.
Key Words. Below the abstract, provide, and identify as such, three to 10 key words
or short phrases that will assist indexers in cross-indexing your article. At least three
terms from the medical subject headings (MeSH) list of Index Medicus should be
used. The use of MeSH headings greatly facilitates the identification of your article by
online search engines and improves the likelihood that interested readers can
retrieve your article. Assistance in locating MeSH headings is provided
at: http://www.nlm.nih.gov/mesh/MBrowser.html
Text. Divide text of scientific articles into sections labeled Introduction, Methods,
Results, and Discussion. For other types of articles, consult recent issues of the
JPHD for further guidance. All acronyms must be spelled out when they first appear
in the text.
39
Introduction. Clearly state the purpose of the article and summarize the rationale for
the study. Give only strictly pertinent references, and do not review the subject
extensively.
Methods. Describe your methods clearly and in sufficient detail to allow other
workers to reproduce the results. Give references to established methods, including
statistical methods; provide references and brief descriptions for methods that have
been published but are not well known; describe new or substantially modified
methods, give reasons for using them, and evaluate their limitations. When reporting
investigations involving human subjects, indicate whether the procedures followed
were in accordance with the ethical standards of the responsible committee on
human experimentation.
Results. Present results in logical sequence in the text, tables, and illustrations. Do
not repeat in the text all the data in the tables or figures; rather emphasize or
summarize only important observations.
Discussion. Emphasize the new and important aspects of the study and conclusions
that follow from them, particularly as these relate to public health. Do not repeat in
detail data given in the Results section. Include in the Discussion the implications of
the findings and their limitations, and relate the observations to other relevant
studies. Avoid unqualified statements and conclusions not well supported by your
data. State new hypotheses when warranted, but clearly label them as such. Include
recommendations when appropriate.
Acknowledgments. Acknowledge only persons who have made substantive
contributions to the study. Obtain written permission from persons acknowledged by
name, because readers may infer their endorsement of the data and conclusions. A
description of sources of funding, financial disclosure, and the role of sponsors must
be included in this section.
Conflicts of Interest. Include this section as part of Acknowledgements, but only if
the authors have personal financial interests related to the subject matters discussed
in the manuscript.
Footnotes and Appendices. Except in tables and figures, footnotes should not be
used. Appendices may be placed on the JPHD website by Blackwell after
consultation with the editor.
References. References for research manuscripts are in general limited to no more
than 30; for brief communications please limit to ten or fewer. The author(s) must
verify cited references against the original documents. JPHD uses the “Vancouver”
40
style and information can be found at the Uniform Requirements page and well as
some
examples
at
(http://www.nlm.nih.gov/bsd/uniform_requirements.html).
Identify references in text, tables, and legends by Arabic numerals in parentheses;
number consecutively in the order in which they are first mentioned in the text. Avoid
using abstracts as references. Abstracts not published in the periodical literature
(e.g., printed only in an annual meeting program) may be cited only as written
communications in parentheses in the text. “Unpublished observations” and
“personal communications” may not be used as references, although references to
written, not oral, communications may be inserted (in parentheses) in the text. For
papers accepted but not yet published; designate the journal and add “in press.”
Information from manuscripts submitted but not yet accepted should be cited in the
text as “unpublished observations” (in parentheses). Acceptable forms of references
are based on an ANSI standard style adapted by the National Library of Medicine
and authors are encouraged to refer to the examples of reference styles provided in
the Uniform Requirements. Systematic reviews do not have a specific limitation on
number of references.
Tables. Type each table on a separate page. Number tables with an Arabic numeral
consecutively and supply a brief title for each. Explain in footnotes all nonstandard
abbreviations used in each table. (Please refer to the JPHD, Volume 60, No. 4, page
347-8 to confirm these characters if you plan to use these symbols).
Illustrations and Legends. Submit the required number of complete sets of figures.
Figures should be of a high standard and if necessary, professionally drawn. Label
each figure indicating the number of the figure. Cite each figure in the text in
consecutive order. Type or print out legends for illustrations using double spacing,
starting on a separate page, with Arabic numerals corresponding to the illustrations.
When symbols, arrows, numbers, or letters are used to identify parts of the
illustrations, identify and explain each one clearly in the legend. Explain the internal
scale and identify the method of staining in photomicrographs. The Journal cannot
reproduce color images or figures.
Photographs of People. The Journal of Public Health Dentistry follows current
HIPAA guidelines for the protection of patient/subject privacy. If an individual
pictured in a digital image or photograph can be identified, his or her permission is
required to publish the image. The corresponding author may submit a letter signed
the patient authorizing the Journal of Public Health Dentistry to publish the
image/photo. Or, a form provided by the Journal of Public Health Dentistry
(available here or by clicking the “instructions and Forms” link in Manuscript Central)
may be downloaded for your use. The approval must be received by the Editorial
Office prior to final acceptance of the manuscript for publication. Otherwise, the
image/photo must be altered such that the individual cannot be identified (black bars
over eyes, tattoos, scars, etc.). The Journal of Public Health Dentistry will not publish
41
patient photographs that will in any way allow the patient to be identified, unless the
patient has given their express consent.
Publication
Prior and Duplicate Publication. Manuscripts are not accepted for consideration if
they are based on work that has been or will be published or submitted elsewhere
before appearing in the JPHD. Exceptions are consistent with the policy on duplicate
or redundant publication developed by the International Committee of Medical
Journal
Editors
Ann
Intern
Med
1997;126(1):36-47;
or
online
at http://www.acponline.org/journals/resource/unifreqr.htm. Copies of any closely
related manuscripts should be submitted to the editor along with the manuscript that
is to be considered by the JPHD.
Authorship
All persons designated as authors should qualify for authorship. Each author should
have participated sufficiently in the work to take public responsibility for the content.
Authorship credit should be based only on substantial contributions to: (1) conception
and design, or analysis and interpretation of the data; and to (2) drafting the article or
revising it critically for important intellectual content; and on (3) final approval of the
version to be published. Conditions 1, 2, and 3 must all be met. The editor may ask
for verification of these conditions for each author.
Copyright Issues
JPHD encourages the posting of manuscripts resulting from NIH-funded research to
PubMed Central (www.pubmedcentral.nih.gov) in order to promote public access to
critical research findings. Authors whose manuscripts are accepted for publication in
JPHD may post the final, edited version of the manuscript as soon as the printed
journal version is distributed.
Submission of Manuscripts and Correspondence
Manuscripts should be submitted through the ScholarOne Manuscripts site
at:http://mc.manuscriptcentral.com/jphd. Follow the guidelines for submitting at the
site.
Questions on manuscript submission, cover letters, and copyright assignments
should be directed to the journal administrator at: [email protected].
Questions regarding the appropriateness of articles for the journal or questions about
the review and acceptance process should be directed to the editor
at: [email protected].
A covering letter, signed by all authors, should be mailed or FAXED (217-529-9120)
to be received at the same time as the manuscript. A scanned copy of a signed letter,
sent electronically as a PDF, is also acceptable. It should include (1) information on
prior or duplicate publication or submission elsewhere of any part of the work as
defined in the Uniform Requirements; (2) a statement of financial or other
42
relationships that might lead to a conflict of interest; (3) a statement that the
manuscript has been read and approved by all the authors, that the requirements for
authorship have been met, and that each author believes that the manuscript
represents honest work; and (4) the name, address, and telephone number of the
corresponding author who is responsible for communicating with the other authors
about revisions and final approval of the proofs. A scanned copy of the signed letter
may be sent electronically or mailed to the journal administrator at above address.
Manuscript Submitted Previously to Another Journal
If a manuscript recently underwent peer review by another journal, authors should
disclose this information. They should include either the previous critique or a cover
letter with the new submission that explains how the authors have modified the
manuscript to address the previous (outside) critique.
Review and Action
Manuscripts are acknowledged upon receipt, reviewed by the editorial staff, and if
they meet minimal publication criteria, are sent to at least two outside referees for a
blind review.
Accepted manuscripts are examined and editorial revisions likely will be made to add
clarity and to conform to the JPHD style. Authors will be sent proofs prior to printing.
Upon acceptance, papers become the permanent property of the JPHD and may not
be reproduced by any means, in whole or in part, without the written consent of the
editor.
Peer Reviewer Nominations
The editor selects the reviewers for each submission and encourages
recommendations for reviewers from submitting authors. Thus, during the submission
process, authors may nominate 2 to 4 external referees to review their manuscript
(please provide at least their name and email address). The best reviewers are
authors of publications on which your research builds and which you cite. Peer
reviewers must have a publishing track in the area the manuscript deals with.
When suggesting peer reviewers, conflicts of interests should be avoided, that is,
suggested referees should not:
be from the same department or (ideally) the same university;
have been a research supervisor or graduate student of one of the authors within the
past five years;
have collaborated with one of the authors within the past five years or have plans to
collaborate in the immediate future;
be employees of non-academic organizations with which one of the authors has
collaborated within the past five years;
or be in any other kind of potential conflict of interest situation (eg, personal,
financial).
43
We ask applicants not to contact suggested referees in advance. The editor reserves
the right to send the manuscript to other referees.
Reporting Guidelines for Specific Study Designs
Authors are encouraged to consult best practice guidelines relevant for their research
design.
Research
reports
frequently
omit
important
information.
Randomized Controlled Clinical Trials (RCTs) are highly encouraged and should be
reported in accordance with the CONSORT statement (http://www.consortstatement.org/).
A diagram illustrating the flow of participants through the trial is required
(http://www.consort-statement.org/index.aspx?o=1077). Please complete and include
the CONSORT checklist with the submission.
In accordance with recommendations from the ICMJE (Uniform Requirements) it is
strongly recommended that RCTs be registered in a WHO accredited trial registry
(this is mandatory for industry sponsored trials). Please mention the International
Standard Randomized Controlled Trial Number (ISRCTN) (or a comparable trial
identifier) at the end of the abstract (in brackets), as well as when you first mention
the acronym of a RCT in the manuscript.
Reporting guidelines have also been developed for a number of other study designs
and as JPHD encourages reviewers to use these guidelines during the peer review
process, authors are well advised to use these checklists as well during research
planning
and
manuscript
preparation.
Examples
include:
for observational epidemiology studies the STROBE guidelines (http://www.strobestatement.org/) and for meta-analysis and systematic reviews the QUORUM
statement, (Lancet. 1999 Nov 27;354(9193):1896-900).
Early View
The Journal is part of the Wiley Interscience Early View service. Articles are
published on a regular basis online in advance of their appearance in a print issue.
These articles are fully peer reviewed, edited, and complete—they only lack page
numbers and volume/issue details—and are considered fully published from the date
they first appear online. This date is shown with the article in the online table of
contents. Because Early View articles are considered fully complete, please bear in
mind that changes cannot be made to an article after the online publication date even
if it is still yet to appear in print.
The articles are available as full text HTML or PDF and can be cited as references by
using their Digital Object Identifier (DOI) numbers. For more information on DOIs,
please seehttp://www.doi.org/faq.html.
To view all the articles currently available, please visit the journal homepage
athttp://onlinelibrary.wiley.com/doi/10.1111/jphd.2008.9999.issue-9999/issuetoc.
Upon print publication, the article will be removed from the Early View area and will
appear instead in the relevant online issue, complete with page numbers and
volume/issue details. No other changes will be made.
44
The implementation of Early View for JPHD represents our commitment to publishing
articles as soon as possible for readers, reducing time to publication considerably
without sacrificing quality or completeness.
NIH Policy
Wiley-Blackwell supports authors by posting the accepted version of articles by NIH
grant-holders to PubMed Central. The accepted version is the version that
incorporates all amendments made during peer review, but prior to the publisher's
copy-editing and typesetting. This accepted version will be made publicly available
12 months after publication in the journal. The NIH mandate applies to all articles
based on research that has been wholly or partially funded by the NIH and that are
accepted for publication on or after April 7, 2008. For more information about the
NIH's Public Access Policy, visit http://publicaccess.nih.gov.
Wiley-Blackwell also offers its OnlineOpen and Funded Access services. Upon
payment of the OnlineOpen or Funded Access fee, we will deposit the published
version of the article into PubMed Central, with public availability in PubMed Central
and on the journal's website immediately upon publication.
Copyright
If your paper is accepted, the author identified as the formal corresponding author for
the paper will receive an email prompting them to login into Author Services; where
via the Wiley Author Licensing Service (WALS) they will be able to complete the
license agreement on behalf of all authors on the paper.
For authors signing the Copyright Assignment Form
If the OnlineOpen option is not selected the corresponding author will be presented
with the copyright form to sign. The terms and conditions of the copyright form can be
previewed here.
Terms and Conditions [PE to add existing non-standard license PDF to OTIS and
provide link from Online Library once live]. Please do not complete this PDF until you
are prompted to login into Author Services as described above.
Note to Contributors on Deposit of Accepted Version
Funder arrangements
Certain funders, including the NIH, members of the Research Councils UK (RCUK)
and Wellcome Trust require deposit of the Accepted Version in a repository after an
embargo period. Details of funding arrangements are set out at the following website:
http://www.wiley.com/go/funderstatement. Please contact the Journal production
editor if you have additional funding requirements.
Institutions
Wiley has arrangements with certain academic institutions to permit the deposit of
the Accepted Version in the institutional repository after an embargo period. Details
of
such
arrangements
are
set
out
at
the
following
website:
http://www.wiley.com/go/funderstatement
45
For authors choosing OnlineOpen
If the OnlineOpen option is selected the corresponding author will have a choice of
the following Creative Commons License Open Access Agreements (OAA):
Creative Commons Attribution License OAA
Creative Commons Attribution Non-Commercial License OAA
Creative Commons Attribution Non-Commercial -NoDerivs License OAA
To preview the terms and conditions of these open access agreements please visit
the
Copyright
FAQs
hosted
on
Wiley
Author
Services
http://authorservices.wiley.com/bauthor/faqs_copyright.asp
and
visit
http://www.wileyopenaccess.com/details/content/12f25db4c87/Copyright-License.html.
If you select the OnlineOpen option and your research is funded by The Wellcome
Trust and members of the Research Councils UK (RCUK) you will be given the
opportunity to publish your article under a CC-BY license supporting you in
complying with Wellcome Trust and Research Councils UK requirements. For more
information on this policy and the Journal’s compliant self-archiving policy, please
visit: http://www.wiley.com/go/funderstatement.
46
Anexo 6
PLANILHA DE CÓDIGOS - PROFISSÕES
Código
Resposta
1
Aposentado (a)
2
Estudante
3
Técnicos e profissionais de nível
intermédio:
Técnica em enfermagem
Técnico em Refrigeração
Consultora
Pessoal Administrativo e similares:
Caixa de operadora
Auxiliar de Secretária
Agente Educacional
Secretária
Contadora
Operadora de caixa
Auxiliar contábil
Administradora escolar
Auxiliar administrativo
Auxiliar de Escritório
Quadros superiores da administração
pública, dirigentes, etc:
Funcionário Público (Municipal, Estadual
e Federal)
Microempresário
Especialistas das profissões intelectuais
e científicas:
Professor, Pedagogo (a), Fisioterapeuta,
Enfermeira, Veterinário, Enfermeira,
Agrônomo,
Agricultores e trabalhadores qualificados
da agropecuária:
Agricultor
Domadora de Animais
Técnico Agrícola
Operários, artífices e trabalhadores
similares:
Ajudante de pedreiro
Carpinteiro
Eletricista
Operador de escavadeira
Pedreiro
Pintor
Servente
Pessoal dos serviços e vendedores:
Açougueiro
Agente de serviços complementares
Ajudante de cozinha
4
5
6
7
8
9
47
Atendente de lanchonete
Atendente de farmácia
Autônoma
Auxiliar de confeiteira
Auxiliar de limpeza
Auxiliar de Saúde Bucal
Auxiliar de serviços gerais
Balconista
Bicicleteiro
Cabelereiro
Camareira
Caseira
Chapista
Comerciante
Confeiteira
Costureira
Cuidadora de idosos
Do lar
Doméstica/Diarista
Empacotadora
Escriturário
Esteticista canina
Fiscal de loja
Funcionário do HUSM
Garçom
Guincheiro
Instrutora
Lojista
Manicure
Mecânico
Motoboy
Motorista
Músico
Operador CNC
Padeiro
Porteiro
Preparador automotivo
Recepcionista
Revendedor
Sapateiro
Serviços gerais
Vendedor (a)
Vigilante
Zelador
Não informada
48