Public opinions on community water fluoridation.
Quinonez, Carlos R. ; Locker, David
Community water fluoridation (CWF) has been promoted as the most
equitable and cost-effective dental caries preventive measure of modern
society. (1) Indeed, the Centers for Disease Control and Prevention list
CWF among the top ten public health achievements of the twentieth
century. (2) Across Canada, CWF coverage varies from as low as 0 to 4%
in the Yukon and British Columbia, to as high as approximately 75% in
Alberta and Manitoba. (3) Within the dental profession, there is minimal
debate concerning the effectiveness of CWF, and overall, the profession
is an ardent supporter of the practice. (4,5) Yet regardless of its
recognized successes, within popular culture there remains considerable
debate regarding the safety and value of CWF.
For example, a petition calling for the national discontinuation of
CWF was recently registered under the Government of Canada's
Auditor General Act, (6) while an Application for Review registered
through the Government of Ontario's Environmental Bill of Rights
has resulted in a formal review of the province's CWF policies and
regulations. (7) Across the country, municipal governments are also
debating the issue, (8-12) and anecdotally, policy leaders have
suggested a developing awareness of seriously degraded CWF
infrastructure.
In the current environment, there is concern among policy leaders
as to whether the practice remains acceptable to Canadians generally,
and specifically in lieu of competing resource demands. As a result, in
order to inform the evidence base surrounding the CWF debate, this study
asks: What are public opinions on CWF?
METHODS
Data were collected in April 2008 from a representative sample of
Canadian adults by means of a national telephone interview survey using
random digit dialling and computer-assisted telephone interview
technology (N=1,005, assumes maximum variance and a 95% confidence
interval of [+ or -]3%). A private firm was employed to collect the data
as part of its weekly national omnibus survey. The participation rate
for this weekly survey is approximately 3%, meaning that, on average,
32,000 to 44,000 numbers are dialled to gather a sample of approximately
1,000. Among attempted calls, approximately 21,000 are busy signals, no
answer, answering machine, or invalid numbers. The survey is conducted
in both French and English, dependent on participant preference.
Willingness to participate in the survey is taken to imply consent, and
no personal identifiers are collected. The data received by the
researchers were weighted to replicate regional population
distributions, by age and sex, according to 2001 Census data. The study
received expedited review and approval from a university ethics board.
The 15-item survey reproduced questions from recent work conducted
in Australia, (13,14) and incorporated questions suggested by the
Ontario Association of Public Health Dentistry. The survey obtained data
on: a) knowledge of CWF (e.g., Have you heard or read about CWF? As you
understand it, what is the purpose of CWF?); b) beliefs about CWF (e.g.,
Do you believe that CWF is effective? Do you think CWF is safe? Do you
support CWF?); c) general health and dental care behaviours (e.g., Do
you use fluoride-containing toothpaste? Do you avoid fluoride-containing
products? How would you rate your oral health? When was the last time
you visited a dentist?); and d) socio-demographics (age, gender, income,
education, number of children).
Using SPSS 13.0, simple descriptive analyses were undertaken.
Bivariate logistic regression odds ratios were used to assess
relationships between opinions on CWF, self-reported health and dental
care behaviours, and socio-demographic characteristics. Multivariate
logistic regression odds ratios were then calculated for three outcomes
(i.e., the odds of having heard or read about CWF, the odds of
supporting CWF, the odds of avoiding water or products that contain
fluoride).
RESULTS
Forty-five percent of this sample of Canadian adults had heard or
read about CWF (Table 1). They had heard or read about CWF predominantly
from print and electronic media (Table 2). Of those who knew about CWF,
the great majority (79.5%) understood that it was used to prevent dental
caries (Table 2). Similarly, 63.0% believed that CWF was safe, and 59.7%
believed that it was effective (Table 1).
Importantly, 62.4% of those who knew about CWF supported the idea
of having fluoride added to their local drinking water (Table 1). Of
these, the great majority (89.6%) would continue to support the practice
if governments had to spend money on new equipment and training (Table
1). Finally, among the entire sample, 70.9% reported using
fluoride-containing toothpaste, and 16.3% reported trying to avoid
products or water that contained fluoride (Table 1).
From a public health perspective, it is important to understand
what characterizes knowledge of CWF. In this regard, Table 3 documents
the odds of having heard or read about CWF. Bivariately, it appears that
as age, income and education increase, so does an awareness of CWF.
Conversely, when compared to urban areas, those who lived in rural areas
were less aware of CWF, as were those families with the youngest
children. Multivariately, income and education remain as the strongest
predictors of having heard or read about CWF.
It is also important to understand what characterizes support for
CWF. In this regard, Table 4 documents the odds of supporting CWF.
Bivariately, it appears that women, those with children, those who pay
for dental care out-of-pocket, and those who avoid fluoride, were all
less likely to support CWF; while those with greater incomes and those
who visit the dentist more regularly were more likely to support CWF.
Multivariately, income, having children, visiting frequency, and
avoiding fluoride remain as predictors. A new relationship also appears
relative to insurance, meaning that those who used public insurance were
less likely to support CWF.
Finally, it is also important to understand what characterizes the
minority who avoid water or products that contain fluoride. In this
regard, Table 5 documents the odds of attempting to avoid fluoride.
Bivariately, those in rural areas and those with children under 6 years
were more likely to avoid fluoride. Those with more income and education
were less likely to avoid it. Multivariately, those with children under
6 years remains as the only predictor.
DISCUSSION
These data tell us that approximately one in two Canadians know
about CWF. Of those who know about it, the majority think it is safe,
support it, and do so even if new resource demands are made in terms of
equipment and training. Yet irrespective of this support, CWF in Canada
is arguably experiencing social challenges. For example, during the
writing of this report, a municipal plebiscite in one Canadian community
asked: Are you in favour of the fluoridation of the public water supply
of this municipality? There was a 35% voter turnout, and the great
majority (87%) voted that they were not in favour. (15) Yet in a
plebiscite only two years earlier in the same community, approximately
66% had been in favour of fluoridation. (16)
Stakeholders suggest that this turn in public opinion is largely
the result of the well-organized efforts of anti-fluoride groups,
specifically through their strong presence on the Internet. From the
point of view of policy leaders, while there is ample evidence that CWF
is an effective means to control dental caries, there now exists a very
real challenge: How to maintain current levels of CWF while addressing
what appears to be an increasing social resistance to the practice?
First, it is necessary to not get caught up with the fervour of
anti-fluoride sentiment. No amount of credible science will satiate such
appetites. For the moment, policy leaders are well supported in their
belief that the general public perceives CWF as a viable option, and
this, in turn, is strongly reflected in the committed response produced
by numerous federal agencies to the petition registered under the
Auditor General Act. (17) Second, if any action is taken to counter
anti-fluoride sentiment, a social marketing approach under the purview
of 'issues management' and 'communications'
expertise in governments is a good direction.
Importantly, these data can inform this direction, as they help
characterize knowledge of CWF, support for CWF, and the tendency to
avoid fluoride. As demonstrated, all of these outcomes are associated
with patterns that are generally described as 'disparities' in
the oral health arena, meaning that age, rural residence, income,
education, the frequency of dental visits, and insurance coverage, all
appear to play some role in determining these states.
More importantly, these data also point to the potentially harmful
aspects of anti-fluoride discourse. For example, it appears that gender
and having children, in particular very young children, plays a role in
perceiving CWF and fluoridation as a negative thing. This has important
implications in terms of risk: if the strongest predictor of not
supporting CWF is the active avoidance of fluoride-containing products
(e.g., fluoridated toothpaste), it is conceivable that the anti-caries
effect of fluoride is completely lost in certain households; again,
potentially those households with the youngest children. This actually
corresponds well with informal accounts by paediatric dentists
suggesting that dental caries in very young children are appearing with
greater frequency. While no data are available for Canada, recent
evidence from the US, generally considered a good proxy, demonstrates
that there has been an overall increase in dental caries among 2-5 year
old children. (18)
This study's findings are also consistent with international
evidence on public opinions of CWF, which dates back to the 1950s, with
the most recent evidence published in 2008. (13,14,19-33) This evidence
suggests that knowledge about fluoridation varies across and within
countries, and is largely dependent on experience with CWF. In the US,
for example, Beal (30) noted that knowledge of CWF grew from
approximately 50% in the 1950s to approximately 70% by the 1970s, likely
as a result of its increasing prevalence. The most recent evidence from
the US suggests that, by 1990, knowledge stood at approximately 62%.
(29) Studies also confirm the role of the media as the predominant
source of knowledge for CWF. (26,28,32)
A general trend of diminishing support for CWF has also been noted
internationally. (31,33) There appears to be a general trend that those
with high income or education are more likely to know and support CWF,
as are those who visit the dentist with more frequency. (13,27,29,32)
The most recent evidence demonstrates gender as a predictor, meaning
that women appear to be less supportive of CWF. (13)
It is also necessary to discuss the limits of this study's
methods and findings. For example, there is an increasing concern that
telephone interview surveys are not as representative as they used to
be, especially since more and more people opt for cellular telephones
instead of conventional landlines. To be sure, without weighting the raw
data to replicate the age distribution of the population, this
study's data are clearly overrepresented by older adults. It is
thus arguable that there is some level of selection bias relative to the
method employed.
These data are also time sensitive, meaning that changes in public
perception can be rather rapid. In this regard, policy leaders should
not take these data as representative evidence on 'the voting
public.' It has been noted that while "opinion polls may show
large percentages in favour of fluoridation, when it is voted upon in
public referenda it is often defeated, suggesting that public opinion
[is] unpredictable and inconsistent" (ref. 32, p. 43). A related
limitation is that this study did not ask whether participants felt
strongly enough about CWF such that they would go out and vote on the
matter.
Overall, within these limitations, this study nevertheless provides
useful information where there had been none. To conclude, it appears
that Canadians still support CWF, and that in moving forward, policy
leaders will need to attend to two distinct challenges: the influence of
anti-fluoride sentiment, and the potential risks created by avoiding
fluoride.
Received: May 13, 2008
Accepted: September 25, 2008
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(28.) Pollick H. A pre-referendum survey of fluoridation attitudes
and intended vote. Commun Dental Health 1988;5(1):49-62.
(29.) Centers for Disease Control. Knowledge of the purpose of
community water fluoridation - United States, 1990. MMWR Weekly
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(Ed.), The Prevention of Dental Disease. Oxford, UK: Oxford University
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(32.) Chikte U, Brand A. Attitudes to water fluoridation in South
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Carlos R. Quinonez, DMD, MSc, David Locker, BDS, PhD, DSc, FCAHS
Authors' Affiliation
Community Dental Health Services Research Unit, Faculty of
Dentistry, University of Toronto, Toronto, ON
Correspondence and reprint requests: Dr. Carlos R. Quinonez, Room
#521A, Community Dental Health Services Research Unit, Faculty of
Dentistry, University of Toronto, 124 Edward Street, Toronto, ON M5G
1G6, Tel: 416-979-4908, ext. 4493, Fax 416-979-4936, E-mail:
carlos.quinonez@utoronto.ca
Table 1. Public Opinions on CWF
N (%)
Yes No
Have you heard or read anything about CWF? 462 (46) 533 (53)
Do you believe that CWF is effective in the 276 (60) 108 (23)
prevention of tooth decay?
Do you believe that fluoridating the drinking 291 (63) 96 (21)
water is safe?
Do you support the idea of having fluoride 288 (62) 144 (31)
added to your local drinking water?
If governments had to spend money on new 258 (90) 22 (8)
equipment and training, would you still
support the practice?
Do you use fluoride-containing toothpaste? 713 (71) 195 (19)
Do you try to avoid products or water that 163 (16) 786 (78)
contain fluoride?
N (%)
Don't Know Total
Have you heard or read anything about CWF? 10 (1) 1005 (100)
Do you believe that CWF is effective in the 78 (17) 462 (100)
prevention of tooth decay?
Do you believe that fluoridating the drinking 75 (16) 462 (100)
water is safe?
Do you support the idea of having fluoride 30 (7) 462 (100)
added to your local drinking water?
If governments had to spend money on new 8 (2) 288 (100)
equipment and training, would you still
support the practice?
Do you use fluoride-containing toothpaste? 97 (10) 1005 (100)
Do you try to avoid products or water that 56 (6) 1005 (100)
contain fluoride?
Table 2. Knowledge of CWF
N %
Where did you read or hear about fluoridation?
Print media 181 39.2
Electronic media 119 25.7
Friends 38 8.2
Clinic 5 1
Dentist 10 2.3
Educational institutions 39 8.4
Don't know 70 15.2
Total 462 100
As you understand it, what is the purpose of
adding fluoride to the drinking water?
Prevents tooth decay, protects teeth, or related 367 79.5
response
Purifies the water or related response 31 6.7
Other 24 5.2
Don't know 40 8.6
Total 462 100
Table 3. Odds of Having Heard or Read About CWF
Variables Model 1: Unadjusted p value
OR * [95% CI]
Socio-demographics
Female 0.93 [0.73, 1.20] 0.593
Age 1.31 [1.19, 1.44] 0.001
Rural 0.76 [0.58, 0.98] 0.033
Income 1.27 [1.16, 1.39] 0.001
Education 1.74 [1.51, 2.00] 0.001
Children <17 0.92 [0.69, 1.21] 0.539
Children <6 0.60 [0.39, 0.92] 0.020
Children 6-12 1.42 [0.93, 2.18] 0.106
Children 13-17 1.38 [0.90, 2.13] 0.141
Oral health and dental care
characteristics
Self-rating of oral health 1.06 [0.94, 1.21] 0.347
Visiting frequency 1.14 [0.99, 1.30] 0.066
Insurance status
Through my employment Reference
Through someone else's employment 0.69 [0.47, 1.01] 0.056
Out-of-pocket 1.08 [0.81, 1.42] 0.617
Public program 0.76 [0.43, 1.34] 0.347
Variables Model 2: Adjusted OR p value
[dagger] [95% CI]
Socio-demographics
Female
Age 1.34 [0.96, 1.86] 0.086
Rural 1.10 [0.64, 1.90] 0.723
Income 1.38 [1.15, 1.65] 0.001
Education 1.59 [1.22, 2.07] 0.001
Children <17
Children <6 0.61 [0.33, 1.12] 0.110
Children 6-12
Children 13-17
Oral health and dental care
characteristics
Self-rating of oral health
Visiting frequency
Insurance status
Through my employment
Through someone else's employment
Out-of-pocket
Public program
* Model 1 entered all variables independently, with N ranging from 302
for 'Children 13-17' to 994 for 'Age.'
[dagger] Model 2 entered significant variables (p<0.05) from Model 1,
adjusting for all variables simultaneously, N=977.
Table 4. The Odds of Supporting CWF
Variables Model 1: Unadjusted p value
OR * [95% CI]
Socio-demographics
Female 0.60 [0.40, 0.89] 0.012
Age 1.16 [1.00, 1.36] 0.056
Rural 0.69 [0.46, 1.05] 0.084
Income 1.33 [1.15, 1.53] 0.001
Education 1.17 [0.94, 1.44] 0.158
Children <17 0.63 [0.40, 0.98] 0.039
Children <6 0.70 [0.36, 1.37] 0.296
Children 6-12 1.84 [0.95, 3.58] 0.071
Children 13-17 0.79 [0.41, 1.53] 0.481
Oral health and dental care
characteristics
Self-rating of oral health 1.22 [1.0, 1.49] 0.053
Visiting frequency 1.44 [1.14, 1.83] 0.002
Insurance status
Through my employment Reference
Through someone else's employment 0.66 [0.38, 1.25] 0.201
Out-of-pocket 0.63 [0.40, 0.98] 0.04
Public program 0.61 [0.24, 1.53] 0.288
Avoids fluoride 0.07 [0.03, 0.13] 0.001
Variables Model 2: Adjusted OR p value
[dagger] [95% CI]
Socio-demographics
Female 0.68 [0.37, 1.28] 0.235
Age
Rural
Income 1.26 [1.03, 1.55] 0.025
Education
Children <17 0.46 [0.25, 0.83] 0.011
Children <6
Children 6-12
Children 13-17
Oral health and dental care
characteristics
Self-rating of oral health
Visiting frequency 1.75 [1.22, 2.51] 0.002
Insurance status
Through my employment
Through someone else's employment 0.75 [0.31, 1.82] 0.528
Out-of-pocket 0.68 [0.34, 1.37] 0.281
Public program 0.17 [0.04, 0.80] 0.025
Avoids fluoride 0.04 [0.01, 0.10] 0.001
* Model 1 entered all variables independently, with N ranging from 137
for 'Children 13-17' to 446 for 'Gender.'
[dagger] Model 2 entered significant variables (p<0.05) from Model 1,
adjusting for all variables simultaneously, N=310.
Table 5. Odds of Avoiding Water or Products that Contain Fluoride
Variables Model 1: Unadjusted p value
OR * [95% CI]
Socio-demographics
Female 0.88 [0.62, 1.23] 0.437
Age 1.13 [0.99, 1.29] 0.067
Rural 1.49 [1.06, 2.10] 0.021
Income 0.80 [0.71, 0.90] 0.001
Education 0.76 [0.63, 0.91] 0.003
Children <17 0.90 [0.62, 1.32] 0.586
Children <6 1.96 [1.09, 3.55] 0.026
Children 6-12 1.31 [0.73, 2.35] 0.361
Children 13-17 0.64 [0.34, 1.18] 0.149
Oral health and dental care
characteristics
Self-rating of oral health 0.89 [0.75, 1.05] 0.17
Visiting frequency 0.96 [0.80, 1.16] 0.676
Insurance status
Through my employment Reference
Through someone else's employment 1.24 [0.75, 205] 0.405
Out-of-pocket 1.27 [0.87, 1.86] 0.218
Public program 1.03 [0.47, 2.26] 0.934
Variables Model 2: Adjusted OR p value
[dagger] [95% CI]
Socio-demographics
Female
Age
Rural 1.56 [0.81, 3.00] 0.183
Income 0.87 [0.70, 1.09] 0.87
Education 1.13 [0.82, 1.56] 0.466
Children <17
Children <6 2.00 [1.03, 3.85] 0.041
Children 6-12
Children 13-17
Oral health and dental care
characteristics
Self-rating of oral health
Visiting frequency
Insurance status
Through my employment
Through someone else's employment
Out-of-pocket
Public program
* Model 1 entered all variables independently, with N ranging from 296
for 'Children 13-17' to 954 for 'Gender.'
[dagger] Model 2 entered significant variables (p<0.05) from Model 1,
adjusting for all variables simultaneously, N=254.
