Nicotine Dependence Treatment. Elements of Addiction. Addiction. Addiction. Tobacco use is a serious oral health problem

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1 Why should dentistry be involved with tobacco dependence treatment? Tobacco use is a serious oral health problem Nicotine Dependence Treatment Quitting Techniques Clinical Intervention Protocols Elements of Addiction The desire to experience the effects Ritual (woven into everyday life) Atmosphere (cues to use) Mind-set (strong emotional cues) Addiction Addicts seek serenity through an object, chemical or event Loss of control in terms of usage, frequency, duration, dosage and resulting behaviors, in spite of the known harmful effects Addiction Denial feeds the addictive cycle Denial process: Those problems (disability and early death) only happen to a few other people.. not me 1 of 15

2 Nicotine is a mood and behavioral altering agent: At times tobacco can act as a stimulant At other times produce tranquilizing effects Tobacco is as addictive as heroin (as a mood and behavior altering agent) Nicotine is: 1000X more potent than alcohol X more potent than barbiturates 5-10X more potent than cocaine or morphine A 1 pack per day smoker takes 200 hits daily (1 PPD= 73,000 puffs a year) This constant intake of a fast acting drug eventually produces dependence 1PPD = 7,000 cigarettes a year Tobacco is a positive reinforcer: It is repeated because it is rewarded Stimulus >>>> Response >>>> Reward cycle of smoking Nicotine causes changes in brain function: Altered brain electrical metabolic and neurohormonal activity As tobacco use increases, there is an increase in the number of nicotine receptors in the brain Nicotine combines with a number of neurotransmitters in the brain: Dopamine...Pleasure, suppress appetite Acetylcholine.Arousal, cognitive enhancement Serotonin Mood modulation, suppress appetite Norepinephrine..Arousal, suppress appetite Vasopressin Memory improvement Beta-endorphin..Reduce anxiety / tension 2 of 15

3 Drug addiction: Physiological Psychological Sociocultural Behavioral Physiological dependence: Tolerance Dependence Withdrawal symptoms (after abstinence) Psychological dependence: Stimulation Tension reduction Handling Craving Pleasurable relaxation Habit Behavioral (Sociocultural) factors: Social activity Numerous daily rituals Family origin & cultural practices Great deal of time spent in activities to obtain or use tobacco Important social, occupation, or recreational activities given up or reduced because of use Quitting involves a serious psychological loss. A significant life style change! 3 of 15

4 Criteria for Nicotine Withdrawal Depressed mood Insomnia Irritability, frustration or anger Anxiety Difficulty concentrating Restlessness Increased appetite or weight gain Addiction 80-90% of alcoholics are heavy smokers Active alcoholics are less likely to succeed in quitting than smokers with no history of alcoholism Addiction Tobacco dependence treatment can be successful for alcoholics Tobacco dependence treatment can be provided simultaneously with alcoholism treatment 30-50% of smokers have a history of depression Nicotine may act as an antidepressant in some smokers smoking cessation may lead to depression and relapse It may be best to recommend smoking cessation when no major changes in the treatment of a psychiatric disorder are underway Simply having a psychiatric disorder is not a reason not to make a quit attempt John Hughes, MD, Psy Serv, % of MI patients continue to smoke 63% of smokers who undergo surgery to clear blocked vessels continue to smoke, even though smoking after surgery substantially reverses any benefit gained from the procedure Mayo Clinic Proceedings of 15

5 50% of smokers who are diagnosed with cancer continue to light up 25% of heart transplant patients go back to smoking after their surgery Barriers to quitting * Fear of weight gain * Fear of withdrawal * Fear of failure 40% who have had their larynx removed start smoking again through the stoma in their throat Tobacco cessation is not a single isolated event -- but rather a continuing extended process The goal is to help a tobacco user through the stages of quitting Precontemplation Contemplation Preparation for Action Action Maintenance Relapse Precontemplation (60% of users) These users deny having a problem and have no intention of quitting Raising their awareness of the benefits of quitting in a very low-key approach may help Let them know that your office would be happy to help them if they do become interested Contemplation (32% of users) They know they have a problem They would like to quit someday They have indefinite plans to quit within 6 mos. People can remain stuck in this stage for years 5 of 15

6 Preparation for Action (8% of users) They are ready to quit within the next month They have good reasons to quit and may have tried a number of times But they have not necessarily resolved their ambivalence Action Normally takes 3 to 6 months to complete Maintenance May last for 6 months to a lifetime Relapse and through the cycles again the majority of relapsers do not go all the way back to precontemplation After 1-2 year abstinence..20% relapse after 4-5 years..7% relapse after 5 years most are home free Our advice and support can encourage tobacco users to progress through the stages until they are successful It takes many people a number of attempts, sometimes over a number of years before they succeed Action followed by relapse is much better than no action at all ( practice quitting ) Quit attempts The average smoker tries to quit about once every 3 years 30% of tobacco users make an attempt every year only 2-5% succeed on their own Over 70% of smokers have already made at least one attempt 6 of 15

7 The difference between a successful quitter and a failure is that the successful person has failed more than the failure You must have patience, a sensitive manner, and a chronic mindset when helping tobacco users You haven t failed until you stop trying You don t know which attempt will be successful Never give up! Two Basic Quitting Techniques Cold turkey Gradually (tapering) Smoking reduction Nicotine fading switching to lower tar / nicotine brands cigarette filters What is the difference between regular & light/ultra light cigarettes? Gradual reduction (tapering) reduce number of cigarettes (probably not very effective) Alternative strategies Acupuncture Hypnosis Laser therapy 7 of 15

8 Physically aversive strategies Smoke aversion rapid smoking blown smoke forced chain smoking Individual or Group Counseling Agency for Healthcare Research and Quality (AHRQ) clinical practice guideline for treating tobacco use and dependence NCI protocols (5 A s) Associated with Lower Quit Rates low readiness to change high nicotine dependence psychiatric comorbidity low self-efficacy environmental risks other smokers at home / workplace high stress level Quit rates Healthcare clinicians can achieve quit rates From 18% (from one provider) to 23% (from multiple providers) Brief sessions of 3 minutes or less = 13% 1 year quit rates Sessions longer than 10 minutes = 22% 1 year quit rates Success At 10% stop rate, about 28 patients per dental office will quit using tobacco each year Each year US practitioners could help over 3 million patients be tobacco-free Tobacco abstinence is the ultimate goal, but moving patients to a higher stage of change should be considered a measure of success 8 of 15

9 Success Those we have assisted and who continue to use tobacco, but at a lower level, have achieved a level of success We must be anti-tobacco use, anti-disease and anti-disability, never anti-smokers Dr. Antonia Novello Overtly direct & confrontational styles evoke high levels of resistance Empathetic styles are associated with little resistance & better long-term change Smokers are experts on their own lives and they alone hold solutions to their personal difficulties Ambivalence I want to quit, but Smokers must quit for THEIR personal reasons using THEIR timetable and THEIR desire to change 9 of 15

10 Relapse When one recognizes and verbalizes it, the need to regain control of ones life is a strong motivator of behavior The intensity of tobacco withdrawal symptoms often peaks during the first week post-quit About 65% of self-quitters relapse during the first week The Big Three causes of relapse are: Life stresses Being around other smokers Ingestion of alcohol Ask Advise Assess Assist Arrange The 5 A s Dental office protocols Tobacco use on medical/dental history Q Ask every patient about his/her tobacco use If we would help you quit, would you be interested? How do you feel about your smoking/st use? If users are interested, have them fill out a Tobacco Use Assessment form 10 of 15

11 Brief Tobacco Cessation Intervention Medical concerns ASK Number of cigarettes, cigars, pipe bowls per day Number of ST cans/pouches per week Number of years used How soon after you wake up do you use tobacco? within 30 minutes more than 30 minutes Brief Intervention ASK Previous quit attempts # of attempts longest quit period method(s) used how long ago was the last attempt to quit years months Reasons for wanting to quit Brief Intervention ADVISE Discuss oral effects of tobacco (personalize) Oral lesions & periodontal diseases Emphasize the benefits of cessation Use a low-key, non-judgmental, respectful, sensitive, caring manner Brief Intervention ASSESS willingness to make a quit attempt Stage of Change Precontemplation (stop here & re-assess next visit) Contemplation Preparation Brief Intervention ASSIST (depending on stage of change) Ask those interested in quitting if they would like to talk on the phone with a tobacco cessation coach. If so have them fill out: MN Tobacco Quitline Fax Form (middle section) and return the form to (Stafne mail box) Provide and discuss self-help pamphlets Give a list of local quit programs & phone helplines S. of D. Individual Counseling Clinic ( ) Encourage a quit date (for those who are ready) Consider pharmacotherapy options 11 of 15

12 12 of 15

13 Brief Intervention ARRANGE Follow-up patient status (with their permission) Phone calls Letters Office visits Quit date Follow-up: Week 1-2 Month 1, 3, 6, 12 Brief Intervention Documentation Document results of the intervention on the brief intervention form Document in progress notes: Tobacco cessation intervention List any pharmacotherapy suggested or prescribed for the control and prevention of oral diseases Brad Brad is a 43 yr old lawyer, a new patient to your office He and his wife have two children in high school He had diabetes (controlled by diet) and he takes medication for high blood pressure Brad had some periodontal surgery five years ago He has lost some teeth and is interested in dental implants His previous dentist told him that because of continued bone loss around some of his teeth, more periodontal treatment should be done before implants Brad His response to your questions about his smoking: I have heard about the effects of secondhand smoke and I would like to be a better role model for my children. I m also a little concerned about shortness of breath and very concerned about the possibility of implant failure. I enjoy smoking but I would really like to quit soon. I have tried to quit before and I m afraid I will fail again. I know I need help. Brad Brief Intervention ASK 30 Camel Light cigarettes a day For 28 years Lights up as soon as he gets out of bed He has tried to quit a number of times Cold turkey and nicotine gum One week was the longest tobacco-free period 13 of 15

14 Brad Brief Intervention ADVISE Raise his awareness of the effects of his smoking on tooth loss, periodontal treatment results, and dental implant complications The risks of secondhand smoke to his wife (who does not smoke) and to his children Brad Brief Intervention ASSESS willingness to quit: Precontemplation Contemplation Preparation The stage of change Brad is in will determine how you will ASSIST him Brad Brief Intervention ASSIST (depending on stage of change) Ask Brad if he would be willing to talk on the phone with a tobacco cessation coach. If so have him fill out: MN Tobacco Quitline Fax Form (middle section) put your name in top section & return form to or Provide and discuss self-help pamphlets Give a list of local quit programs & the phone quitline Encourage a quit date (if he is ready) Consider pharmacotherapy options (D1320) Examples of Quit Programs MN Tobacco Helpline (Quit Plan) PLAN Free one-on-one counseling by telephone American Lung Association Freedom from Smoking List local phone number Nicotine Anonymous (12 step counterpart to AA) U of MN SD Tobacco Cessation Clinic ( ) Customized multi-component individual counseling Mayo Nicotine Dependence Center 8 day residential program Rochester MN ( ) Internet Programs: / Brad Pharmacotherapy Options Medical concerns are HBP (meds), diabetes (diet control) and shortness of breath No history of depression or other psychiatric problems Possible medication options: 21 mg patch plus nicotine lozenge Zyban alone or Zyban plus 21 mg nicotine patch Chantix Brad Brief Intervention ARRANGE for follow-up (with permission) Phone calls Letters or (if patient agrees) Office visit 14 of 15

15 Brad Brad wanted to talk on the phone with a tobacco cessation coach he found it helpful Brad had a friend who used Chantix and was able to quit He wanted to try it The phone coach said he would need a prescription from a physician or dentist Brad did not have a history of depression or other psychiatric problems so Chantix was Rx The dental office called during the first week of the quit date and at 1-2 week intervals Brad Brad was tobacco-free for 2 weeks but then started using a couple cigarettes a day He was asked to continue on the Chantix and encouraged to get back to zero Reviewing his reasons for wanting to quit: Role model for children, shortness of breath, and possible dental implant failure Web site Office Tobacco Cessation Interventions Tobacco Use and Cessation Topics Lecture outlines Forms that can be used to help set up a tobacco dependence program in a clinic/office How to communicate with tobacco using patients (Digital journal article) 15 of 15

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