Understanding Nicotine Addiction and Tobacco Intervention Techniques for the Dental Professional

Transcription

1 Understanding Nicotine Addiction and Tobacco Intervention Techniques for the Dental Professional Arden G. Christen, DDS, MSD, MA; Jennifer A. Klein, RDH, MSA; Stephen J. Jay, MD; Joan A. Christen, BGS, Ms; James L. McDonald Jr., PhD; Christianne J. Guba, DDS, MSD Continuing Education Units: 3 hours The purpose of this course is to alert dental professionals to the harmful effects of tobacco, both to the oral cavity and to the body. The course is also designed to teach professionals specific skills they may utilize to help tobacco users become free of their addiction. A significant amount of the course material applies to both smoked and smokeless tobacco; however, additional information on smokeless tobacco is presented in the ADAA continuing educational course, Understanding the Dangers and Health Consequences of Spit Tobacco Use. Conflict of Interest Disclosure Statement The authors report no conflicts of interest associated with this work. ADA CERP The Procter & Gamble Company is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at: Overview In recent years, the stage has been set for all dental professionals to become actively involved as facilitators and leaders in tobacco education and control efforts. 1

2 One goal of Healthy People 2020 is to increase to at least 75% the proportion of the population of primary care and oral health care providers who routinely advise cessation and provide assistance and follow-up for all of their tobacco using patients. In this millennium, we expect an ever-increasing number of dentists, hygienists, and assistants to participate in clinical and community interventions that focus on both tobacco prevention and cessation strategies. Although 65% of general dentists advise most or all of their patients who smoke, only about 11-27% provide patients with self-help materials or routinely record tobacco use. Many lack confidence in providing cessation advice. The fact is, helping dental patients to quit using tobacco can be practically accomplished in clinical settings by oral health care professionals. Twenty years of accumulated evidence has shown the efficacy of this approach. Oral health care providers are able to offer this service with few interruptions in their daily routine. Additionally, many patients whom they help respond with gratitude and loyalty. Dental professionals, as well as other health care workers, have an ethical obligation to inform their patents about the hazards of tobacco use and to encourage tobacco users to stop. Additionally, the dental team needs to praise and support those patients (especially impressionable young people who have never used tobacco). Currently, about 46 million Americans are smokers, and another 12 million are smokeless tobacco users. About 440,000 tobacco-related premature deaths occur each year in the United States. A vast majority of those who use tobacco would like to stop; in fact, about 50 million cigarette smokers have given up tobacco since Still, about 25% of our population smoke cigarettes and evidence suggests that heavy usage (the consumption of 25 or more cigarettes per day) occurs among a large proportion of smokers. The purpose of this course is to alert dental professionals to the harmful effects of tobacco, both to the oral cavity and to the body. The course is also designed to teach professionals specific skills they may utilize to help tobacco users become free of their addiction. A significant amount of the course material applies to both smoked and smokeless tobacco; however, additional information on smokeless tobacco is presented in the ADAA continuing educational course, Understanding the Dangers and Health Consequences of Spit Tobacco Use. Learning Objectives Upon completion of this course, the dental professional will be able to: Summarize the harmful effects of tobacco on the body. Explain the addictive nature of nicotine. Discuss the psychological and sociocultural aspects of tobacco use. List the steps which can be initiated to create a smoke-free dental practice. Describe the dental professional s role in a dental office smoking cessation program. Identify the cycle of change and its relationship to smoking behaviors. Demonstrate the supportive role oral healthcare professionals can have in helping patients to become tobacco-free. Course Contents Glossary Effects of Tobacco Use Health Hazards of Tobacco Use Oral Effects of Tobacco Use Nicotine Addiction Addiction Physical and Psychological Characteristics of Nicotine Addiction Delivering the Smoke-Free Message: Programs That Work Findings and Recommendation Tobacco Cessation Programs for the Dental Office The Dental Professional s Role in a Smoking Cessation Program Stages of Change What to Say Suggested Dialogue 2

3 Make Your Message Relevant Fear of Weight Gain The Cost of Smoking Summary Questions and Answers Course Test References About the Author Glossary Addiction an overwhelming compulsion to ingest a substance or engage in a process with increasing frequency and intensity in order to experience its mind-altering effects and/or to avoid the pain of its withdrawal. Craving an intense and often prolonged desire, yearning, hunger or appetite for foods or substances. Dependency, physiological the physiological reliance upon a drug or substance, resulting in specific body cell alterations; a condition in which continued usage becomes necessary to maintain the body s state of normalcy and balance. Dependency, psychological an emotional reliance on addictive substances and/or ritualistic behaviors. Erythroplakia a particularly dangerous form of oral cancer which appears as a red or velvetyappearing patch. Habit a highly automatic behavior intensively learned and practiced over a prolonged period of time. Leukoplakia a white intraoral patch related to all forms of tobacco usage and considered to be precancerous. Malignant cancerous, and therefore potentially life-threatening. Nicotine the principle alkaloid of tobacco and its addictive agent. Nicotine Replacement Therapy ( NRT ) an effective quit-smoking strategy which utilizes nicotine-containing delivery devices (nicotine gum, inhaler, nasal spray, patch, or lozenge which helps to reduce and control nicotine cravings and withdrawal symptoms; generally administered for a 3- to 6-month period, while the addictive, psychological, and sociocultural aspects of cigarette smoking are simultaneously being addressed and overcome. Relapse the reactivation of addictive behavior after abstinence has been achieved and maintained for a significant period of time. Slip a temporary, minor reversal to former addictive practices; of lesser intensity and duration than a relapse. Also called: A Slight Lapse In Progress. Sobriety complete abstinence from cigarette smoking; a term used by Smokers Anonymous. Smokers Anonymous a self-help program adapted for smoking cessation and based on the Twelve Steps of Alcoholics Anonymous. Tolerance a state which requires increasing amounts of the addictive drug to achieve the same effects. Varenicline Also known as Chantix in America, or Champix in Europe. is a nonnicotine prescription medicine that comes in pill form. Vasoconstriction a narrowing or constriction of blood vessels. Withdrawal syndrome predictable signs and symptoms caused by altered central nervous system activity, and appearing after a routinely received drug dosage is discontinued or rapidly decreased. Effects of Tobacco Use Health Hazards of Tobacco Use According to the numerous U.S. Surgeon General s Reports on Smoking and Health, issued since 1964, smoking has been causally linked to heart disease, other vascular diseases, diabetes, and cancer of the mouth, pharynx, esophagus, lung, pancreas, and bladder. It is also implicated in the development of gastric ulcers, chronic obstructive lung disease, chronic bronchitis, 3

4 emphysema, sinusitis and other respiratory disorders. Pregnant women who smoke are more likely to have premature, low birth-weight infants or spontaneous abortions. There is now evidence that nonsmokers who inhale the secondary sidestream smoke from tobacco products are also at greater risk for these conditions. Children raised in homes where parents smoke are more prone to respiratory diseases. They are also more likely to use tobacco than those who are raised in tobacco-free homes. The average age for experimentation with cigarettes and smokeless tobacco is 12 to 13 but many individuals start earlier. Teenage girls smoke more than teenage boys among 17- to 19-years-olds, the ratio is five females to every four males. Tobacco use is a pediatric concern. Close to 80% of adult smokers started smoking before the age of 18. In the United States, more than 6,000 children and adolescents try their first cigarette each day. More than 3,000 children and adolescents become daily smokers every day, resulting in approximately 1.23 million new smokers under the age of 18 each year. Among adults who had ever smoked daily, 89 percent tried their first cigarette and 71 percent were daily users at or before age 18. Among high school seniors who had used smokeless tobacco, 79 percent had first done so by the ninth grade. By the time they are high school seniors, 22 percent of adolescents smoke daily. Young people experiment with or begin regular use of tobacco for a variety of reasons related to social and parental norms, advertising, peer influence, parental smoking, weight control, and curiosity. Nicotine dependence, however, is established rapidly even among adolescents sometimes as early as two weeks! Because of the importance of primary prevention in this population, the dental health care team should pay particular attention to delivering these messages to its patients. Specifically, because tobacco use often begins during preadolescence dental professionals should routinely assess and intervene with this population. Oral Effects of Tobacco Use Tobacco s damaging oral effects are well documented, and should be easy for dental personnel to identify. All dental health professionals should deliver personalized stopusing messages to patients, especially when they learn that these individuals have adverse oral conditions that are linked to tobacco usage. Dentists, assistants and hygienists have access to teachable moments at chairside when they can explain to their patients the tobacco-related, oral ill-effects from which they are currently suffering. Contrary to people pictured in advertisements of tobacco products, people who smoke are very likely to have bad breath (halitosis). The breath of cigar and pipe smokers is more offensive than that of cigarette smokers because of the intense odors that emanate from cigar and pipe tobaccos. Inhaled smoke can create lung odors which often results in halitosis; its severity is generally in direct proportion to the amount of tobacco routinely consumed and the duration of the usage. A condition known as hairy tongue occurs when the solids and gases in tobacco help prevent the tongue s surface cells from sloughing off normally. As a result, yellowish, white, brown or black papillae are formed. Resembling furlike projections, they trap bacteria and food debris on the tongue s surface (Figure 1). This phenomenon also contributes to halitosis. Figure 1. Hairy Tongue (Black) Used with Permission, Smokers have significantly more stains and calculus deposits on their teeth than nonsmokers. These discolorations may become heavy on teeth, dentures and restorations. Smoking also has a detrimental effect on gingival tissues. Conditions such as acute necrotizing ulcerative gingivitis (ANUG) are more common in smokers; additionally, other periodontal conditions are frequently seen in the mouths of tobacco users. Dental providers need to inform their periodontic patients who smoke that a definite link exists between cigarette use and disease. While 44% 4

5 of periodontic patients smoke, only 25% of the general U.S. public smoke cigarettes. Scientific evidence clearly shows that smokers have more severe periodontal diseases (including periodontitis) than do nonsmokers. In fact, continued smoking is extremely detrimental to the success of periodontal therapy. Ninety percent of refractory periodontic patients (as compared to twenty-five percent of the general population) are smokers. With smokeless tobacco use, recession and irritation of the gingiva routinely occur adjacent to where the quid, or tobacco product, is held. A 30-year study on 18,893 teeth has shown that cigarette smokers are 70% more likely to need root canal therapy than non-smokers. The amount of time smoked and the amount of time smoke-free was directly related to their risk. Over 4,000 chemicals and gases in tobacco smoke as well as their by-products may irritate the oral cavity. Chemicals such as ammonia, aldehydes, arsenic, benzo(a)pyrene, volatile acids, hydrogen cyanide, ketones, lead, pesticides, hydrocarbons, and radioactive polonium may all be present in smoke and smokeless tobacco. Sinusitis is a potentially disabling condition that causes an acute or chronic inflammation of the tissues lining the maxillary and frontal sinus air spaces. It occurs about 75% more often among smokers than nonsmokers and may be related to the chemical make-up of tobacco smoke. As a powerful vasoconstrictor, nicotine also reduces blood flow to many tissues. This drug action may lead to delayed wound healing following oral surgery. Additionally, the incidence of dry socket among smokers is more than four times greater than among nonsmokers. This condition can occur when negative oral pressure, created as smoke is drawn into the mouth, disrupts the bloods clot in the postoperative extraction socket. Leukoplakia is an oral white patch or plaque that cannot be characterized clinically or pathologically as any other disease (Figure 2). Considered a precancerous condition, it is often associated with tobacco use. Any intraoral Figure 2. Leukoplakia Used with Permission, white lesions of this nature should be considered malignant until ruled out by microscopic examination (biopsy). Some leukoplakia lesions will regress if tobacco use is discontinued. Another condition commonly seen in smokers is nicotine stomatitis or smokers palate. Here, the roof of the mouth becomes thickened and white, and elevated bumps, which look like areas of cobblestone, form around the partially blocked openings of salivary gland ducts. This abnormality, most commonly seen in pipe and cigar smokers, often disappears when the smoker quits and rarely develops into cancer. Epidermoid carcinoma (squamous cell carcinoma) is the most common oral cancer (Figure 3). Most typically seen in cigarette smokers, it is frequently found on the buccal mucosa or tongue. In addition, pipe smokers are more likely than other tobacco users to develop lip cancer. Erythroplakia, a red lesion, may also be associated with malignancy (Figure 4). Any red or white lesion, even those which are innocent looking, must have biopsies performed if they do not heal within a few weeks. Treatment of oral cancers may consist of surgery, radiation, chemotherapy or a combination of these approaches. Nicotine Addiction Many U.S. Surgeon General s Reports have presented scientific evidence that cigarettes and other forms of tobacco are addictive. Numerous other studies on animals and humans have verified this report, showing that nicotine is the agent in tobacco that leads to addiction. A major conclusion of these documents is that the pharmacologic and behavioral processes that 5

6 Figure 3. Squamous Cell Carcinoma of the Tongue Used with Permission, Figure 4. Erythroplakia Used with Permission, determine tobacco addiction are similar to those that determine addiction to other drugs, such as heroin and cocaine. Evidence of the addictive nature of nicotine has existed in the medical literature since the early 1900 s, but the concept gained much greater acceptance and credibility with the release of these important government publications. Nicotine is found chiefly in the tobacco plant and all tobacco products contain significant amounts of nicotine. This drug is readily absorbed into the bloodstream either from tobacco smoke, which enters the lungs, or from smokeless tobacco, which is present in the mouth or nose. The blood levels of nicotine are relatively similar among subjects using different forms of tobacco. Once in the bloodstream, this powerful pharmacologic agent is rapidly distributed throughout the body in a variety of ways. Nicotine enters the brain within seven to ten seconds after inhalation. It interacts with specific receptors in brain tissue and initiates very diverse physiologic effects, which are quickly experienced by the user. Nicotine causes skeletal muscle relaxation and cardiovascular and hormonal alterations, including increased heart and breathing rates, blood vessel constriction (which raises blood pressure), and paradoxically, feelings of both stimulation and relaxation, depending on the circumstances under which it is used. Smokers may use tobacco to aid concentration, as an energy boost, or for its calming effects. Addiction Addiction may be defined as an overwhelming compulsion to ingest a substance or engage in a process with increasing frequency and intensity, in order to experience its mind-altering effects and/or to avoid the pain of its withdrawal. As with many other addictive substances, tobacco users develop tolerance over a period of time; that is, they begin to require increasing amounts of the drug in order to achieve the same effects. While human beings have no inborn need for tobacco, they often learn to use tobacco during childhood or adolescence. Initially, they may be influenced by role models, the mass media, and peers. Once they become accustomed to the effects of the nicotine and the socially rewarding aspects of tobacco use, their need to continue usage becomes strongly reinforced. At this point, both physiological and psychological factors begin to exert a powerful influence on them. Physical and Psychological Characteristics of Nicotine Addiction The characteristics of nicotine addiction include: Stimulation tobacco and nicotine help to organize thoughts and actions. Handling enjoyment in watching smoke and manipulating cigarettes, cigarette packages, matches, ashes, etc. Relaxation nicotine has a tranquilizing effect especially after a meal or sexual activity, or during coffee or alcohol consumption. Craving hunger for a cigarette when not smoking. Tension reduction short-term stress relief caused by nicotine s overall effect(s) on the brain. Habit reinforcement of certain behaviors by associating them with pleasurable activities. 6

7 Physiological dependency occurs when brain cells adapt so completely to a drug that they require it for normal functioning; when sudden drug abstinence occurs, signs and symptoms of withdrawal also occur. In nicotine dependency, tobacco craving is often the most predominant physiological symptom. Other withdrawal manifestations include irritability, restlessness, headache, drowsiness, gastrointestinal disturbances, reduced heart rate, sleep disturbances and impaired concentration, judgment and psychomotor performance. One out of every three smokers attempts to quit each year, but only 7% are successful in remaining smoke-free for more than one year. Many people who have already stopped smoking were never heavy users; they may not have actually been addicted to nicotine. It is estimated that about 33% of all male smokers and 20% of all female smokers are classified as heavy smokers (persons who use 25 or more cigarettes per day). The percentage of heavy smokers has been steadily increasing since 1965, while many of the more casual, light smokers have quit. Because the obstacles to stopping are great, it is important to offer sincere support to those who are motivated to give up tobacco. Many smokers try several times before they are successful. Rather than viewing their previous attempts as failures, smokers should be encouraged to credit themselves for achieving any degree of abstinence whatsoever. The most important message that can be relayed to these people is Try, try again! Additionally, by offering them self-help materials and informing them of available community smoking cessation programs, dental health professionals can actively help these persons to quit. One of the most positive sociocultural changes in recent years is the move toward smoke-free public buildings, restaurants and bars, transportation, and places of employment. This shift in our national attitude exerts additional pressure to give up tobacco. The public is becoming better informed about the deleterious effects produced by ETS (Environmental Tobacco Smoke). Delivering the Smoke-Free Message: Programs That Work In 2008, an updated, 276-page clinical practice guideline, Treating Tobacco Use and Dependence, was released by the Public Health Service. The guideline, a comprehensive review of over 6,000 scientific articles, offers simple and effective interventions for all current and former tobacco-using patients and recommends that all patients should be asked if they use tobacco and should have their tobacco-use status documented on a regular basis. For a copy, telephone CANCER. Findings and Recommendation The key recommendations of the updated guideline, Treating Tobacco Use and Dependence, based on the literature review and expert panel opinion, are as follows: 1. Tobacco dependence is a chronic condition that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can significantly increase rates of long-term abstinence. 2. It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting. 3. Tobacco dependence treatments are effective, across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt to use the counseling. 4. Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective in this Guideline. 5. Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity. Two components of counseling are especially effective, and clinicians should use these when counseling patients making a quit attempt: Practical counseling (problem solving/skills training) Social support delivered as part of treatment 7

8 6. Numerous effective medications are available for tobacco dependence and clinicians should encourage their use by all patients attempting to quit smoking except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e. pregnant women, smokeless tobacco users, light smokers, and adolescents). Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase long-term smoking abstinence rates: Bupropion SR Nicotine gum Nicotine inhaler Nicotine lozenge Nicotine nasal spray Nicotine patch Varenicline Clinicians also should consider the use of certain combinations of medications identified as effective in this Guideline. 7. Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication. 8. Telephone quitline counseling is effective with diverse populations and has broad reach. Therefore, both clinicians and health care delivery systems should ensure patient access to quitlines and promote quitline use. 9. If a tobacco user currently is unwilling to make a quit attempt, clinicians should use the motivational treatments shown in this Guideline to be effective in increasing future quit attempts. 10. Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans include the counseling and medication identified as effective in this Guideline as covered benefits. The basic intervention techniques chosen for the above programs include the systematic use of a protocol known as the Five A s. These are: ASK patients about their tobacco use at every appropriate opportunity. Identify and document tobacco use status for each patient. ADVISE all tobacco users to stop. In a clear, strong and personalized manner, urge every tobacco user to quit. ASSESS willingness to make a quit attempt. Determine the patient s readiness to make a change. ASSIST patients in stopping. Use counseling and pharmacotherapy to help a patient quit. ARRANGE for supportive follow-up procedures. Schedule a follow-up contact, preferably within the first week after the quit date. Tobacco Cessation Programs for the Dental Office It is realistic for most dental practices to incorporate tobacco education into existing office procedures. Many patients will stop using tobacco if they receive cessation advice from a trusted health professional. By asking patients to complete the necessary cessation-related forms while waiting in the reception area, the staff will need only a few appointment minutes to ask about tobacco use and offer advice accordingly. Additionally, when a lesion or any abnormality which can be associated with tobacco use is found, the dental professional has a unique and potent opportunity, a teachable moment, to present the tobacco-recovery message. Cessation can be mentioned in some manner at every dental visit, however brief the message may be. Repetition is often a key factor in success. Individual patients will need varying amounts of time. Some people will be selfstarters, while others may need more guidance. For instance, they may need to gain insight into their personal strengths and support systems, which can help them through the cessation process, or they may need to create a group of individualized quitting strategies. By providing patients with a smoke-free professional environment, the dental office and other health care settings can exert a positive influence on tobacco users and those in the process of quitting. To establish credibility, a dental office no-smoking policy is essential. A prominent sign such as Thank You for Not Smoking should be displayed in the reception 8

9 area. Free quit-smoking pamphlets and selfhelp material, published by the American Cancer Society and American Lung Association, should also be available for interested patients to read and take home. Ashtrays should be removed from all office areas. Because tobacco advertising is very prevalent in popular magazines, those in charge of reception room reading material might consider displaying only those publications that do not include tobacco ads. Dental professionals might choose to include magazines that contain tobacco advertising but cross out the ads with a taped or marked blacked or red X. Those who use either of these strategies are firmly declaring their office s antitobacco philosophy. The medical/dental health history must address tobacco use by asking patients to note whether they use tobacco, which forms of tobacco they use, how long they have taken the product(s), and how much they are consuming daily. After reviewing this written information, the assistant can place an appropriate sticker on the chart of each patient who smokes to remind the staff to Ask about tobacco usage at every appropriate opportunity. During the oral examination, the dental team can increase patient awareness by delivering a personalized message about tobacco use, and relating it to any pertinent systemic health history finding or oral condition that has been noted. These findings might include: chronic bronchitis, sinusitis, heart disease, emphysema, hypertension, respiratory disease, stains on the teeth, calculus build-up, periodontal pocketing, or suspicious soft-tissue lesions, such as leukoplakia. A good time to recommend that a patient stop smoking is at the end of a dental procedure, when the person s mouth is clean and fresh. While some patients will appreciate this concern and be ready to act, others will resist. If the information is presented in a caring and noncoercive manner, usually the patient will not respond to it defensively, even those who are not ready to quit. The suggestions given and 9

10 the patient s responses should be documented in the dental record. Accurate record keeping will remind the dental professional to ASK, ADVISE, and ASSESS effectively and appropriately during subsequent appointments. Without internal motivation, it is unlikely that an individual will stop using tobacco. If a patient s quitting interest and drive are low, dental professionals should simply state they are available to help whenever necessary. Health professionals should not badger patients to quit or display any judgmental or condescending attitudes when dealing with smokers or recovering smokers. Those who are highly motivated and ready to stop smoking should be asked to select a quit date. While most smokers who quit manage to accomplish this on their own, some may require assistance. At this point, patients and dentists should discuss all available options. If the patient is interested in a formalized quitting procedure, s/he can be provided with a written list of telephone numbers, dates and locations of all reputable community programs and their fees. The American Cancer Society, American Lung Association, Seventh Day Adventists, Smoker Stoppers and numerous community-oriented quit smoking programs, such as State Health Departments and telephone quit lines are involved in effective cessation programs, which are offered free or at nominal cost. Smokers Anonymous support groups, based on the same principles as Alcoholics Anonymous, are active in many regions of the country and may be helpful to the would-be quitter, as well as to those who have already given up tobacco. For heavy smokers who are highly motivated to quit, nicotine reduction therapy is a viable option. This approach is based on the use of a nicotine-containing product. When nicotinecontaining gum is chewed slowly it gradually releases nicotine directly into the bloodstream through the oral mucosa. It is designed to maintain blood levels that will help to offset withdrawal symptoms, which are a common cause of relapse during the first three months of smoking abstinence. 10

11 The prescription for certain nicotine-containing medication can be obtained from the physician or dentist. It is important to use current prescribing guidelines and to carefully instruct patients on its proper usage. The American Dental Association (ADA) Guide to Dental Therapeutics (third edition), released in the fall of 2003, provides a 13-page article which condenses information related to the use of prescription and non-prescription medications used by dentists to help their patients quit using tobacco. Chapter 32, entitled, Cessation of Tobacco Use, and authored by a dentist, provides practical, hands-on advice. It discusses all commercially available products covering their generic and brand names, indications for use, dosage ranges and interactions with other agents. The American Dental Association is firmly behind the utilization of these products in clinical practice. Every dental practice should have this publication for office use. When dentists prescribe a tobacco cessation product, they are actually treating dental conditions. According to the Public Health Service, at present, long-term smoking abstinence rates are currently and reliable being increased by six firstline pharmacotherapies: Buproprion SR; nicotine gum; nicotine inhaler; nicotine nasal spray and nicotine patch and nicotine lozenge. Several days after the quit-smoking dates, dental office personnel can contact these persons who are using Nicotine Replacement Therapy and re-emphasize proper medication usage. At this time, it may be necessary to adjust dosages or review usage techniques. Conduct follow-up monitoring of the patient s progress at monthly intervals thereafter. While nicotine reduction therapy or the use of Zyban are the only FDA approved clinically proven approach for smoking cessation available at this time, it is to be expected that the FDA will approve new pharmaceutic agents for the purposes of smoking cessation. Many other methods have been used with varying degrees of success. These include hypnosis, acupuncture, laser therapy, aversion therapy (rapid smoking or smoking in an enclosed chamber), tapering (decreasing the number of cigarettes smoked over a period of time) and nicotine fading (e.g. using filtered brands to gradually reduce the amount of smoke inhaled). Switching to a lower tar or nicotine cigarette is not advisable as studies show that smokers who change to these brands usually will compensate for the nicotine loss by either inhaling more deeply, smoking more cigarettes, or taking more puffs. Presently, a wide array of over-the-counter selfhelp products are also being developed and marketed. However, most smokers can actually quit on their own when their motivation becomes strong enough. The dental team must work together to help their patients become smoke-free. But first, they must cooperate with one another. The ASSIST protocol can be applied to coworkers and patients alike. Dental assistants frequently have chair side time with patients and are in a unique position to show concern, empathy, and encouragement toward potential quitters. Those who are former smokers can serve as credible role models of success. Because of the traditional way in which dental appointments are scheduled, it is relatively easy to ARRANGE smoking cessation follow-up visits. A telephone call to a client on the designated quit day, notes in the office newsletter, and continual reassurance at subsequent appointments can all contribute to patient s success. Fortunately, a great deal of the damage caused by cigarette smoking is reversible. Any positive changes in oral health (such as less stain and calculus on the teeth) can be noted during office visits. The Dental Professional s Role in a Smoking Cessation Program Dental professionals can actively help patients to stop using tobacco by taking the following actions: Become nonsmoking role models. Encourage coworkers to become smoke-free, at least during working hours. Promote a smoke-free environment throughout the dental office. Remove all ashtrays from reception areas, and provide patients with stopsmoking pamphlets and attractive smoking cessation displays. The American Lung Association, American Cancer Society, National 11

12 Cancer Institute, and American Dental Association are all excellent resources for free or reasonably priced materials. Maintain an inventory of appropriate educational handouts. Make certain that medical/dental health history forms include questions which address tobacco use. Identify charts of all tobacco users with an appropriate sticker. Change the sticker to a Quit Smoking sticker when appropriate to reinforce and support them at each visit. Provide information about practice-based tobacco cessation efforts in the office newsletter (e.g., a list of healthy, sugar-free snacks, which those giving up tobacco may enjoy). Post or release via the newsletter an I QUIT list of patients in the practice (after obtaining their individual permission). This activity can serve as a practice-builder as well as a positive reinforcement to those who have been successful. Communicate to the whole dental team any relevant personal information that might positively or negatively influence the patient s ability to quit. Make written notes in the patient s chart. Telephone potential quitters on or shortly after their designated quit day to see how they are doing. Answer any questions as needed. This can be done at the same time as appointments are being confirmed. Compliment those (especially young patients) who do not use tobacco in any form. Tobacco is considered a gateway drug for marijuana, since marijuana use is generally preceded by tobacco use. Often, people initially become addicted to nicotine through smokeless tobacco use; as time passes, they frequently switch to smoking products. Talk with tobacco-using patients about quitting and support those who have already stopped. Some health care professionals are concerned that if they approach their smoking patients with cessation advice, they will alienate or offend them. In reality, a vast majority of tobacco users would like to stop, but do not know how to go about it. To relate to the smokers or recovering smokers in a supportive nonthreatening way, dental professionals need to understand the general levels of quitting motivation, and their specific applications to individual patients. Stages of Change What to Say Prochaska and DiClemente have identified six stages through which people pass in attempting to stop using tobacco. As dental professionals learn to meet individual patient needs, they should be aware of these various motivational levels of readiness for quitting smoking. The stages are as follows: Precontemplation: The person has not yet considered stopping. Contemplation: The person has thought about stopping, but is not ready to act. Desire or Readiness: The person admits to sincerely wanting to quit. Action: The person is ready to attempt the quitting process, has selected a quit date and individualized strategies. Maintenance: The person is no longer using tobacco, is attempting to remain tobacco-free. Relapse: The person has returned to smoking one or more cigarettes daily, after stopping for a significant period of time. Suggested Dialogue The following scenarios suggest possible dialogues which dental health professionals can have with patients, after assessing their motivational level or commitment to tobacco cessation. Precontemplation Stage Question: Have you thought about stopping smoking (or using smokeless tobacco)? If the 12

13 answer is no, express your concern about the patient s health, and help identify health advantages which would be gained by quitting. (Use information from the health history form.) Respect the patient s right to continue smoking. If they do not decide to quit, indicate that you will inquire again at future visits. Contemplation Stage Question: Have you thought about stopping? If the answer is yes, assess past experience ( Have you ever quit before? ) and discuss available recovery resources. What has worked for you previously, in past attempts to stop? Stress that most individuals make multiple attempts to quit, and the chances for success increase with each effort. Would you be interested in accepting our help? Dental professionals should express the desire to help when patients are ready. Identify personal barriers (such as fears of weight gain and failure), and review all available resources that offer help (e.g., self-help materials, office counseling, group participation and outside referrals. Desire/Readiness and Action Stages Question: Are you ready to set a future quit date? Which strategies for stopping do you prefer? At this level, the dental team is preparing to negotiate a recovery plan with the patient. The patient should be asked to set a reasonable quit date (e.g., within one to four weeks in the future), and to consider a range of possible cessation strategies for personal use. Substitute activities for smoking (exercise, hobbies, etc.) can be explored if the patient shows interest or asks for help. Maintenance Stage Question: How are you doing in your effort to stop smoking? Is there something else we can do to help? A follow-up telephone call can serve as a positive reinforcement to patients, offering them needed reassurance and support. Even when patients have not been successful, the staff should interpret quitting attempts positively and express empathy. If patients raise questions about coping skills or proper use of nicotine replacement products, address their concerns immediately. Relapse Stage Question: Have you smoked (even taken a puff) in the past seven days? If the answer is yes, ask What seemed to cause the slip? Is there a way you might have avoided it? Patients who have returned to smoking may benefit from learning to distinguish between a slip and a relapse. A slip involves the occasional smoking of only a few cigarettes, while a relapse is characterized by a return to former levels of smoking, or in some cases, even higher levels. Stress to the patient that a slip can be viewed as a slight lapse in progress. Reassure patients that relapses are common. The likelihood of permanent success increases with repeated attempts to stop. Question: Are you still interested in becoming tobacco-free? Oral health providers must continue to offer nonjudgmental, sympathetic support and encouragement to those who have relapsed; however, tobacco users must personally confront and own their habit, and choose to return to the action and maintenance steps of the quitting process. As an oral health professional, what do I say to patients about smoking/tobacco cessation? Many practitioners want to know what messages will have the most impact, and how they can be delivered in a meaningful and effective way. An effective cessation message focuses on the benefits of becoming a nonsmoker, rather than the detriments of continuing to smoke. However, when responding to this perspective, some smokers may rationalize that the damage caused by their smoking is already done. In keeping with a positive theme of hope, the practitioner can say: It is never too late to quit smoking. When you quit, most of the effects of smoking are reversible. Smoking cessation is the single most important step that you can take to enhance the length and quality of your life. Your mouth will be a lot healthier and fresher when you quit smoking. When you quit smoking, you will no longer be inhaling more than 4,000 harmful chemicals and gases. 13

14 Make Your Message Relevant It is critically important for the dental team to interact with patients who smoke, and to carefully explain how their specific dental problems are linked to their smoking behaviors. For example, during treatment, if a team member notes an oral condition related to tobacco use, not only can they discuss the problem with the patient, but also can encourage the patient to observe this condition by using a hand mirror. Additionally, the team member can assess the individual s readiness to set a quit date. Through discussion with the auxiliary and a review of welldocumented notes (kept in the treatment record), the dentist can make a diagnosis and arrange for appropriate follow-up. As they gain experience in discussing tobacco issues with patients, oral health professionals can become as comfortable with cessation issues as they are with details concerning periodontal pocket depths and plaque control. During subsequent appointments, as dental health care providers interact with their patients who smoke, they can relay the following messages: As your dentist (dental assistant or hygienist), I must advise you to stop smoking now. Have you ever thought about quitting? Have you ever tried to stop before? If so, What happened? Did you know that you have periodontal disease? Quitting smoking would really help to slow down the rate of gum disease that is developing in your mouth. You need to have gum surgery, but you will not heal properly unless you quit smoking. Smoking is a common cause of bad breath. You may be able to solve this problem completely if you quit using cigarettes. How about choosing a quit date within the next few weeks, now that you have decided to stop smoking? Fear of Weight Gain The fear of weight gain discourages many smokers (especially women) from trying to quit. Weight issues should be acknowledged and dealt with openly. The following responses may help to diffuse weight issues: Did you know that as many as a third of people who quit smoking do not gain any weight? And those who do generally gain only 5 to 9 pounds. The health risks that you are taking by smoking are far greater than the risk of nominal weight gain. If you exercise regularly, you can ease withdrawal symptoms and counteract weight gain. Now that you have given up smoking and want to eat more often, you need to avoid high-calorie snacks. Many of the foods that are good for oral health will also help you to avoid weight again. Be careful about substituting high sugar items like gum or breathe mints for tobacco. Encourage individuals with weight gain concerns to closely monitor their calories, sugar, and fat intake and to increase their activity levels. Regular exercise not only speeds metabolism, tones muscles, improves cardiovascular function, reduces tension, and burns calories, it also stimulates the release of endorphins, which can positively affect mood and disposition. While general health gains resulting from smoking cessation are well documented and dramatic, the psychological benefits associated with quitting are equally valid and impressive. Compared with current smokers, former smokers have a greater sense of self-efficacy, freedom, and control over their personal circumstances. The following supportive comments may motivate the patient who smokes to make a commitment to cessation: It sounds to me as if you would like to regain control of your life again by quitting smoking. That s a worthy goal! Just think of all the freedom you ll have when you quit! Every cigarette that you do not smoke represents a bit of freedom that you have gained. These encouraging statements can be offered to patients from a health professional who is a former smoker: 14

15 Although this has been one of the most difficult tasks that I have ever accomplished as an adult, it is one of the most satisfying things I have ever done. More than 3 million Americans quit every year. In fact, there are now over 50 million of us who are ex-smokers. I can tell you from personal experience that it can be done. Why not give it a try? I will be here to support you. This empathic response can be given to smokers who tried to quit, but did not achieve cessation: I really respect the fact that you gave quitting a good try. Not everyone succeeds on their first try, but many people are able to quit after making several attempts. Why not try again? The Cost of Smoking Although very few people quit smoking to save money, they are quite surprised to discover the actual cost of their tobacco use. The following comments are examples of how a health professional might motivate a resistant smoker to a state of cessation readiness: Do you realize that, as a pack-a-day smoker ($5.29 per pack multiplied by 365 days), you are spending over $1900 a year on your addiction? When you smoke, you pay three times- first, with your money; second, with your health; and third, with more money as you try to regain your health. When you quit smoking, why not set aside the money that you would have spent on cigarettes, and on your first anniversary as a nonsmoker, reward yourself with a special purchase? Summary The dental team can use their professional knowledge and skills to lead smoking patients toward recovery; additionally, they can display candor, sensitivity and empathy in helping these individuals to make this positive choice. As they work together cooperatively within these parameters, the entire team s efforts will be wisely invested. Questions and Answers Is there an up-to-date list of tobacco-use control and cessation web sites? Yes. Refer to these sites: The CDC website - quit_smoking/how_to_quit/index.htm Top 5 Quit Smoking Websites - about.com/od/quittingsmoking/tp/quit-smoking- Websites.htm The American Dental Association (ADA) The Office of the Surgeon General - www. surgeongeneral.gov/tobacco/default.htm Where can I get authoritative information relating to tobacco that can use at chairside? The American Dental Association Annual Catalog has a number of current pamphlets, posters and videos relating to the ill-effects produced by smoked and smokeless tobacco. Some are even available in Spanish. This catalog is available to ADA members at Example - swe?swecmd=start&sweho=siebel.ada.org For useful information, call The American Dental Association s Council on Access, Prevention and Professional Relations ( ). Also contact the National Institute of Dental and CranioFacial Research s Oral Health Information Clearing House ( ). At the time of this course revision in November 2010, The Family Smoking Prevention and Tobacco Control Act is requiring tobacco packaging to have larger and more visible warnings. Final regulations will be designated no later than June 22, Cigarette companies will have to comply within 15 months of the final ruling. The Act will require 9 warnings to be placed on all surfaces of the package and placement on the top 50% of the package. Proposed warnings include high resolution, full color graphics. The following website has materials that can be obtained to use for educational purposes: List_Complete.pdf 15

16 The senior author has prepared a 6 x 9 full color, 8-page pamphlet that depicts tobacco s effects on the oral cavity. Designed for dental office use, it contains twenty-four color photographs, which show the nature and extent of dentally-related tobacco-related problems. This pamphlet, Tobacco and Your Mouth, is available in bulk from The Health Connection, 55 West Oak Ridge Dr., Hagerstown, MD 21740, Tel: Is there a continuing education course that can teach the dental health care team about office-based tobacco cessation programs? Yes. The Indiana University Nicotine Dependence Program, in conjunction with the Dental School and the Indiana University School of Medicine, conduct periodic workshops on State-of-the-Art Smoking Cessation Interventions. This program is designed to educate the health professional about care management for the highly dependent tobacco user. The program which includes lectures, case-presentations and hands-on, skill-building workshops, teaches and demonstrates how to assess, diagnose, and develop treatment plans and deliver effective tobacco cessation interventions. Participants will learn how to use behavioral and pharmacologic aids to promote cessation. Information dealing with reimbursement issues will also be presented. Dental participants will receive an appropriate number of credit hours for attending this workshop. For more details, contact the Indiana University School of Medicine, Division of Continuing Education:

17 Course Test Preview To receive Continuing Education credit for this course, you must complete the online test. Please go to and find this course in the Continuing Education section. 1. One out of every smokers attempts to quit each year. a. 3 b. 10 c. 17 d Nicotine reaches the brain seconds after inhalation. a. 2 b. 7 c. 20 d is a white intraoral patch related to the use of all forms of tobacco and is considered to be precancerous. a. Hairy tongue b. Erythroplakia c. Leukoplakia d. Sinusitis 4. Pregnant women who smoke are more likely to: a. deliver their babies prematurely b. produce low birth-weight infants c. have spontaneous abortions d. all of the above 5. The incidence of after oral surgery is four times greater in smokers than nonsmokers. a. dry socket b. ANUG c. hairy tongue d. sinusitis 6. are more likely to develop lip cancer. a. Smokeless tobacco users b. Cigar smokers c. Pipe smokers d. Cigarette smokers 7. is not considered a symptom associated with nicotine withdrawal. a. Irritability b. Restlessness c. Headache d. All may be associated with nicotine withdrawal 17

18 8. Tolerance refers to a. the reduction in tobacco use that occurs with increasing age b. an emotional reliance on addictive substances or behaviors c. the need for increasing quantities of a drug to produce the same effect d. a prolonged, intense desire for nicotine 9. is NOT one of the first-line medications approved by the FDA for smoking cessation: a. Nicotine gum b. Lobeline Sulfate c. Bupropion SR d. Nicotine nasal spray 10. A temporary minor reversal to former addictive practices (of less intensity than a relapse) is known as. a. precontemplation b. contemplation c. maintenance d. a slip 11. is not one of the 5A s used in the National Cancer Institute s tobacco intervention program. a. ACT b. ADVISE c. ASSIST d. ARRANGE 12. A smoker who has thought about quitting smoking but has not yet stopped is in the stage of change referred to as. a. precontemplation b. contemplation c. action d. maintenance 13. Close to percent of adult smokers began smoking by the age of. a. 75/17 b. 80/18 c. 60/16 d. 90/ is produced by smokers and inhaled by non-smokers. a. Secondary smoke b. Sidestream smoke c. Carbon Monoxide d. A and B are both correct 15. The addictive substance present in all forms of tobacco is. a. tar b. nicotine c. heroine d. cocaine 18

19 16. Teenage girls smoke teenage boys. a. more than b. less than c. equal to 17. If fear of weight gain is a problem can be discussed. a. regular exercise to speed metabolism b. facts vs. myths that 1/3 of quitters do not gain weight c. the health risks of smoking are worse than the possibility of gaining 5-9 pounds d. all of the above 18. Nicotine tends to the vessels in the body. a. dilate b. constrict c. open d. pressurize 19. Acute health risks associated with smoking include. a. syncope b. diabetes c. impotence and infertility d. none of the above 20. The percentage of heavy smokers has been steadily increasing while the more casual, light smokers are quitting. For heavy smokers who are highly motivated to quit, nicotine reduction therapy is a viable option. a. Both statements are true. b. The first statement is true. The second statement is false. c. The first statement is false. The second statement is true. d. Both statements are false. 19

20 References 1. Benson, W., Christen, A.G., Crews, K.M., Madden, T.E., Mecklenburg, R.E., Tobacco-Use Prevention and Cessation: Dentistry s Role in Promoting Freedom From Tobacco, Journal of the American Dental Association. 131(8): August Christen, J.A., Christen, A.G., Defining and Addressing Addictions: A Psychological and Sociocultural Perspective, Indiana University School of Dentistry. March pp Christen, A.G, Tobacco and Your Mouth: The Oral Health s Team of What Tobacco Does to the Oral Cavity, 8-page Educational Pamphlet, The Health Connection, Hagerstown, Maryland Christen, A.G., McDonald, J.L., Klein, J.A., et al. A Smoking Cessation Program for the Dental Office, 4th ed. Indiana University School of Dentistry, Indianapolis, IN, pp Christen, A.G., Klein, J.A., Tobacco and Your Oral Health, Quintessence Publishing Co., Carol Stream, Illinois pp Christen, A.G., Helping Patients Quit Smoking: Lessons Learned in the Trenches, Quintessence International 29(4): , April Christen, A.G., Tobacco Cessation, the Dental Profession, and the Role of Dental Education. Journal Dental Education 65(4): , April Christen, A.G., Jay SJ, Christen, JA. Tobacco Cessation and Nicotine Replacement for Dental Practice. General Dentistry 51(6), November/December, Crews KM, Gordy FM, Penton-Eklund N, Curran AE, Clay JR. Tobacco Cessation: A Practical Dental Service. General Dentistry 47(5): , September-October, Dolan TA, McGorray SP, Grinstead-Skigen CL, Mecklenburg RE. Tobacco Control Activities in U.S. Dental Practices. Journal American Dental Association 128: , Dolan TA, McGorray SP, Grinstead-Skigen CL, Mecklenburg RE. Tobacco Control Activities in U.S. Dental Practices. Journal American Dental Association 128: , Fiore, M.C., Bailey, W.C., Cohen, S.J., et al. Treating Tobacco Use and Dependence, Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June Food and Drug Administration, Nov. 2010, Proposed Cigarette Product Warning Labels fda.gov/tobaccoproducts/labeling/cigaretteproductwarninglabels/ucm htm Accessed November 23, Glick M. Smoking Cessation: No Longer a Choice. Journal American Dental Association. 136(8): , Hu S., Pallonen U., McAlister AL. Knowing How to Help Tobacco Users. Journal of the American Dental Association. 137(2): , February Klein, J.A., Guba, C.J., Helping Patients Quit Smoking: The Role of the Dental Assistant, The Dental Assistant, 58(2):13-16, March/April Klein, J.A., Tobacco Cessation Communication Skills. Contemporary Oral Hygiene 3(6): July/August Kotlyar M, Hatsukami DK. Managing Nicotine Addiction. Journal Dental Education 66(9): September, Lindblom E, Campaign for Tobacco Free Kids Fact Sheet, June 16, tobaccofreekids.org/research/factsheets/pdf/0072.pdf. Accessed June 30, Mecklenburg, R.E., Cessation of Tobacco Use, Chapter 32, In: ADA Guide to Dental Therapeutics, 3rd Edition, Chicago, Illinois, American Dental Association, pp National Institutes of Health, Smokeless Tobacco or Health: An International Perspective, Monograph 2. National Cancer Institute, NIH Publication No , September pp Quit Solutions Website. Accessed October 22, The Health Consequences of Using Smokeless Tobacco: A Report of the Advisory Committee to the Surgeon General, U.S. Dept of Health and Human Services: 86:2874, Spiller, M.S. (2010) Dr Martin Spiller s Website - Accessed October 27,