Smoking Cessation Practice Guidelines for Registered Dental Hygienists

1
Smoking Cessation Practice Guidelinesfor
Registered Dental Hygienists

• Carol Southard, RN, MSNSmoking Cessation
  Specialist

2
The use of tobaccoconquers men with a certain
secret pleasure so that those who have once
been accustomed theretocan hardly be restrained
therefrom
Sir Francis Bacon

• Historica Vital et Mortis 1622

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a custome lothsome to the Eye, hatefull to the
Brain, dangerous to the Lungs, and in the black
stinking fume thereof, nearest resembling the
horrible, stigian smoke of the pit that is
bottomlesseMy position on the use of
tobaccoKing James I, 1604
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Tobacco Facts

• 1 public health problem in the United States
• Most preventable cause of morbidity and mortality
• Causes more deaths each year than alcohol, motor
  vehicle accidents, suicide, AIDS, homicide,
  illicit drugs and fires combined
• Proven risk factor for heart disease, malignant
  neoplasms and stroke
• One-third of all tobacco users will die
  prematurely

6
Comparative Causes of Annual Deaths in the United
States
Number of Deaths (thousands)
AIDS Alcohol Motor Homicide
Drug Suicide Smoking
Vehicle
Induced
Source CDC
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Impact of Smoking

• Smoking is now conclusively linked to acute
  myeloid leukemia and cancers of the cervix,
  kidney, pancreas and stomach
• Smoking is now also known to cause pneumonia,
  abdominal aortic aneruysm, cataracts and
  periodontitis
• Smoking harms nearly every organ of the body,
  damaging a smoker's overall health even when it
  does not cause a specific illness

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Oral Cavity Risks

• The most significant risk factor in the
  development and progression of periodontal
  disease
• Major risk factor for oral and pharyngeal cancer
• Tobacco use responsible for about 75 of all oral
  cavity cancers - mouth, tongue lips, throat,
  nose, larynx
• Smokers have 6 times the risk for mouth cancer as
  nonsmokers

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Oral Cavity Risks

• Tobacco users have from 3 to 17 times as much
  larynx cancer as nonsmokers
• Smoking is a key risk factor for gum disease
• Smoking while pregnant linked to cleft palate and
  cleft lip
• Children who are exposed to secondhand cigarette
  smoke are more likely to develop cavities in
  their baby teeth

10
Impact of Secondhand Smoke

• Many millions of Americans are still exposed to
  secondhand smoke
• Secondhand smoke exposure causes disease and
  premature death
• Children exposed to secondhand smoke are at an
  increased risk for sudden infant death syndrome
  (SIDS), acute respiratory infections, ear
  problems, and more severe asthma. respiratory
  symptoms and slows lung growth children
• Exposure of adults to secondhand smoke has
  immediate adverse effects on the cardiovascular
  system and causes coronary heart disease and lung
  cancer
• The scientific evidence indicates that there is
  no safe level of exposure to secondhand smoke
• Eliminating smoking in indoor spaces fully
  protects people from exposure to secondhand smoke
  - separating sections, air cleaning systems, and
  ventilating buildings cannot eliminate the risk
  of exposure

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Smoking Statistics

• About 44.5 million Americans are current smokers
  20.9
• 23.4 of men and 18.5 of women smoke in US
• Prevalence
• Native Americans Alaskan Natives (33.4),
• Persons reporting two or more races (31.0)
• Caucasians (22.2 )
• African Americans (20.2 )
• Hispanics (15.0 )
• Southeast Asians (11.3 )

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Smoking Incidence Scope

• In 2002, 17.3 percent of pregnant women aged 15
  to 44 smoked cigarettes in the past month
  compared with 31.1 percent of nonpregnant women
  of the same age group.
• The annual toll on the nations health and
  economy is staggering 440,000 deaths, 8.6
  million people suffering from at least one
  serious illness related to smoking,
• 75 billion in direct medical costs 82 billion
  in lost productivity.

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Smoking Trends

• Since 1974, the smoking prevalence in men has
  decreased by about 1 a year, in women 0.33
• Prevalence has remained fairly constant since
  1992
• Children raised in households where one or both
  parents smoke are 2 to 5 times more likely to
  smoke
• 1/3 of households with children under 6 years old
  contains at least one smoker
• 90 of smokers begin smoking before age 21

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Tobacco is Not an Equal Opportunity Killer

• Smoking affects young, the poor, depressed,
  uninsured, less educated, blue-collar, and
  minorities most in the US
• Addiction affects those with the least
  information about health risks, with the fewest
  resources to resist advertising, and the least
  access to cessation services
• Those below poverty line are gt40 more likely to
  smoke than those above poverty line

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Unequal Patterns of Use and Exposure

• 38 of persons with 9-11 yrs education
• 40 of cooks/truckers
• 1/3 of service workers covered by smoke-free
  policies
• Social norm for low SES different from high SES

• 13 of persons with college degree or higher
• 3 of lawyers
• ½ of white collar workers covered by smoke-free
  policies
• Higher SES less likely to be exposed to
  parent/peer smokers

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Smoking Population Trend Lines
The Department of Health and Human Services has
set a goal of reducing smoking prevalence to 12
or less by 2010.
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Cessation Facts

• About 30 of patients are current smokers
• 70 of smokers say they are interested in
  quitting
• Only 10 to 20 plan to quit in the next month
• About 46 of smokers try to quit in a given year
• The majority of smokers try to quit on their own
• Overall, self-quitters have a success rate of 2
  to 5
• Half of all smokers eventually quit

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Tobacco Intervention

• 75 of health providers THINK it is a good idea
• 10 routinely do it
• - not confident about subject
• - questionable goals
• - afraid of negative reaction from patient
• - feel patient might be offended
• - not enough reimbursement
• - not enough time

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Dental Intervention

• 33-50 of smokers report visiting a dentist
• annually
• 40 of dentists do not routinely ask about
  tobacco
• use
• 60 do not advise tobacco users to quit

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Practice Implications

• Only a minority of smokers report being advised
  to quit by a health care provider
• There is substantial evidence that even brief
  smoking cessation counseling can be effective
• Tobacco use status assessment, documentation and
  intervention by RDH and/or DDS would have a huge
  impact on cessation efforts

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History of the SCI

• 14 member task force met September 2003
• Summit sponsored by the RWJF SCLC
• Grant awarded in November 2003
• A nationwide campaign designed to promote smoking
  cessation intervention by dental hygienists

"The advice of a dental hygienist can be a major
motivation for a quit attempt by a patient who
smokes. -- Tammi O. Byrd, RDH, ADHA President
2003-2004
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ADHA Tobacco Cessation Task Force
Tammi O. Byrd, RDH Katie L. Dawson, RDH,
BS Jacquelyn L. Fried, RDH, MS JoAnn R.
Gurenlian, RDH, PhD Kirsten Jarvi, RDH, BS C.
Austin Risbeck, RDH
Rebecca Wilder, RDH, BS, MS Lisa M. Esparza,
RDH, BS Maria Perno Goldie, RDH, MS Barbara
Heckman, RDH, MS Kathleen Mangskau, RDH, BS,
MPA Margaret M. Walsh, MS, Ed.D
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The Objective
Baseline and Target Increase to 50 the
percentage of dental hygienists that screen their
clients regarding tobacco use (rate, type and
amount) by 2006.Baseline 25 in 2001 Journal of
Dental Hygiene study (Winter 2001)

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Main Elements of the SCIYear One
Educational Program Ask. Advise. Refer. SCI
Liaison Program Designate a liaison in each
state Dedicated Website www.askadviserefer.org
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SCI Year Two

• Grant renewed November, 2004
• SCI Project Manager, January, 2005
• SCI Administrative Assistant
• SCI Liaisons in-state support
• Six state presentations

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SCI Year Three

• Grant renewed November, 2005
• SCI Project Consultant
• SCI Administrative Assistant
• SCI Liaison education support
• Twelve district presentations

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Three Minutes or Less Can Save Lives

• The advice of a health care professional can more
• than double smoking cessation success rates.
• Tobacco dependence is a chronic disease
• that demands treatment.
• Effective interventions have been established and
  
• should be utilized with every current and
  former
• tobacco user.
• There is no other clinical practice that has more
  
• impact on reducing illness, preventing death,
  and
• increasing quality of life.

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Ask. Advise. Refer. Systematic Approach
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Ask. Advise. Refer. 5 As
Ask
Ask. Every patient/client about tobacco use.
Advise
Assess
Assist
Advise. Every tobacco user to quit.
Arrange
Refer. Determine willingness to quit. Provide
information on quitlines.
Refer to Quitlines
ADHA Smoking Cessation Initiative (SCI)
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SCI Protocols

• Step 1 Ask 1 min
• Systemically ask every client about tobacco use
  at every visit.
• Determine if client is current, former, or never
  tobacco user.
• Determine what form of tobacco is used.
• Determine frequency of use.
• Document tobacco use status in the dental record.

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SCI Protocols

• Step 2 Advise 1 min
• In a clear, strong, and personalized manner, urge
  every tobacco user to quit.
• Tobacco users who have not succeeded in previous
  quit attempts should be told that most people try
  repeatedly (on average 3 to 8 times) before
  permanent quitting is achieved.
• Employ the teachable moment link oral findings
  with advice.

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SCI Protocols

• Step 3 Refer 1 min
• Asses if client is interested in quitting.
• Assist those interested in quitting by providing
  information on
• Statewide or national quitlines, websites and
  local cessation programs.
• Use proactive referral if available
• Request written permission to fax contact
  information to a cessation quitline or program.
  Inform the client that cessation program staff
  will provide follow-up.
• Document referral on dental record.
• Use reactive referral provide client with
  contact information
• Arrange follow-up at periodontal maintenance
  visit and/or schedule a phone call

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What are Quitlines?

• Tobacco Quitlines are
• telephone-based tobacco
• cessation services available in
• all states and are accessed
• through a new federal toll-free
• number.
• They provide callers with a number of services
• Individualized telephone counseling
• Educational materials
• Referrals to local programs

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Refer to

• Current list of all state quitlines
• www.askadviserefer.org
• Department of Health and Human Services Quitline
  
• 1-800-QUITNOW (784-8669)
• Information Service Website
• http//www.smokefree.gov
• Web based cessation program
• http//smokefree.gov/
• or
• http//www.quitnet.com

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Online Smoking Cessation Assistance

• On-line smoking cessation services now available
  for smokers who prefer using computers over
  telephones
• Anonymity is a plus, as with telephone quitlines
• Early studies show promising efficacy
• www.quitnet.com
• www.smokeclinic.com
• www.tobaccoschool.com

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SCI Scripts

• If the client uses tobacco
• How many cigarettes per day do you smoke
• How many cigars per day do you smoke?
• How many bowls of pipe tobacco do you use
• per day?
• How many dips of chewing tobacco do you use per
  day?
• Do others in your household use tobacco?

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SCI Scripts

• For the client who never regularly used tobacco
• Congratulations, you have made a wise decision
  to protect your health.
• Congratulations on being a non-smoker.

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SCI Scripts

• For the client who quit using tobacco
• Congratulations, you made a wise decision.
• Congratulations on quitting tobacco use. We
  have some good programs to help you remain
  tobacco-free. I can give you the contact
  information for the program.

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SCI Scripts

• For the client who currently uses tobacco
• Have you thought about quitting?
• I can help you even if you do not want to quit.
  Let me give you the phone number for the
  statewide quitline. You can receive free
  counseling on how to quit and remain
  tobacco-free.
• Quitlines have had proven success in helping
  people get through the difficult stages of
  quitting and many people prefer to use them.

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SCI Scripts

• More available scripts for
• Pregnant mothers
• Hospitalized clients
• Heart Attack clients
• Parents of children and adolescents
• Lung, head and neck cancer clients
• Youth

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Nicotine Dependence

• The most powerful of all addictions to overcome
• Nicotine acts on nicotinic acetylcholine
  receptors in both the central nervous system and
  the peripheral nervous system resulting in a
  physical and biologic basis for physical
  dependence
• Psychological dependence
• Habitual dependence

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Neurochemical Effects of Nicotine

• Nicotine

• Dopamine Pleasure
• Norepinephrine Appetite Suppression
• Acetylcholine Arousal, Cognitive Enhancement
• Vasopressin Memory
• Serotonin Mood Modulation
• ß-endorphin Anxiety Reduction

Benowitz NL. Primary Care. 1999 26 619.
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Biology of Addiction

• Addictive drugs stimulate release of dopamine
  (brain neurotransmitter)
• Dopamine produces feelings of pleasure
• Pleasure reinforces repeat administration
• Tolerance develops
• Abrupt discontinuation leads to symptoms of
  withdrawal

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Nicotine Addiction Cycle
Benowitz NL. Med Clin North Am. 1992 76 423.
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Unique Qualities of Nicotine Addiction Through
Smoking

• Cigarette is a highly engineered drug-delivery
  system
• Inhaling produces a rapid distribution of
  nicotine to the brain
• Drug levels peak within 10 seconds in the brain
• Acute effects dissipate within minutes, causing
  the smoker to continue frequent dosing throughout
  the day
• Average smoker takes 200-300 boluses to the brain
  per day
• Easy to get, easy to use, and it is legal!

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Nicotine Absorption

• Primary routes respiratory tract, buccal
  mucosa,
• skin
• Absorption is pH-dependent
• Oral absorption
• - mouth is acidic
• - oral tobacco products buffered to increase
  mouth pH to 7.0-8.0
• - pH-altering beverages affect absorption

Benowitz NL. Primary Care. 1999 26 619.
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Nicotine Absorption

• Lung absorption ionized non-ionized
• 90 absorption across respiratory epithelium
• Alkaline form irritates throat
• Ionized form allows more nicotine to be
  dissolved
• in the tar droplets
• Absorbed in tar, nicotine is less irritating to
  throat

Benowitz NL. Primary Care. 1999 26 619.
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Rates of Absorption
Benowitz NL. Primary Care. 1999 26 619.
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Nicotine Withdrawal Symptoms

• Constant craving of cigarettes
• Insomnia
• Irritability
• Anxiety
• Frustration
• Anger

• Depression
• Difficulty concentrating
• Restlessness
• Decreased heart rate
• Increased appetite
• Fatigue

Withdrawal peaks within 24-48 hours and
diminishes over 1 to 3 months.
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Assessing the Degree of Addiction

• How many cigarettes are smoked on average per
  day?
• How much time typically elapses between waking
  and the first cigarette?
• What is the longest period of time between
  cigarettes before craving?

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Assessing Nicotine Dependence

• 1. How soon after you wake do you smoke your
  first cigarette or take your first dip?
• lt30 minutes 2
• 31 - 60 minutes 1
• gt60 minutes 0
• 2. How many cigarettes per day or tins per week
  do you use?
• lt10 cigarettes or lt1 tin
  0
• 11 - 20 cigarettes or 1 - 2 tins
  1
• 21-30 cigarettes or gt2-3 tins
  2
• gt30 cigarettes or gt 3 tins
  3
• 3. Do you find it difficult to refrain from
  using tobacco in places where it is forbidden
  (e.g., movies, work, etc)?
• Yes
  1
• No
  0
• Scoring 0 - 2 (LOW) 3 - 4
  (MEDIUM) 5 - 6 (HIGH)

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Treatment Facts

• The efficacy of several smoking cessation
  therapies is well established
• All proven treatments appear to be equally
  effective quit rates are doubled
• Early evidence suggests allowing smokers to
  choose treatment produces better outcomes
• The Agency for Health Care Policy and Research
  (AHCPR) published updated smoking cessation
  guidelines in 2000 for primary care clinicians

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Clinical Interventions

• The 5 As for patients willing to make a quit
  attempt
• The 5 Rs for patients unwilling to make a quit
  attempt at this time
• Relapse prevention for patients who have recently
  quit
• Intensive interventions should be provided when
  possible
• Health care administrators, insurers, and
  purchasers should institutionalize guideline
  findings

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Pharmacotherapy

• Seven first-line FDA approved therapies reliably
  increase long-term smoking abstinence rates
• All approximately double the rate of cessation
  when compared to placebo
• All help with symptoms of withdrawal

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Nicotine Replacement Therapy

• Goal is to replace nicotine from cigarettes in
  order to reduce or eliminate physical withdrawal
  symptoms
• Pharmacokinetic properties differ but none
  deliver nicotine to the circulation as fast as
  does inhaling cigarettes
• Effectiveness of all are broadly similar
• Few health interventions have such overwhelming
  evidence of effectiveness

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Plasma Nicotine ConcentrationsCigarettes versus
NRT

• Cigarettes
• 1 cigarette produces rapid surge of plasma
  nicotine
• ? by about 25 ng/ml in minutes declines rapidly
• NRT
• No form achieves plasma nicotine concentrations
  as high as those from smoking 20 cigarettes/day
• Does not reproduce immediate effect of smoking

Tang JL, Law M, Wald N. BMJ. 1994 308 22.
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NRT Contraindications

• No evidence of increased cardiovascular risk with
  NRT except with acute disease
• Medical contraindications
• Immediate myocardial infarction (lt 2 weeks)
• Serious arrhythmia
• Serious or worsening angina pectoris
• Accelerated hypertension

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Nicotine Gum

• Available since 1984
• OTC 1995
• 2 mg recommended for patients smoking less than 1
  pack per day
• 4 mg for patients smoking over 1 pack/day
• Full dose absorbed in about 20 minutes

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Efficacy of Nicotine Gum (n 13 Studies)
Estimated Abstinence Rate
Odds Ratio (95) CI

Pharmacotherapy
Placebo (reference group)
1.0
17.1
23.7
1.5 (1.3 - 1.8)
Nicotine gum
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Nicorette Clinical use and Dosing Schedule

• Proper Chewing Technique
• Chew slowly
• Stop chewing when peppery taste occurs
• Park gum
• Chew gum again when peppery taste fades

• Dosing Schedule
• Wk 1-6 1 piece q1-2h
• Wk 7-9 1 piece q2-4h
• Wk 10-12 1 piece q4-8h
• Max dose 24 pieces/day

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Nicotine Patch

• Available since 1994
• OTC 1996
• 21 mg recommended for patients smoking 1 pack per
  day
• 14 mg for patients smoking 1/2 pack/day
• 7 mg for patients smoking 5 or less cigarettes a
  day
• Full dose absorbed in about 2 hours

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Efficacy of Nicotine Patch (n 27 Studies)
Odds Ratio (95) CI
Estimated Abstinence Rate

Pharmacotherapy
Placebo (reference group)
1.0
10.0
17.7
1.9 (1.7 - 2.2)
Nicotine patch
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Nicotine Transdermal PatchesDosing
66
Nicotine Inhaler

• Available since 1998 - Rx
• Each cartridge delivers 4 mg of nicotine over 80
  inhalations
• Full dose absorbed in about 20 minutes
• Designed to combine pharmacological and
  behavioral substitution

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Nicotine Inhaler

• Nicotine is absorbed through buccal membrane
• Satisfies hand-to-mouth ritual of smoking
• Two-fold increase in quit rates at 12 months

• Dosage
• Initial treatment
• 6 cartridges/day increase prn to max 16
  cartridges/day
• min of 3 weeks, up to 12 weeks or longer as
  needed
• Gradual dosage reduction
• if needed over additional 12 weeks

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Schematic of the Nicotine Inhaler
Sharp point that breaks the seal
Cartridge
Air/Nicotine Mixture Out
Sharp point that breaks the seal
Mouthpiece
Air In
Porous Plug Impregnated with Nicotine
Aluminum Laminate Sealing Material
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Efficacy of Nicotine Inhaler (n 4 Studies)
Odds Ratio (95) CI
Estimated Abstinence Rate

Pharmacotherapy
Placebo (reference group)
1.0
10.5
22.8
2.5 (1.7 - 3.6)
Nicotine inhaler
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Nicotine Nasal Spray

• Available since 1996 - Rx
• Each spray delivers 0.5 mg of nicotine
• Full dose absorbed in less than 3 minutes
• Minimum recommended treatment is 8 doses per day

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Nicotine Nasal SprayDosage and Pharmacokinetics

• Dosage 1-2 sprays in each nostril every hour for
  6-8 wks
• 1mg (1 dose) 1 spray in each nostril
• max dose 40 doses/day or 5 doses/hr
• Pharmacokinetics
• 1/2 - 2/3 of dose absorbed systemically
• time to peak 3-15 minutes
• absorption is decreased with colds or rhinitis

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Nicotine Nasal SprayNicotrol NS

• Metered dose pump 10mg/ml 10ml (200 sprays)
• Designed for quick delivery of nicotine
• Similar efficacy to patches and gum
• May be most beneficial to highly dependant smokers

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Efficacy of Nicotine Nasal Spray (n 3 Studies)
Odds Ratio (95) CI
Estimated Abstinence Rate

Pharmacotherapy
Placebo (reference group)
1.0
13.9
30.5
2.7 (1.8 - 4.1)
Nicotine nasal spray
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Nicotine Lozenge

• Available since 2002 - OTC
• 2 mg recommended for patients who smoke more than
  30 minutes after waking
• 4 mg for patients who smoke within 30 minutes of
  waking
• Full dose absorbed in about 20 minutes

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Nicotine Lozenge

• Oral NRT
• Like hard candy, dissolves in mouth
• One lozenge every 1-2 hours for the first six
  weeks one lozenge every 2-4 hours during weeks
  7-9 one lozenge every 4-8 hours during the final
  weeks 10-12.

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Combination Nicotine Replacement Therapy

• Combining the nicotine patch and a
  self-administered NRT (either nicotine gum or
  nicotine nasal spray) is more efficacious than a
  single form of NRT

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NICOTINE DELIVERY SYSTEMSPLASMA CONCENTRATIONS
Cigarette
Gum (4 mg)
Gum (2 mg)
Inhaler
Nasal spray
Patch
Reprinted with permission from Schneider et al.,
Clinical Pharmacokinetics 200140(9)661684.
Adis International, Inc.
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Non-Nicotine MedicationsBupropion

• An atypical antidepressant with dopaminergic and
  noradrenergic activity
• First FDA approved non-NRT
• Risk of seizure is 0.1 or less
• Can be used in combination with NRT
• Is effective in those with no current or past
  depressive symptoms

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Bupropion SR

• Available by prescription only (USA)
• Dosing
• Start 1-2 weeks before quit date
• 150 mg orally once daily x 3 day
• 150 mg orally twice daily x 7-12 weeks
• No taper necessary at end of treatment
• Maintenance consider as a maintenance therapy
  for up to 6 months post-cessation

80
Efficacy of Bupropion SR (n 2 Studies)
Odds Ratio (95) CI
Estimated Abstinence Rate

Pharmacotherapy
Placebo (reference group)
1.0
17.3
30.5
2.1 (1.5 - 3.0)
Bupropion SR
81
Dose-Response Trial
82
Comparative Trial
83
6-MONTH QUIT RATES (Minimal Contact)
Data adapted from Hughes et al. JAMA
19992817276.
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Multiple Pharmacotherapy

• Bupropion SR may be combined with any of the NRTs
• Combination NRT
• Patch gum or patch nasal spray is more
  efficacious than a single NRT
• Encourage in patients unable to quit using single
  agent
• Combined NRT not currently FDA approved

85
Non-Nicotine MedicationsVarenicline

• A partial nicotinic acetylcholine receptor
  agonist
• Specifically indicated for use as an aid in
  smoking cessation
• Provides some nicotine effects to ease withdrawal
  symptoms
• Blocks effects of nicotine

86
Varenicline (Chantix)

• Recommended dosage
• Start 1 week before quit date
• 0.5 mg for 3 days
• Then 0.5 mg BID for 4 days
• Then 1 mg BID for up to 12 weeks

87
Varenicline (Chantix)

• Efficacy
• Six clinical trials N3659
• Self-report verified by CO measurement
• 1 in 5 quit at 1 year
• Precautions
• Nausea reported by 1/3
• Pregnancy Category C
• NO Contraindications

88
Pharmacotherapy for Light Smokers

• Consider reducing dose of first-line
  pharmacotherapies
• Bupropion SR may be prescribed at full strength

89
Extended Use of Pharmacotherapy

• First-line tobacco dependence medications may be
  considered for extended use, especially in
  patients with persistent withdrawal symptoms
• Evidence shows that a minority of patients
  continue ad libitum NRT agents
• Does not present known health risks
• FDA has approved bupropion SR for a long-term
  maintenance indication

90
Psychosocial Therapies

• Behavioral therapy is the only proven
  psychosocial treatment for smoking cessation
• Usually administered in a group setting
• Can also be conducted on an individual basis
• Major disadvantage is limited availability and
  acceptability

91
Alternative Therapies

• Acupuncture
• Hypnosis
• Massage
• Laser

92
AHCPR Guidelines

• Ask every patient at every visit if he or she
  smokes
• Record patients smoking status with vital signs
• Ask patients about their desire to quit
• Motivate patients who are reluctant to quit
• Help motivated smokers to set a quit date
• Prescribe nicotine replacement therapy
• Help patients resolve problems from quitting
• Encourage relapsed smokers to try quitting again

93
AHCPR Guidelines

• Documenting tobacco use status at every clinic
  visit will increase rates of clinician
  intervention and can increase abstinence rates
• Identification guides effective and appropriate
  intervention based on patients tobacco use
  status and willingness to quit

94
Vital Signs Stamp
VITAL SIGNS

Blood Pressure
Pulse
Weight
Temperature
Respiratory Rate
Current Former Never
Tobacco Use
(circle one)
95
Elements of a Counseling Intervention

• Quit date
• Set a stop date, preferably within 2 weeks
• Starting on the quit date, total abstinence is
  essential
• Past quit experience
• Identify what helped and what hurt in previous
  quit attempts
• Anticipate triggers or challenges in upcoming
  attempt
• Discuss challenges/triggers and how patient will
  successfully overcome them

96
Elements of a Counseling Intervention (contd)

• Alcohol
• Since alcohol can cause relapse, the patient
  should consider limiting/abstaining from alcohol
  while quitting
• Other smokers in the household
• Quitting is more difficult when there is another
  smoker in the household
• Patients should encourage housemates to quit with
  them or not smoke in their presence

97
Five As

• Ask - initial step is to identify if client uses
  tobacco
• Advise - deliver clear, strong, personal, and
  straightforward advice about the importance
  of quitting emphasize four R's risks,
  relevance, rewards, repetition
• Assess - willingness to make a quit attempt
• Assist - set quit date, offer pharmacologic and
  behavioral support
• Arrange - follow-up to prevent relapse

98
The Five As of a Three-Minute Intervention
(continued)

• Ask about tobacco use
• Every patient on every visit
• Past/present tobacco use
• Smoking as a vital sign
• WT_____HT_____BP_____TEMP_____P_____
• Tobacco Use Current Former Never

WT_____HT_____ BP______ TEMP______P______ CC
________________________________________
Tobacco Use (circle) Current
Former Never
Fiore MC, Bailey WC, Cohen SJ, et al. Treating
Tobacco Use and Dependence. Clinical Practice
Guideline. Rockville, MD U.S. Department of
Health and Human Services. Public Health Service.
June 2000. Page 28.
99
The Five As of a Three-Minute Intervention
(continued)

• Advise patient to quit
• Stress importance of quitting
• Personalize advice
• Example This is the third time you have had
  bronchitis this year. Your smoking is affecting
  your health.
• Deliver strong, firm message
• Example Quitting smoking is the best way to
  reduce your health risk.

Fiore MC, Bailey WC, Cohen SJ, et al. Treating
Tobacco Use and Dependence. Clinical Practice
Guideline. Rockville, MD U.S. Department of
Health and Human Services. Public Health Service.
June 2000. Page 28.
100
The Five As of a Three-Minute Intervention
(continued)

• Assess willingness to make quit attempt now,
  e.g., within next 30 days
• On a scale of 1 to 10, how motivated are you?
• If patient is willing to quit
• Provide assistance
• Offer intensive treatment or refer patient
• If patient is unwilling to quit
• Provide motivational intervention
• Relevance, risks, rewards, roadblocks and
  repetition
• Special populations (adolescents, pregnant
  smokers)

Fiore MC, Bailey WC, Cohen SJ, et al. Treating
Tobacco Use and Dependence. Clinical Practice
Guideline. Rockville, MD U.S. Department of
Health and Human Services. Public Health Service.
June 2000. Page 29.
101
The Five As of a Three-Minute Intervention
(continued)

• Assist by helping patient formulate quit plan
• Set quit date within 2 weeks
• Tell family and friends for support
• Anticipate challenges
• Withdrawal during first few weeks
• Remove all tobacco products and alcohol from
  environment

Fiore MC, Bailey WC, Cohen SJ, et al. Treating
Tobacco Use and Dependence. Clinical Practice
Guideline. Rockville, MD U.S. Department of
Health and Human Services. Public Health Service.
June 2000. Page 29.
102
The Five As of a Three-Minute Intervention
(continued)

• Arrange follow-up contact (in person/by phone)
• Timing
• Preferably during first week
• Second follow-up contact within first month
• Actions during follow-up contact
• Congratulate success
• Assess pharmacotherapy use consider more
  intensive treatment
• If tobacco use has occurred, review circumstances
  and elicit recommitment to total abstinence
• Remind patient a lapse can be a learning
  experience

Fiore MC, Bailey WC, Cohen SJ, et al. Treating
Tobacco Use and Dependence. Clinical Practice
Guideline. Rockville, MD U.S. Department of
Health and Human Services. Public Health Service.
June 2000. Page 31.
103
The 5 Rs to Enhance Motivation for Patients
Unwilling To Quit

• RELEVANCE Tailor advice and discussion to each
  patient
• RISKS Discuss risks of continued smoking
• REWARDS Discuss benefits of quitting
• ROADBLOCKS Identify barriers to quitting
• REPETITION Reinforce the motivational message
  at every visit

104
Stages of Change

• Precontemplative (not ready to consider quitting)
• Contemplative (planning to quit in next 6 months,
  no stop date set, ambivalent)
• Preparation (planning to quit, stop date set)
• Action (has quit)
• Maintenance (has not used for more than 6 months)
• Termination (no longer any serious temptation)

105
Precontemplation

• Employ consciousness-raising to help the smoker
  to think of quitting in next six months
• Discuss smokers feelings about the idea of
  quitting
• Review advantages of quitting/inconveniences of
  smoking
• Counsel about risks of smoking
• Adapt message to suit the beliefs, knowledge, and
  attitudes of the smoker

106
Contemplation

• Assure that advantages of quitting will be more
  significant than inconveniences
• Offer confidence that the smoker can do it
• Identify obstacles in quitting and explore
  solutions
• Encourage the smoker to picture life as an
  ex-smoker
• Reinforce the reasons given by the smoker to
  change

107
Preparation

• Ask smoker to set quit date
• Explore the possible behavioral substitutes
• Discuss the strategies and available resources
• Help smoker to decide on a plan of action
• Encourage observation of smoking behavior in
  order to be aware of patterns/vulnerable times
• Motivate smoker as the planning takes place

108
Action

• Support the smoker and the actions taken for
  change
• Discuss any relapses and develop plan to deal
  with relapses as necessary
• Ask questions about triggers
• Strongly suggest to the smoker to keep on using
  strategies for at least three months
• Refer to group program or support group as needed
• As necessary, revise therapies

109
Maintenance

• Help to recognize and use strategies to prevent
  relapses
• Reevaluate the strategies based on smokers
  knowledge, behavior and modify as needed
• Reinforce reasons for quitting
• Reinforce self confidence in quitting
• Encourage rewards!
• Reinforce decision to quit - commitment!

110
Termination

• Most smokers say this never really occurs -
  desire for a cigarette never disappears
• Maintenance becomes less vigilant over time
• Withdrawal is manageable
• No longer any serious temptation

111
Relapse Considerations

• Encourage quit attempt as soon as possible after
  relapse
• Adequacy of nicotine replacement therapy dosage
• Length of treatment
• Follow up contact is vital
• Relapse rates are highest during first few days
  of cessation
• Referral to smoking cessation specialist after 2
  to 3 relapses

112
Preventing Relapse

• Relapse prevention interventions should be
  provided with every smoker who has recently quit
• Crucial to address relapse the first 3 months
  after quitting
• Strategies to use with recent quitters
• Encourage continued abstinence
• Invite discussion of benefits, success
  milestones, problems encountered or anticipated
• Use or refer to an intensive intervention as
  appropriate

113
Ambivalence
Patients task to articulate and resolve
ambivalence.
Clinicians role to help him/her examine and
resolve ambivalence.
114
Special Populations

• In general, treatments found to be effective in
  the guideline should be used with all populations
• Some special populations may have concerns that
  can be addressed within the context of treatment
• Women
• Racial and ethnic minorities
• Adolescents
• Older smokers

115
Pregnant Smokers

• Augmented interventions approximately doubles
  abstinence rates relative to usual care
• Greatest health benefits result from cessation
  early in pregnancy, however, pregnant women
  should be encouraged to quit anytime during
  pregnancy
• Pharmacotherapy should be considered when a
  pregnant woman is otherwise unable to quit, and
  when the likelihood of quitting, with its
  potential benefits, outweighs the risks of the
  pharmacotherapy and potential continued smoking

116
Smokers with Comorbidities

• Smokers with a psychiatric comorbidity or
  chemical dependency should be offered
  guideline-based treatments
• Psychiatric disorders are more common in smokers
  than the general population and carry a higher
  rate of relapse
• Bupropion SR or nortriptyline should be
  considered in smokers with a history of
  depression
• Smoking cessation does not appear to interfere
  with recovery from chemical dependency

117
Weight Gain

• Clinicians should openly address postcessation
  weight gain concerns
• Acknowledge weight gain is likely but typically
  limited
• Encourage concentration on smoking cessation now,
  weight control later
• Recommend healthy diet and physical activity
• Consider pharmacotherapy, particularly bupropion
  SR and nicotine gum, shown to delay (but not
  prevent) weight gain

118
Non-Cigarette Tobacco Users

• Smokeless/spit tobacco users can be treated
  successfully using counseling treatments found to
  be effective in the guideline
• Brief interventions in a dental setting can
  effectively treat smokeless/spit tobacco users
• Users of smokeless/spit tobacco, cigars, pipes
  should be identified and offered treatment

119
Metabolic Effects

• Potentiates Metabolism of
• Beta-blockers
• Insulin
• Caffeine
• Adrenergic antagonists
• Acetaminophen
• Oxazepam (Serax)
• Imipramine (Tofranil)
• Propoxyphene napsylate
• (Davocet, Darvon)
• Theophylline

• Antagonizes Metabolism of
• Adrenergic agonists

120
Coding for Treatment of Tobacco Use and
Dependence

• Record
• ADA Code 1320 Tobacco Counseling for the
  Control and Prevention of Oral Disease

121
Program Agenda

• Session 1
• Session 2
• Session 3
• Session 4

• Orientation Introductions
• Understanding addiction
• Preparation_________________
• Benefits of Quitting
• Withdrawal Symptoms
• Cessation Strategies__________
• QUIT DAY_________________
• Motivation Reinforcement
• Support Systems

122
Program Agenda

• Session 5
• Session 6
• Session 7
• Session 8

• Lifestyle issues
• Nutrition/Weight
• Exercise____________________
• Stress Management
• Relaxation Skills
• New Self-image______________
• Ex-smokers panel_____________
• Graduation Celebration
• Relapse Prevention

123
Power of Intervention

• The costs of providing brief interventions is 3
  per smoker
• Implementing such interventions could quadruple
  the national annual cessation rate, translating
  to roughly 4.8 million quitters
• Adding brief behavioral counseling and medication
  can increase the cessation rate sixfold,
  translating to roughly 7.2 million quitters

124
The Benefits Of Quitting Smoking

• At 1 year excess risk of coronary heart disease
  decreases to half that of a smoker
• At 5 years stroke risk reduces to that of people
  who have never smoked

125
The Benefits Of Quitting Smoking

• At 10 years the risk of lung cancer drops to
  one-half that of continuing smokers
• At 15 years the risk of coronary heart disease is
  now similar to that of people who have never
  smoked and the risk of death returns to nearly
  the level of people who have never smoked

126
The Benefits Of Quitting Smoking

• Children in households will be less likely to
  become smokers once their parents quit. All
  family members will be exposed to less
  second-hand smoke.
• Former pack-a-day smokers save about 120-190 a
  month.

127
Benefits of Quitting

• Mortality ratios for oral cancer diminish
• Premalignant lesions may regress after the
  discontinuation of smoking or stopping smokeless
  tobacco use
• Decreases the risk of second or multiple primary
  tumors in patients with a previous cancer of the
  oral cavity or pharynx

Martin et al. 1999
128
Why Dental Hygienists?

• Have interviewing skills.
• Have educating skills.
• Have motivating skills.
• Have counseling skills.
• Dental hygiene is the most frequently provided
  service.
• Follow-up procedures have always been an
  important part of the dental hygiene practice.

129
Systems Changes

• Can reduce smoking prevalence.
• Makes it easier for dental hygienists to help
  tobacco users quit.
• Requires changes in the systems in the profession
  and in the dental office.
• A simplified approach is more likely to lead to
  successful interventions.
• A simplified approach opens the door to more
  intensive interventions.

130
Systems Changes in the Dental Office

• A system in the office can be brief, simple and
  does not need to disrupt the practice routine.
• Organize the team and assign team duties and
  responsibilities.
• Implement an office-wide tobacco user
  identification system.
• Identify and track tobacco use status.
• Refer tobacco users to a quitline.

131
Program Responsibilities

• Dentist Program Director
• ADVISE to quit, prescribe pharmacotherapy.
• Dental Hygienist Program Coordinator
• Determine willingness to quit, REFER to quitline.
  Track tobacco use status.
• Dental Assistant
• Assist front office making follow-up calls
  concerning quit dates.
• Front Office
• Update health history and ASK about tobacco use
  status. Telephone patient/client just before and
  soon after quit date.

132
Make it a Priority!

• Single most effective step to lengthen and
  improve patients lives
• Quitting smoking has immediate and long-term
  benefits and is well worth the difficulty, both
  for patient and clinician
• The health care systems neglect of the tobacco
  user exacts costs that sum to thousands of lives
  and billions of dollars in added health care
  expenditures

133
In Summary

• Brief tobacco dependence treatment is effective
  and every patient who uses tobacco should be
  identified, urged to quit, and offered at least
  one of these treatments
• Patients willing to quit should be provided
  treatments identified as effective
• Patients unwilling to quit should be provided an
  intervention to increase their motivation to quit

134
Conclusions

• Nicotine dependence is a chronic condition
• Every patient who uses tobacco should be offered
  treatment
• It is essential that clinicians and health care
  delivery systems institutionalize the consistent
  identification, documentation and treatment of
  every tobacco user
• Brief tobacco dependence treatment is effective
• There is a strong dose-response relationship
  between the intensity of tobacco dependence
  counseling and its effectiveness
• Numerous effective pharmacotherapies now exist
• Tobacco dependence treatments are both clinically
  effective and cost-effective relative to other
  medical and disease-prevention interventions

135

• Lives saved from smoking cessation would swamp
  all the benefits accrued if each year every
  person underwent every cancer screening procedure
  recommended by the American Cancer Society.
• Steven A. Schroeder, MD
• Medical Director
• Smoking Cessation Leadership Center

136
Health professionals shouldnt grade themselves
on how many people they can get to quit, but
rather how many times they give the message when
the opportunity arises.
Under these criteria, there is no reason not to
have an intervention success approaching 100
137
About the ADHA Website

• www.askadviserefer.org
• Available to download for all dental hygienists
  and their clients
• Protocols Scripts Document
• PowerPoint Presentations
• Fact Sheets (for the Consumer the Dental
  Hygiene Professional)
• Ask. Advise. Refer. Flyer
• Liaison Resource List
• Quitline Resource List
• Relevant State National News and Announcements

138
(No Transcript)
139
Resources

• www.tobacco.org
• http//www.ctcinfo.org The Center for Tobacco
  Cessation
• www.umassmed.edu/behavmed/tobacco/
• Addressing Tobacco in Managed Carewww.atmc.wisc.e
  du
• www.cdc.gov/tobacco
• http//www.smokefree.gov NCI site

140
Surgeon Generals Web site

• The full text of the guideline documents and the
  meta-analyses references for online retrieval are
  available at
• www.surgeongeneral.gov/tobacco/default.htm
• The Clinical Practice Guideline
• The Quick Reference Guide
• Consumer Versions

141
ADHAs SCI Project Consultant

• Carol Southard, RN MSN
• Smoking Cessation Initiative Project Consultant
• American Dental Hygienists' Association
• 444 N. Michigan Ave., Suite 3400
• Chicago, IL 60611
• 1-800-243-ADHA, ext. 220
• E-mail carols_at_adha.net

142
References

• Clinical Practice Guideline Panel and Staff, A
  Clinical Guideline for Treating Tobacco Use and
  Dependence. JAMA, 283, 3244-54, 2000.
• Fiore MC, Bailey WC, Cohen SJ, et al. Treating
  tobacco use and dependence. Rockville, MD.
  Department of Health and Human Services, Public
  Health Service, 2000.
• Hughes, JR. New treatments for smoking cessation.
  Cancer Journal for Clinicians 2000 50 143-155.
• Lancaster T, Stead L, Silagy C, Sowden A.
  Effectiveness of interventions to help people
  stop smoking findings from the Cochrane Library.
  BMJ 2000 321 355-8.
• Rigotti, N. Treatment of tobacco use and
  dependence. New England Journal of Medicine 2002
  346 506-512.
• US Department of Health and Human Services,
  Clinical Practice Guideline Treating Tobacco Use
  and Dependence. US Department of Health and Human
  Services, Public Health Service, June 2000.
• US Department of Health and Human Services. The
  Surgeon Generals Report on The Health
  Consequences of Smoking. US Department of Health
  and Human Services, Public Health Service, 2004.