Title: Helping Tobacco Users Quit: Dental Hygienists Leading the way as Effective Cessation Counselors
1Helping Tobacco Users Quit Dental Hygienists
Leading the way as Effective Cessation Counselors
- Presented By
- Tavia Rauch, BA, CRT
2Center for Smoking Cessation atSeton Health
- Funded by NYSs Tobacco Control Program to
provide free services to healthcare providers - Training, technical assistance, and follow up to
healthcare institutions and providers on
addressing tobacco dependence with patients and
helping them quit - Eight counties served Albany, Schenectady,
Rensselaer, Columbia, Green, Schoharie, Delaware,
Otsego
3- Trainings, free supplies educational resources
for hygienists and their practices - Fun contests and other incentive-based promotions
check for updates often on our website
www.Quitsolutions.org
4Program Overview
- Forward What you should know about nicotine
addiction - Rationale Why address tobacco use and encourage
cessation in dental practices? - Communication Effective counseling principles
and techniques to assist you in providing
effective interventions with patients who use
tobacco - Continuity A systems approach to permanently
translate evidence based methods into practice - Folder contents
5Evidence-based PracticesStrategies that Work in
Tobacco Control
- Increases price of tobacco
- Clean Indoor Air (Smoking bans restrictions)
- Mass Media campaigns with interventions (i.e.,
part of comprehensive tobacco control programs)
- Availability of treatment for tobacco dependence
- Provider reminder systems
- Telephone counseling and support
- Reducing patient costs for treatment
Source Guide to Community Preventive Services ,
Systematic Reviews recommendations
6New Yorks Tobacco Cessation Environment
Media
Self-Quit
- Tobacco Dependence Treatment
- Health Care Providers Organizations
- Community Programs
Policy
Tobacco Users
Community Action
- New York State Smokers Quitline
- Counseling NRT
- Information self-help Materials
- Referral
Health Care System
7Why Are Cigarettes So Dangerous?
8Tobacco Nicotine
- Tobacco was cultivated and used
- since 6000 BC
- Nicotine makes up 5 of the
- tobacco plant
- One cigarette contains 8-20mg of nicotine
- When a cigarette is smoked, 1mg is absorbed into
- the body
- Delivered through skin, lungs and mucous
membranes
9Cigarettes Are Poison
- Nicotine is sold commercially as
- a pesticide
- Consuming one cigarette will make a toddler very
ill - 60 mg, about 3-4 cigarettes, if consumed will
kill an adult
10- A BURNING CIGARETTE is a small chemical
manufacturing plant, that produces over 4,000
chemicals including - 43 Carcinogens
- 400 toxins
- Nicotine
11Chemicals in Tobacco Smoke
- Butane lighter fluid
- Cadmium batteries
- Toluene solvent
- Ammonia cleaner
- Acetic acid vinegar
- Methane sewer gas
- Arsenic - Poison
- Carbon Monoxide
- poisonous gas
- Methanol rocket fuel
- Formaldehyde
- embalming fluid
12The Cold, Hard Facts about Spit.
- Placed inside of the users mouth wad for a
continuous high from the nicotine - CHEW a leafy form of tobacco sold in pouches.
Users keep the chew between the cheek and gums
for several hours at a time. - PLUG chew tobacco that has been pressed into a
brick. - SNUFF a powdered, moist form of tobacco sold in
tins. Users put the snuff between the lower lip
or cheek and the gum. As well, some users will
sniff it. Using snuff is also called dipping.
13Smokeless ? Safe.
- 8 10 chews/dips per day 2 cans per week is
equivalent in nicotine content to 30 40
cigarettes per day - Made from a mixture of tobacco, nicotine,
sweeteners, abrasives, salts and chemicals - Contains more than 3000 chemicals, about 28 known
carcinogens more addictive than cigarettes
because it contains higher levels of nicotine
U.S. Dept. of Health and Human Services, National
Institutes of Health, NIH Publication No.
03-3270, July 2003
14Laced with the Same Kinds of Toxic Chemicals
- Polonium 210 (nuclear waste)
- Tobacco-specific N-nitrosamines or TSNAs
- Formaldehyde
- Nicotine
- Cadmium
- Cyanide
- Arsenic
- Benzene
- Lead
15Leading Causes of Preventable Death
- Tobacco Use
- Obesity
- Secondhand Smoke
16Secondhand Smoke-Did You Know That
- Children are twice as likely to develop cavities
in baby teeth - ¼ would not have developed cavities
- 50 of children in the U.S. are exposed to
secondhand smoke
17There is No Safe Level of Exposure to Secondhand
Smoke.
- It is a known cause of SIDS
- Children are more likely to have lung problems,
ear infections, and severe asthma - Even a brief pass through drifting tobacco smoke
can be harmful
18What the Science Says
- Most children breathe SHS in their homes
- Almost 3 million children in the U.S. under the
age of 6 breathe SHS at home at least 4 days per
week - 40-59 of all youth in the U.S. live in homes
where others smoke in their presence
19In the United States
- 38,000 65,000 people die each year from heart
disease and lung cancer caused by passive smoking
20Tobacco Industry Marketing
- 516 million annually is spent on cigarette
advertising and promotion in NYS - Point-of-purchase ad
- Magazines Ads in Clinical or Residential Areas
21The Brain and Nicotine
22Nicotine and other Addictive Drugs
- Nicotine stimulates an increase in the release
of dopamine, a neurotransmitter associated with
feelings of pleasure.
- Studies show that brain changes during withdrawal
from nicotine are similar to those that occur
when withdrawing from heroin, cocaine and
alcohol.
23EASY COME
Once inhaled, nicotine goes to the lungs and is
easily absorbed into the blood stream, and routed
directly to the brain. This takes 7 seconds!
24EASY GO
Liver, Lungs, Kidneys. Mutant Enzymes
25Neurotransmitter
Neurotransmitter
Neuron
Neuron
Neuron
26- Neurons typically release a small amount of
acetylcholine - Nicotine mimics the effects of the brain chemical
acetylcholine - Within 10 seconds of inhaling a cigarette the
brain is flooded with nicotine and a large
release of acetylcholine.
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28- The flood of nicotine signals the brain to
release dopamine. - This happens with all addictive drugs.
- The brain becomes adjusted to high levels of
nicotine, dopamine and acetylcholine. - The problem The brain can no longer be content
with normal levels of acetylcholine. - Without nicotine the smoker experiences
withdrawal, increased nervousness, lack of
concentration and craving. - These symptoms subside within a month
29Tolerance
- Nicotine activates the release of dopamine and
then deactivates its release. - The first cigarette of the day is the most
enjoyable but as more are smoked enjoyment
subsides. - This is called tolerance. It fades overnight.
The next morning the dopamine cells are once
again kicked up a notch and then kicked down.
30The Cycle
Benowitz NL. Med Clin North Am. 1992 76 423.
31Nicotine Affects Brain Emotions
- Regulating mood
- Controlling anger and anxiety
- Acting as a stimulant or relaxing a person
depending on the situation - Providing a sense of control
32Nicotine Affects the Body
- Increasing metabolism
- Decreasing appetite
- Dulling the sensation of pain
- Producing a slight high
33Physical Withdrawal Symptoms
- Sweating
- Weight gain
- Cough
- Nausea
- Fatigue
- Drowsiness
- Constipation / diarrhea
- Muscle aches / cramps
- Excessive saliva
- Warmer hands and feet
- Runny nose
- Sensory changes in the mouth and nose
34Psychological Withdrawal Symptoms
- Anxiety
- Irritability
- Restlessness
- Depression
- Anger
- Intense cravings
- Reduced coping ability
- Feeling weepy
- Listlessness
- Trouble concentrating
35The Cycle ? Triggers
- The longer one smokes, the more dependent he /
she becomes the occasional cigarette becomes 20
to 30 each day - Positive effects physical, social reinforce
smoking behavior - Repetition of use in specific situations create
strong associations triggers - After meals -While driving -Talking on the
phone - Breaks during the work shift -Morning cup of
coffee
36Tobacco Dependence as a Chronic Disease
- Tobacco dependence demonstrates features of a
chronic disease - Long term disorder
- Periods of relapse and remission
- Requires an ongoing rather than acute care
37Nicotine Addiction Is Classified As Nicotine Use
Disorder in DSM-lV
- Criteria Includes Any 3 During
- a 1-year Time Span
- Tolerance to nicotine with decreased effect and
increasing dose to obtain same efficacy - Withdrawal symptoms after cessation
- Smoking more than usual
- Persistent desire to smoke despite efforts to
decrease intake - Extensive time spent smoking or purchasing
tobacco - Postponing work, social, or recreational events
in order to smoke - Continuing to smoke despite health hazards
38The 12 Truths About Smokers
- What Every Hygienist Needs to Know for Treating
Patients Who Smoke
39Truth 1 People dont start smoking, they
have one or two.
- Most addictive substance on the planet
- More addictive than heroin and cocaine
- It is harder to quit than heroin
- Dopamine Dopaminergic Effects
40Percent of Those Ever Using Who Become Addicted
41Abstinent Rate at One Year for Heroin, Smoking
Alcohol
42Truth 2People who smoke wish that they didnt
- No one ever says, Im glad I started this.
- 70 state they want to quit
- American Cancer Society did a study and reported
that 95 of smokers wished to have their smoking
removed
43Truth 3Smokers feel like second class
citizens
- Corralled outside to smoke
- Comments/complaints from others
- They feel weak-minded I cant do this.
- Even more so for pregnant women who smoke
44Truth 4Ex-smokers do not go back to smoking,
they have just one.
- Why cant an ex-smoker have just one?
- Because its 100x easier to have the next just
one. - Therein lies the rub. Increases exponentially
45Truth 5But if you do have one
- Slips are normal, if not expected
- Many quitters who slip experience extreme guilt
- Does not mean relapse
- Prepare ahead of time and create a slip plan.
46Truth 6When a smoker quits its a miracle
- There is no success formula
- Motivators are different for everyone
- Seasoned cessation counselors have learned not to
predict
47Truth 7Smokers do fear the harm that cigarettes
cause
- They often will not verbalize it, but smokers
know its potentially causing harm - Important to be sensitive to this
- Denial
- Psychologically Protects
- Perpetuates compulsion
48Truth 8People smoke because it is too
uncomfortable not to. It is an addiction.
- Physical dependency
- Interacts with CNS receptors.
- Facilitates release of neurotransmitters
dopamine, norepinephrine, acetylcholine,
glutamate serotonin. - Produces pleasure, arousal, relaxation, improves
concentration, reduces anxiety prevents weight
gain - Dependence produced is similar to that of opiates
cocaine - Psychoactive effects causes smoking behavior to
be reinforced
49Truth 9Cigarette smoking is a habit the size
of Texas!
- Lets do the math for the patient who smokes 1
ppd - 1 cigarette 12 drags
- 20 cig./day x 12 240 drags/day
- 240 x 365 days 87,600 drags/year
- 87,600 x 20 years 1,752,000 drags
50Truth 9Contd
- For the patient who smokes 2 ppd
- 1 cigarette 12 drags
- 40 cig./day x 12 480/day
- 480 x 365 days 175,200/year
- 175,200 x 20/years 3,504,000
- Each smoking event is connected to the smokers
daily rituals
51Truth 9Contd
- When a smoker quits they are literally bombed
with triggers. - Its time to smoke.... No, I quit.
52Truth 10Cigarette smoking is a psychological
dependency
- People smoke when they are happy, sad, angry,
lonely, tired, excited - Smokers consider their cigarettes a friend a
friend who is always there and never talks back. - They have a smoking voice in their head.
53Truth 11Smokers hate being controlled by
cigarettes
- Smokers dont have a choice they have to smoke.
If they dont, they feel awful - Smokers know they are owned by the pack of
cigarettes - The addiction demands a certain amount of
cigarettes be smoked every day. -
54Truth 11Contd
- The expense of smoking is motivational for many
younger smokers - 1 pack 5.00/day
- 35/week 4 bags of diapers
- 280/month ½ rent
- 1,825/year buy a used car
- 36,500/20 years college education
55Truth 12To allow is to teach
- Health care professionals have significant impact
on a patients smoking - Smoking must be addressed at every patient visit
56Sharpen Your Pencils!
57Morning Break
58Effects of Tobacco on Teeth and Oral Health
- What Every Dental Hygienist Should Be Familiar
With
59Esthetics
- Discoloration of teeth, dentures, and
restorations - Excessive wear on teeth
- Halitosis
- Cleft lips and palates are twice as common
amongst children born to mothers who smoked
during pregnancy - Overgrowth of the papilla of the tongue surface
- Higher levels of calculus formation
Christen AG, Klein JA. Tobacco and Your Oral
Health. Quintessence Book, Illinois 1997
60More Effects on Teeth and Oral Health
- Periodontal diseases
- Periodontitis
- Gingivitis
- Acute necrotizing ulcerative gingivitis (ANUG)
- Dental implants
- Damaging to both the initial and long-term
success of - Delayed wound healing / less favorable treatment
outcomes
Bain CA, Moy PK. The association between the
failure of dental implants and cigarette smoking
Int J Maxillofac Implants. 1993 8609-15
61More Effects on Teeth and Oral Health
- Dental caries
- Salivary changes
- Candidasis
- Leukoplakia
- Malignancies
62Oral Leukoplakia
- Most common potentially malignant lesion defined
as a predominantly white lesion of oral mucosa
that cannot be characterized as any other
definable lesion
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65Site Of The Oral Cavity Affected By Leukoplakia
- Lateral tongue and floor of mouth in cigarette
smokers - Palate in pipe smokers and reverse smokers .
smokers palate - Commissures in bidi smokers
66Site Of The Oral Cavity Affected By Leukoplakia
- Buccal groves in tobacco chewers where they park
the chew - Lower or upper labial mucosa in snuff dippers
67Oral Cancer Facts
- Survival rate has not changed significantly in
over 40 years - Late detection 70 of oral cancer lesions are
identified in stages III and IV - 50 5-year survival rate poor quality of life
68Oral Cancer Risk by Patient Profile
- High risk
- Patients age 40 and older
- Tobacco users (any type, any age, within 10
years) - Highest risk
- Patients age 40 and older who use tobacco
- Consumption of alcohol increases risk 15x
- Patients with history of oral cancer
69High Risk Sites for Oral Cancer
- Lateral tongue
- Lip
- Anterior floor of the mouth
- Soft palate, including anterior and posterior
tonsillar pillars and uvula
70How Does Oral Cancer Present?
- A lump on the lip, or in the mouth, or in the
throat - A sore on the lip, or in the mouth, or
on the tongue, that does not heal
71How Does Oral Cancer Present?
- A white or red patch or black spots
- on the gums, tongue, or lining of the mouth
- Unusual bleeding, pain, or
- numbness in the mouth
- A sore throat that does not go away or a feeling
that something is 'caught in the throat'
Silverman Oral Cancer 5th Ed.
72How Does Oral Cancer Present?
- Difficulty or pain while chewing or swallowing
- Swelling of the jaw that causes dentures to fit
poorly or fall off or become uncomfortable. A
change in the voice or pain in the ear - These symptoms can also be caused by other less
serious problems - It is important that a health care professional
determine the cause of these symptoms early as
possible
73Tobacco Intervention
74The Dental Office is an Excellent Venue for
Providing Tobacco Intervention Services
- Dental Hygienists / Dentists are in a prime
position to show patients the health effects of
tobacco use - You can be as effective if not more so than
primary care physicians in helping patients quit
tobacco
75Interventions are PowerfulProvider Intervention
Quit Rates
- Cold Turkey ? 2 4 quit rate
- Brief Advice 1 3 minute intervention by a
clinician ? 3 6 quit rate - Behavioral Counseling
- Dose related Quit rate increases with time spent
- 10 15 quit rate
- Pharmacotherapy Counseling ? 20
30 quit rate
76The Good News
- More than 50 of patients who smoke make an
annual visit to the dentist - Dental hygienists / dentists are more likely to
see adults for routine care on an annual basis - Patients do have increased success rates with
tobacco cessation with brief interventions from
dental hygienists / dentists
77Tobacco Interventions
- 75 of health care providers THINK it is a good
idea - However, only 10 routinely do itWhy ?
78Common Reported Barriers for Not Helping Patients
Quit
- Not enough time / too busy
- Lack of knowledge
- No financial incentive
- Many tobacco users cannot / will not quit
- Stigmatizing tobacco users
- Respect for Privacy
- Fear of scaring patients away
- Personal beliefs / smoking habits
79Behavior Change A Process, Not a Single Act
- Precontemplation
- Contemplation
- Preparation
- Action
- Maintenance
- Relapse
80Stages of Change
Thinking about it
Im ready
Doing it
Living it
Try again
Not interested
81Movement through stages
- The progression through stages are not
necessarily forward. - 2 steps forward, one back.
- Any progress increased the likelihood of future
success. - The circle is more like an upward spiral.
- American Cancer Society, Living Well, Tobacco Free
82Goal of Treatment
- Goal is to move people along the stages.
- Even if people do not quit, our interventions can
move them to the next stage. - Movement success
83Both the Hygienist and the Patient Bring Things
to the Table
- Hygienist
- Medical information
- Statistics
- Research Results
- Experience
- Community resources / tools for the patient
- Patient
- Unique circumstances/ personal experiences
- Values
- Life priorities
84Components of a Brief Intervention
- 1. Identify patients who use tobacco
- 2. Talk with them briefly
- 3. Provide assistance with quitting or a
motivational intervention
85Motivation is a Key to Change
- Focus on the patients strengths
- Respect the patients autonomy decisions
- Make interventions individualized
- Use empathy, not authority or power
- Recognize that addiction exists along a continuum
- Accept treatment goals that involve incremental
steps toward the ultimate goal
86Its How You Approach Patients About Their
Tobacco Use
- In the spirit of gentle guidance
87Why Patients May Become Resistant/ Defensive When
You Address Their Tobacco Use
- Strategies
- Emphasize personal choice and control
- Reassess readiness, importance, confidence
- Avoid arguing use reflective listening
- Causes
- Take control away
- Misjudge importance, confidence, or readiness
- Meet force with force, lecturing
88Motivational Interviewing
- On a scale of 0 10, how important is it for
you to make a quit attempt? - On that same scale, how confident are you?
(2) (1)
(3)
? ?
? 0 1 2 3
4 5 6 7 8 9 10
89Just Remember Avoid the following Assumptions
- The patient wants to change
- The patient ought to change in a particular way
- Health is the prime motivating factor
- If the patient doesnt decide to change during
this visit, the practitioner has failed
90Public Health Service Guidelines The 5 As
- Ask your patient if he / she uses tobacco
- Advise the patient to quit
- Assess the patients readiness to quit
- Assist the patient with the quitting process
- Arrange for follow up
91Ask
- Do you use tobacco in any form?
- Have you ever used tobacco in the past?
- How many cigarettes / cigars / bowls of pipe
tobacco do you smoke per day? - If the patient uses spit tobacco
- How many cans of snuff do you use per day?
- How many pouches of chew do you use per week?
- Do others in your household use tobacco?
92Asking Youth About TobaccoStarting the
Conversation
- Interview pre-teens privately and explain that
you ask all patients the same questions - Start with open-ended, less personal questions,
then progress to more difficult ones - Consider age and risk factor when shaping the
discussion - First, ask about attitudes / tobacco knowledge /
friends use / peer pressure to experiment, then
ask about actual use / history
93Advise
- The Advice Should Be
- CLEAR
- Strong
- Personal
94Advising Youth
- I think you should ______
- Emphasize that tobacco use is bad for their
health, and focus on short-term risks - Makes clothes / breath / hair stink
- Will not allow you to perform in sports as well
- Talk about the cost factor
- Discuss ways to resist peer pressure
- Offer free educational materials
- Reinforce positive messages within the office
95ASSESS
- Ask every patient if they are willing to make a
quit attempt - Not all patients are ready quit, you can assist
those patients with the motivational interviewing
96Assist
- Whether or not you are ready to quit, I can help
you. Let me give you the phone number for the
statewide quitline. You can receive free
counseling on how to quit and remain tobacco-free
97Arrange
- Schedule follow-up contact, either in person or
via telephone
98An Abbreviated, Approach
- Ask the patient if he / she uses tobacco
- Document tobacco use status at each visit
- Advise the patient to quit
- Refer the patient
- NYS Smokers Quitline
- Fax-to-Quit Program
- Group Support Programs
- Medications
99Motivational Interviewing Summary
- It is important for dental hygienists to
routinely address tobacco use with patients - It can sometimes be difficult to intervene
effectively - Its critical to meet patients where they are
at - A patient-centered approach like MI can improve
the effectiveness of reaching out to patients in
this area - The New York State Smokers Quitline should be
included in all tobacco dependence interventions
100Lunch TimeEnjoy
101Resources to Help Tobacco Users Quit
- -Services of the NYS Smokers Quitline
- -Medications
102What is the New York State Smokers Quitline?
- Free and confidential program that provides
evidence-based tobacco cessation services to New
York State residents who want to stop cigarette
smoking or other forms of tobacco.
103Quitline Overview
- In operation since 2000
- Based at Roswell Park Center Institute, Buffalo
- Serviced 400,000 calls
- Hours of Operation
- Live Specialist Support
- Monday Friday 9am 9pm
- Saturday Sunday 9am 1 pm
- Taped Message Library 24 hours / 7 days
- Tip of the Day 24 hours / 7 days
104A Brief Video Brought to You by the New York
State Smokers Quitline
105Services of the Quitline
- Free and confidential services
- Free NRT starter kit for eligible callers
- Resources for all healthcare settings
- Evidence-based services
- Referrals to local community supports / programs
- Information on NYS health plans cessation
coverage
106Quitline Dos and Donts
- Print or write legibly on the referral form
- Complete all blank sections on the form whenever
possible - Refer patients as often as they request
- Advise patients that they can call as often as
needed - Expect a faxed progress report sent back on the
patients tobacco use status
- Do NOT limit the number of patients a health care
provider may refer - Do NOT refax forms or information that was
previously submitted - Do NOT promise patches or confirm eligibility
this will be done by a Quitline Specialist
107NRT Nicotine Replacement Therapies
- Medications to treat tobacco dependence
108Nicotine Replacement Therapy (NRT)
- Reduce withdrawal symptoms
- Steady dose or self-administered
- Scheduled basis ? tapered ? discontinued
109Did You Know
- There are seven first-line pharmacotherapies
available to help tobacco users quit - Pharmacotherapy is safe and highly effective
- Dentists can prescribe NRT
110By Definition, the Scope of Dentistry Says
- 6601. Definition of practice of dentistry.
- The practice of the profession of dentistry
is defined as diagnosing, treating, operating, or
prescribing for any disease, pain, injury,
deformity, or physical condition of the oral and
maxillofacial area related to restoring and
maintaining dental health. The practice of
dentistry includes the prescribing and
fabrication of dental prostheses and appliances.
The practice of dentistry may include performing
physical evaluations in conjunction with the
provision of dental treatment.
111Nicotine Replacement Therapy
- No evidence of increased cardiovascular risk
- Medical contraindications
- Immediate myocardial infarction lt 2 weeks
- Serious arrhythmia
- Serious or worsening angina
- Accelerated hypertension
112Nicotine Replacement Therapies
- OTC
- Nicotine Patch, Gum, Lozenge
- Prescription
- Nicotine Inhaler, Nasal Spray
- Bupropion, Varenicline non-NRT medications
113Nicotine Transdermal Patch
- Use
- Apply to clean skin upper trunk / arms / back
- 24 hours or 16 hours
- Rotate sites
- Taper dosage over 4 6 weeks 21mg 14mg 7mg
- Advantages
- Over the counter
- Place and forget
- Disadvantages
- Passive
- Local irritation treat with steroid cream
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115Nicotine Gum
- Use
- Chew and park oral absorption
- PRN or fixed schedule every 1 2 hrs, no more
than 24 pieces/day - Advantages
- PRN use active less weight gain
- Disadvantages
- Avoid food / beverage around use
- Hard to chew jaw pain
- Nausea
116Nicotine Lozenge
- Dosing based on time of first cigarette (TTFC)
- Within 30 minutes 4 mg
- Over 30 minutes 2 mg
- Use 9 15 lozenges / day for 6 weeks taper
over the next 6 weeks - 25 higher blood nicotine levels than gum,
otherwise similar - Allow to dissolve dont chew
117Nicotine Oral Inhaler
- Use
- Puff oral absorption
- PRN or fixed schedule max. of 16 cartridges/
day - 1 cartridge 30 minutes of puffing
- Advantages
- PRN use (active)
- Oral / hand behavior
- Disadvantages
- Throat irritation / cough first few days
- Visible
118Nicotine Nasal Spray
- Use
- Spray do not sniffle / inhale
- PRN or fixed schedule 1 2 doses / hour
- Advantages
- Rapid onset
- PRN use active
- Disadvantages
- Irritations caution with sinusitis, rhinitis
- Some potential for dependence
119Bupropion SR
- AKA Zyban or Wellbutrin SR
- Dopaminergic effects
- Reduces cravings, withdrawal
- Less weight gain while using
- Use
- Start 7-10 days prior to quit date
- Continue for 7-12 weeks or longer (gt6 months)
120Bupropion Precautions
- Contraindicated seizure disorder, eating
disorders, electrolyte abnormalities, MAO use - NOT dangerous to smoke while taking
- Monitor blood pressure
- Side effects
- Insomnia (2nd dose early evening helps)
- Dry mouth headaches rash
121Varenicline (ChantixTM)
- FDA approved May, 2006
- Mechanism Partially activates nicotine receptor
in brain - Blocks reinforcing effects if patient smokes
during treatment - Compared to Bupropion Nearly doubles chances of
quitting - Compared to placebo Nearly quadruples chance of
quitting
122Varenicline (ChantixTM)
- Use
- 0.5 mg/day days 1-3
- 0.5 mg twice / day days 4-7
- 1 mg twice / day day 8 until end of treatment
- Course of treatment 12 weeks may be extended
for an additional 12 weeks - Side effects
- Nausea, changes in dreaming, constipation, gas,
vomiting - Not recommended for patients under age 18
- FDA does not recommend this be used with any
other stop-smoking drug
123Assisting Special PopulationsPregnant Women who
Smoke
- Pharmacotherapy should be considered only when
they have been unable to quit without it - The healthcare provider and patient must weigh
the risks and unknown efficacy of NRT in pregnant
women against the substantial risks of continued
smoking
124Adolescents
- Health care providers may consider NRT when other
behavioral treatments have failed - No evidence that NRT is harmful for adolescents
- Bupropion and Varenicline are not recommended for
adolescents
125Multiple Pharmacotherapy
- Bupropion may be combined with any of the NRTs
Varenicline should not be combined with NRT - Combination NRT
- Patch gum or patch nasal spray is more
efficacious than a single NRT - Encourage in patients unable to quit using single
agent - Caution patients on risk of nicotine overdose
- Combined NRT not currently FDA approved
126Off-Label Dosing and Use of NRT
- Use of a drug off-label does not require FDA
approval - Off-label use of NRT is common and may be
essential for effective medical management of
treating tobacco dependence - Typical Advising a patient to use 2 patches if
he/she smokes 2 ppd
JAMA 19952741347,1353,1390. N Engl J Med
19953331196. Arch Intern Med 19951551933.
127NRT In Summary
- NRT does not cause cancer!
- Be aggressive with NRT to evaluate what works
best for the patient - Most patients are under-medicated
- Consider combining medications
- Targets to achieve
- Relieve Withdrawal
- Control Cravings
- Abstinence
128Preventing Relapse
- Most relapses occur within the first 3 months
- Relapse interventions for patients who have
recently quit - Congratulate patient on successes
- Discuss health and benefits success of
cessation - Discussion of threats to maintaining abstinence
129Frequently Asked Questions
130What if my Patient Doesnt Want to Quit?
- Relevance
- Risk
- Rewards
- Roadblocks
- Repetition
131Relevance To Each Patient
- Encourage the patient to indicate why quitting is
personally relevant - Provide motivational information that is relevant
to the patients status, risk, family or social
situation, health concerns - Explain that tobacco use is not the social norm
132RiskOf Continued Smoking / Tobacco Use
- Ask patients to identify potentially negative
consequences of tobacco use that are relevant to
the patient
133RewardsOf Quitting
- Ask patients to identify potential
benefits/rewards of stopping tobacco use - Highlight those that seem most important to your
patients
134RoadblocksAddress Barriers
- Ask patients to identify barriers to quitting and
note treatment options to address barriers i.e.
pharmacotherapy, group support, etc
135RepetitionAt Every Visit
- Motivational interventions should be repeated
every time a patient visits the clinic setting.
Tobacco users who have previously relapsed should
be told that most people make repeated attempts
before long-term cessation success occurs
136Do Insurance Companies Cover the Different
Nicotine Replacement Medications?
- New York Medicaid covers all stop smoking
medications except the lozenge. Patients must
have a prescription and a pharmacist will fill it - Capital District Physician Health Plan CDPHP
covers Inhalers, Nasal Spray, and Zyban - January 2006 Medicare covers all medications
137Medications Coverage Cont
- Blue Shield covers all medications including OTC
prescription needed. Must show proof of
enrollment in a cessation program. - MVP covers Zyban, patches, gum, lozenge. They
will cover 2 cessation courses per year, and
patients must have a drug rider on their policy
138Can We Refer a Patient Who Has no Health
Insurance?
- Absolutely!
- Fax-to-Quit is for any resident of New York State
who would like to stop using tobacco - Once they receive the signed consent form, they
will contact the patient within 3 days they will
then send your practice a progress report on the
patient via fax
139How Can My Practice Incorporate a System So That
We Continue to Address Tobacco Dependence?
- Consistent tobacco user identification and
treatment - Dedicate staff to provide tobacco dependence
treatments - Provide education, resources, and feedback to
promote provider intervention
140Clinical Case Studies
- How would you help the following 3 patients quit
tobacco?
141Evidence Shows
- Advice works
- Systems in place support behavior change
- Patient satisfaction increases
- Cessation medications increase quit rates
- Cessation is cost-effective
142We need to encourage a culture of health care in
which failure to treat tobacco use the chief
cause of preventable death and disease
constitutes an inappropriate standard of care. If
every physician, dentist, nurse, dental
hygienistacross America uses this tool, we would
double quit rates, from one to at least two
million new quitters each year.
- Michael Fiore, MD, Principal author, Clinical
Practice Guidelines, Treating Tobacco Dependence.
2000.
143In Summary
- Taking lt1 minute to refer patients to the
quitline might be the most effective way to help
save lives - Tobacco dependence treatment is effective,
doable, and of service to patients - Its good customer service
- Its good medicineand its the right thing to do.
144For More Information, Questions or Comments,
Contact the Empire Challenge Initiative
- Tavia Rauch, BA, CRT
- Project Coordinator
- Seton Healths Center for Smoking Cessation
- 849 2nd Ave ? Troy, NY 12182
- Ph 518-268-6165 Cell 518-810-4903
- Fax 518-268-5864
- E-mail trauch_at_setonhealth.org
- Visit the Dental Pages on our Website
- www.Quitsolutions.org
145Wrap Up
- Questions?
- Evaluations
- Thank you for your timeand thank you for helping
to save lives