Helping Tobacco Users Quit: Dental Hygienists Leading the way as Effective Cessation Counselors - PowerPoint PPT Presentation

1 / 145
About This Presentation
Title:

Helping Tobacco Users Quit: Dental Hygienists Leading the way as Effective Cessation Counselors

Description:

Fun contests and other incentive-based promotions check for updates often on ... Users keep the chew between the cheek and gums for several hours at a time. ... – PowerPoint PPT presentation

Number of Views:222
Avg rating:3.0/5.0
Slides: 146
Provided by: PKei7
Category:

less

Transcript and Presenter's Notes

Title: Helping Tobacco Users Quit: Dental Hygienists Leading the way as Effective Cessation Counselors


1
Helping Tobacco Users Quit Dental Hygienists
Leading the way as Effective Cessation Counselors
  • Presented By
  • Tavia Rauch, BA, CRT

2
Center 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

4
Program 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

5
Evidence-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
6
New 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
7
Why Are Cigarettes So Dangerous?
8
Tobacco 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

9
Cigarettes 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

11
Chemicals 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

12
The 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.

13
Smokeless ? 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
14
Laced with the Same Kinds of Toxic Chemicals
  • Polonium 210 (nuclear waste)
  • Tobacco-specific N-nitrosamines or TSNAs
  • Formaldehyde
  • Nicotine
  • Cadmium
  • Cyanide
  • Arsenic
  • Benzene
  • Lead

15
Leading Causes of Preventable Death
  • Tobacco Use
  • Obesity
  • Secondhand Smoke

16
Secondhand 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

17
There 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

18
What 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

19
In the United States
  • 38,000 65,000 people die each year from heart
    disease and lung cancer caused by passive smoking

20
Tobacco 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

21
The Brain and Nicotine
22
Nicotine 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.

23
EASY 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!
24
EASY GO
Liver, Lungs, Kidneys. Mutant Enzymes
25
Neurotransmitter
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.

27
(No Transcript)
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

29
Tolerance
  • 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.

30
The Cycle
Benowitz NL. Med Clin North Am. 1992 76 423.
31
Nicotine 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

32
Nicotine Affects the Body
  • Increasing metabolism
  • Decreasing appetite
  • Dulling the sensation of pain
  • Producing a slight high

33
Physical 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

34
Psychological Withdrawal Symptoms
  • Anxiety
  • Irritability
  • Restlessness
  • Depression
  • Anger
  • Intense cravings
  • Reduced coping ability
  • Feeling weepy
  • Listlessness
  • Trouble concentrating

35
The 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

36
Tobacco 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

37
Nicotine 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

38
The 12 Truths About Smokers
  • What Every Hygienist Needs to Know for Treating
    Patients Who Smoke

39
Truth 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

40
Percent of Those Ever Using Who Become Addicted
41
Abstinent Rate at One Year for Heroin, Smoking
Alcohol
42
Truth 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

43
Truth 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

44
Truth 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

45
Truth 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.

46
Truth 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

47
Truth 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

48
Truth 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

49
Truth 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

50
Truth 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

51
Truth 9Contd
  • When a smoker quits they are literally bombed
    with triggers.
  • Its time to smoke.... No, I quit.

52
Truth 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.

53
Truth 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.

54
Truth 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

55
Truth 12To allow is to teach
  • Health care professionals have significant impact
    on a patients smoking
  • Smoking must be addressed at every patient visit

56
Sharpen Your Pencils!
57
Morning Break
58
Effects of Tobacco on Teeth and Oral Health
  • What Every Dental Hygienist Should Be Familiar
    With

59
Esthetics
  • 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
60
More 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
61
More Effects on Teeth and Oral Health
  • Dental caries
  • Salivary changes
  • Candidasis
  • Leukoplakia
  • Malignancies

62
Oral Leukoplakia
  • Most common potentially malignant lesion defined
    as a predominantly white lesion of oral mucosa
    that cannot be characterized as any other
    definable lesion

63
(No Transcript)
64
(No Transcript)
65
Site 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

66
Site 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

67
Oral 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

68
Oral 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

69
High Risk Sites for Oral Cancer
  • Lateral tongue
  • Lip
  • Anterior floor of the mouth
  • Soft palate, including anterior and posterior
    tonsillar pillars and uvula

70
How 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

71
How 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.
72
How 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

73
Tobacco Intervention
74
The 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

75
Interventions 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

76
The 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

77
Tobacco Interventions
  • 75 of health care providers THINK it is a good
    idea
  • However, only 10 routinely do itWhy ?

78
Common 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

79
Behavior Change A Process, Not a Single Act
  • Precontemplation
  • Contemplation
  • Preparation
  • Action
  • Maintenance
  • Relapse

80
Stages of Change
Thinking about it
Im ready
Doing it
Living it
Try again
Not interested
81
Movement 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

82
Goal 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

83
Both 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

84
Components of a Brief Intervention
  • 1. Identify patients who use tobacco
  • 2. Talk with them briefly
  • 3. Provide assistance with quitting or a
    motivational intervention

85
Motivation 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

86
Its How You Approach Patients About Their
Tobacco Use
  • In the spirit of gentle guidance

87
Why 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

88
Motivational 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
89
Just 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

90
Public 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

91
Ask
  • 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?

92
Asking 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

93
Advise
  • The Advice Should Be
  • CLEAR
  • Strong
  • Personal

94
Advising 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

95
ASSESS
  • 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

96
Assist
  • 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

97
Arrange
  • Schedule follow-up contact, either in person or
    via telephone

98
An 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

99
Motivational 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

100
Lunch TimeEnjoy
101
Resources to Help Tobacco Users Quit
  • -Services of the NYS Smokers Quitline
  • -Medications

102
What 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.

103
Quitline 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

104
A Brief Video Brought to You by the New York
State Smokers Quitline
105
Services 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

106
Quitline 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

107
NRT Nicotine Replacement Therapies
  • Medications to treat tobacco dependence

108
Nicotine Replacement Therapy (NRT)
  • Reduce withdrawal symptoms
  • Steady dose or self-administered
  • Scheduled basis ? tapered ? discontinued

109
Did You Know
  • There are seven first-line pharmacotherapies
    available to help tobacco users quit
  • Pharmacotherapy is safe and highly effective
  • Dentists can prescribe NRT

110
By 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.

111
Nicotine Replacement Therapy
  • No evidence of increased cardiovascular risk
  • Medical contraindications
  • Immediate myocardial infarction lt 2 weeks
  • Serious arrhythmia
  • Serious or worsening angina
  • Accelerated hypertension

112
Nicotine Replacement Therapies
  • OTC
  • Nicotine Patch, Gum, Lozenge
  • Prescription
  • Nicotine Inhaler, Nasal Spray
  • Bupropion, Varenicline non-NRT medications

113
Nicotine 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

114
(No Transcript)
115
Nicotine 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

116
Nicotine 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

117
Nicotine 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

118
Nicotine 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

119
Bupropion 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)

120
Bupropion 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

121
Varenicline (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

122
Varenicline (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

123
Assisting 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

124
Adolescents
  • 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

125
Multiple 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

126
Off-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.
127
NRT 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

128
Preventing 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

129
Frequently Asked Questions
130
What if my Patient Doesnt Want to Quit?
  • Relevance
  • Risk
  • Rewards
  • Roadblocks
  • Repetition

131
Relevance 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

132
RiskOf Continued Smoking / Tobacco Use
  • Ask patients to identify potentially negative
    consequences of tobacco use that are relevant to
    the patient

133
RewardsOf Quitting
  • Ask patients to identify potential
    benefits/rewards of stopping tobacco use
  • Highlight those that seem most important to your
    patients

134
RoadblocksAddress Barriers
  • Ask patients to identify barriers to quitting and
    note treatment options to address barriers i.e.
    pharmacotherapy, group support, etc

135
RepetitionAt 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

136
Do 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

137
Medications 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

138
Can 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

139
How 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

140
Clinical Case Studies
  • How would you help the following 3 patients quit
    tobacco?

141
Evidence Shows
  • Advice works
  • Systems in place support behavior change
  • Patient satisfaction increases
  • Cessation medications increase quit rates
  • Cessation is cost-effective

142
We 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.

143
In 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.

144
For 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

145
Wrap Up
  • Questions?
  • Evaluations
  • Thank you for your timeand thank you for helping
    to save lives
Write a Comment
User Comments (0)
About PowerShow.com