Smoking Cessation Practice Guidelines for Registered Dental Hygienists

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Smoking Cessation Practice Guidelinesfor
Registered Dental Hygienists

• Carol Southard, RN, MSNSmoking Cessation
  Specialist

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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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(No Transcript)
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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

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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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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

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Smoking Statistics

• Almost one in four Americans are current smokers
• 28 of men and 23.5 of women smoke in U.S.
• Prevalence is highest among Native Americans
  Alaskan Natives (37.1), then 35.0 percent among
  persons reporting two or more races African
  Americans (25.3 ), Hispanics (23.0 ),
  Caucasians (26.9 ) and lowest among Southeast
  Asians (17.7 )
• 90 of smokers begin smoking before age 21
• 1/3 of households with children under 6 years old
  contains at least one smoker

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Smoking Incidence Scope

• An estimated 71.5 million Americans reported
  current use (past month use) of a tobacco product
  in 2002, a prevalence rate of 30.4 percent for
  the population aged 12 or older
• Among that same population, 61.1 million (26.0
  percent of the total population aged 12 or older)
  smoked cigarettes, 12.8 million (5.4 percent)
  smoked cigars, 7.8 million (3.3 percent) used
  smokeless tobacco, and 1.8 million (0.8 percent)
  smoked tobacco in pipes.
• By age group, the prevalence of cigarette use was
  13.0 percent among 12 to 17 year olds, 40.8
  percent among young adults aged 18 to 25 years,
  and 25.2 percent among adults aged 26 or older.
• Higher proportion of males than females aged 12
  or older smoked cigarettes in 2002 (28.7 vs. 23.4
  percent).

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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 constant since 1992
• Smoking is more common among persons with 11
  years of education or less
• Smoking among adolescents has been decreasing
  slightly (girls still exceeding boys)
• Children raised in households where one or both
  parents smoke are 2 times more likely to smoke

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Smoking Population Trend Lines
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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
• In the past, 90 to 95 of smokers quit on their
  own
• Currently, 1/3 of smokers now use a medication
• Overall, self-quitters have a success rate of 5
  to 10
• Half of all smokers eventually quit

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Practice Implications

• Only half of smokers report being asked about
  smoking by their MD in the past year
• Only a minority report being advised to quit
• 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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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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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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Practice Guideline Changes

• All tobacco products exact devastating costs on
  the nations health and welfare
• For most users, tobacco use results in true drug
  dependence comparable to opiates, amphetamines
  and cocaine
• Chronic tobacco use warrants repeated clinical
  intervention just as do other addictive disorders

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Pharmacotherapy

• Six first-line FDA approved therapies reliably
  increase long-term smoking abstinence rates
• All approximately double the rate of cessation
  when compared to placebo
• Typical rates of smoking cessation are 40 to 60
  at end of drug treatment vs. 20 to 30 on placebo
• At one year, 25 to 30 success rates are reported
  compared to 10 to 15 on placebo
• All help with symptoms of withdrawal
• Two second-line drugs have been identified as
  efficacious

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Medications

• Nicotine Replacement Therapy
• Gum
• Patch
• Inhaler
• Nasal Spray
• Lozenge
• Non-Nicotine Medications
• Buproprion
• Clonidine Hydrochloride
• Nortriptyline Hydrochloride

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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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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
• Cost 6.00 per 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
• Full dose absorbed in about 2 hours
• Cost 4.00 per day

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Nicotine Inhaler

• Available since 1998 - Rx
• Each cartridge delivers 4 mg of nicotine over 80
  inhalations
• Full dose absorbed in about 20 minutes
• Cost 10.00 per day
• Designed to combine pharmacological and
  behavioral substitution

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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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Nicotine Nasal Spray

• Available since 1996 - Rx
• Each spray delivers 0.5 mg of nicotine
• Full dose absorbed in less than 5 minutes
• Minimum recommended treatment is 8 doses per day
• Cost 5.00 per day

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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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Non-Nicotine MedicationsBuproprion

• 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 for Tobacco Dependence

• Features
• Atypical antidepressive substance (amfebutamone)
• Exact mechanism of action unknown dopaminergic/
  noradrenergic/other
• Active ingredient in Wellbutrin
• Dosing
• 300 mg (150 mg initially)
• Begin therapy while still smoking

Zyban prescribing information, 2001.
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Bupropion for Tobacco Dependence

• Side effects
• Dry mouth and insomnia
• Risk of seizure approximately 1 in 1,000
• Contraindicated for patients with seizure
  disorder or predisposing factors that increase
  seizure risk (head injury, active substance abuse)

Zyban prescribing information, 2001.
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Effectiveness of Bupropion for Tobacco Dependence

• Significantly higher abstinence rates than
  placebo during treatment and at 6-,12-month
  follow up
• Combination therapy (with step-down, 24-hour
  nicotine patch)
• Approved indication
• Provided slightly higher abstinence rates than
  bupropion alone

Holm, KJ, Spencer, CM. Drugs. 2000 59
1015. Zyban prescribing information, 2001.
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Dose-Response Trial
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Comparative Trial
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Non-Nicotine MedicationsSuggested/Not FDA
Approved

• Clonidine
• Reduces symptoms of withdrawal
• Effective for smoking cessation
• High frequency of adverse effects limits use
• Nortriptyline
• Effective for smoking cessation in 2 small
  studies
• No other antidepressant has had demonstrated
  efficacy

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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

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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

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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

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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.
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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.
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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.
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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.
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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.
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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

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State of the Art Programs

• Setting of specific quit date
• Interruption of conditioned responses
• Identification and preparation of plans for
  coping
• Attention to relapse episodes
• Encouragement of continued nonsmoking
• Follow up contact
• Social support for quitting and abstinence

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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

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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

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Health Care Costs

• Roughly 46 million Americans report regular
  tobacco use
• Tobacco is responsible for approximately 1 in 5
  deaths each year
• The estimated cost to the American health care
  system is 80 billion in direct costs and 50
  billion in indirect costs

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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

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Why Bother?

• 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

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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

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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

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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.

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Economic Aspects

• Clinically effective and cost-effective
• Special populations
• Should be a covered benefit
• Accreditation criteria should include evaluation
  of availability and utilization of effective
  tobacco assessment and intervention policies
• 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

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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

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• If every physician advised every patient at
  every visit not to smoke, one million Americans
  could escape nicotine addiction each year.
  Michael Fiore, MD
• 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

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References

• 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. The
  Surgeon Generals Report on Women and Smoking. US
  Department of Health and Human Services, Public
  Health Service, 2001.