1	“Save a Life in 3 Minutes" For Washington State Dental Hygienists Sponsored by ADHA on Tobacco Cessation Produced by WA State SCI Margaret J. Fehrenbach, RDH, MS
2	“Not since the polio vaccine has this nation had a better opportunity to make a significant impact in public health.” David Satcher, MD, PhD, Former U.S. Surgeon General
3	Tobacco Use in U.S. The leading cause of preventable death and disability in the United States. The number one risk factor for heart disease and stroke. About 46.5 million adults use tobacco. Leading preventable cause of illness and death responsible for more than 435,000 premature deaths in 2000.
4	The Burden of Tobacco Use in U.S. If current patterns persist, 6.4 million people currently younger than 18 will die prematurely from a tobacco-related disease. Each year, an estimated 3,000 nonsmokers die of lung cancer due to environmental tobacco smoke (ETS.) Chronic bronchitis and emphysema are two common lung diseases specifically associated with smoking. Up to 300,000 children suffer from respiratory tract infections because of exposure to secondhand smoke.
5	Peter Jennings Lung cancer took the life of Peter Jennings, ABC Nightly News Anchor at the young age of 67. He quit for 2 years, then the stress of September 11, 2001 he took up smoking 10-15 cigarettes a day. Peter admitted to using cigarettes to calm him down during a stressful day.
6	The Burden of Tobacco Use in Washington State Every year, more than 8,200 Washingtonians die from tobacco. Nearly 11,000 Washington babies are born to mothers who smoked during pregnancy. Expenditures in Washington for babies’ health problems caused by mothers smoking or being exposed to secondhand smoke during pregnancy are $21 to $62 million annually.
7	The Burden of Tobacco Use in Washington State The estimated smoking-related medical expenditures for Washington totaled $1.15 billion, 11.6% of the total. Washington residents’ federal tax burden caused by tobacco-related health care costs is $962 million annually. Washington state government Medicaid payments directly related to tobacco use are $237 million annually.
8	Oral Cavity Risks Tobacco use responsible for about 75% of all oral cavity cancers - mouth, tongue lips, throat, nose, larynx. Smokers have 6 times the risk for oral cancer as nonsmokers. Tobacco users have from 3-17 times as much laryngeal cancer as nonsmokers.
9	Oral Cavity Risks 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 primary teeth. High risk for root canals (70%).
10	Smoking is Damaging to Periodontal Health Smoking is a major risk factor for periodontitis and may be responsible for more than half of the periodontitis cases. Smokers are 4 times more likely than persons who never smoked to suffer from periodontal disease. Periodontal therapy less effective in smokers. Smokers more likely to have recurrence after treatment
11	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% 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%) smoked cigars, 7.8 million (3.3 percent) used smokeless tobacco, and 1.8 million (0.8%) smoked tobacco in pipes. By age group, the prevalence of cigarette use was 13.0% among 12 to 17 year olds, 40.8% among young adults aged 18 to 25 years, and 25.2% 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%).
12	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.
13	Smoking Population Trend Lines
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15	Smoking Trends in Washington State Tobacco use is increasing in Washington, according to a report from the Washington DOH in certain populations. From 1990 to 1998, smoking rose 38% among high school seniors and nearly doubled among sixth graders. Adult smoking rose in 1996 and 1997, ending a downward trend dating back to the late 1980s.
16	And the advertising continues…
17	Put your money where your mouth is… This next year, the tobacco companies will spend at least $28 to market tobacco products for every one dollar the states spend on tobacco prevention. The tobacco companies spend more on marketing in a single day than 47 states and the DC spend on tobacco prevention in an entire year.
18	Cessation Facts About 30% of patients are current smokers 70% of smokers say they are “interested” in quitting Only 10 - 20% plan to quit in the next month About 46% of smokers try to quit in a given year In the past, 90 - 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 -10% Half of all smokers eventually quit
19	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
20	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
21	Protocols for the Dental Office
22	Protocols Step 1: Ask 1 min Systemically ask every patient about tobacco use at every visit. Determine if patient 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.
23	Protocols Step 2: Advise 1 min In a clear, strong, and personalized manner, urge every tobacco user to quit. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful. Employ the “teachable moment”: link oral findings with advice.
24	Protocols Step 3: Refer 1 min Determine if patient interested in quitting. For those interested in quitting provide information on: Statewide or national quitlines, websites and local cessation programs. Use proactive referral if available Request written patient permission to fax their contact information to a cessation quitline or program. Inform the patient the cessation program staff will contact them. Document referral in dental record
25	What are Quitlines? Tobacco Quitlines are telephone-based tobacco cessation services available in most states which are often accessed through a toll-free number 1-800-QUIT-NOW They provide callers with a number of services: Individualized telephone counseling Educational materials Referrals to local programs
26	Washington State Quitline The caller talks with a specialist, someone who has helped others and may be an ex-smoker themselves. They answer questions and recommend which treatment is best.
27	Washington State Quitline Quit Line staff provide helpful, easy to follow materials that allow the caller to take control of the quitting process and become a quitter for life. The Tobacco Quit Line specialists understand that quitting tobacco takes time. It may take the average person eight attempts to quit.
28	New Feature of Quit Line Tobacco users can now request a phone call from a professionally trained quit coach at the Washington State Tobacco Quit Line. All the Quitline.com visitors need to do then is to just click on the “Click to Call” button and enter their phone number for an immediate return call. People can use “Click to Call” to contact a quit coach for any reason - whether they’re dealing with a craving, have a question about a medication, or want to talk about the quitting process.
29	Scripts If the patient 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” “Do others in your household use tobacco?”
30	Scripts For the patient who never regularly used tobacco: “Congratulations, you have made a wise choice to protect your health.” “Congratulations, you have very good judgment.” “Congratulations on being a non-smoker.”
31	Scripts For the patient 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.”
32	Scripts For the patient 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 most people prefer to use them.”
33	Scripts For the patient who currently uses tobacco: “I know quitting smoking is very difficult. Even people who do not want to quit are successful. Sometimes it takes more than one try. I know you can do it. Let me refer you to the cessation quitline, they can help you quit.” “I can’t see what tobacco is doing to your heart, lungs, brain and other organs, but I would like to show you some changes in your mouth.”
34	Scripts More available scripts for: Pregnant mothers Hospitalized patients Heart Attack patients Lung, head and neck cancer patients Parents of children and adolescents Youth *** See ADHA Website www.askadvicerefer.org
35	Coding for Treatment of Tobacco Use and Dependence Record: ADA Code 1320 – Tobacco Counseling for the Control and Prevention of Oral Disease
36	ADHA Website: www.askadviserefer.org
37	About the Website www.askadviserefer.org Available to download for all dental hygienists and their patients: PowerPoint Presentations Fact Sheets (for the Consumer & the Dental Hygiene Professional) Ask. Advise. Refer. Poster Liaison Resource List Quitline Resource List Relevant State & National News and Announcements FAQs
38	Washington State Information Your state’s SCI Liaison is: Margaret J. Fehrenbach, RDH, MS margaret@dhed.net
39	WSDHA Liaison Activity Creation of Tobacco Cessation Website off Association Website Education at ADHA Annual Session Creation of PowerPoint Program Visiting WSDHA Components Emails to State and Component Leadership about Activity Articles in WSDHA Newsletter
40	WSDHA Website on Tobacco Cessation
41	Treatment Facts The efficacy of several tobacco 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
42	Tobacco Cessation: Products Nicorette Gum: Available OTC Nicotine Patch: Available OTC Nasal Inhaler: Prescription: Nicotrol IS Nasal Spray: Prescription: Nicotrol NS Antidepressant: Prescription: Zyban New FDA-Approved Prescription: Chantix
43	These medications have all been approved by the FDA for tobacco cessation and have been shown to significantly improve abstinence rates.
44	Nicotine Replacement Therapy (NRT) 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
45	Plasma Nicotine Concentrations: Cigarettes versus NRT Cigarettes 1 cigarette produces rapid surge of plasma nicotine by about 25 mg/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
46	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
47	Nicotine Gum Usual dose 1 piece for every 2 cigarettes smoked; recommend use at least 3 months To activate the gum, slowly chew it, (usually about 15 times) until the taste becomes strong, which means the nicotine is being released. To ensure that the nicotine continues to be released, park the gum between the cheek and gum. Some users can feel a tingling sensation as the nicotine releases. When the tingling sensation and/or the strong taste begins to fade, the gum should be chewed again. Each piece of gum should be chewed for about 20 to 30 minutes. If there is no further taste from the gum a fresh piece should be used if required. Do not drink any liquids during or about 15 minutes prior to chewing as this can change the acid/base balance of the saliva and prevent the absorption of the nicotine. The most commonly reported problems associated with gums include sore jaw, mouth and throat inflammations (including mouth ulcers), sticking of the gum to dentures, stomach upset, nausea, dizziness and headache.
48	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
49	Nicotine Patch Treatment of 8 weeks or less has been shown to be as efficacious as longer 16 and 24 hour patches are of comparable efficacy dose according to cigarette use One patch is applied to a clean, dry, hairless area of the body such as the upper arm, the front or side of the chest or on the hip, each morning. A fresh area of skin should be used each day. The patches should not be applied to broken or inflamed skin. With the 24-hour patch a fresh patch is applied every morning, while the 16 hour patch is applied in the morning and removed before going to bed The most commonly reported problems associated with nicotine patches include nausea, vomiting, headache, dizziness, which is usually short-term, and allergic skin reactions at the site where the patch is placed. Applying the patch to a fresh area of skin each day will help to minimize potential skin irritation. Sleep disturbances have been reported in particular with the 24-hour patches, the higher the strength of patch the greater the problem.
50	Nicotine Inhaler Available since 1998 as an 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
51	Nicotine Inhaler Only inhaler-based nicotine buccal delivery system Helps actively control cravings as they happen A survey indicated that 41% who failed to quit partially due to not knowing what to do with their hands
52	Nicotine Inhaler Place the nicotine cartridges into the mouthpiece. The nicotine is released by either a shallow puff or a deep inhalation. Cartridges usually last about 20 minutes and can be smoked at intervals throughout the day. The inhaled air has a menthol flavor. It is recommended to use 6 -12 cartridges per day for the first 8 weeks of treatment, gradually reducing to zero over the following 4 weeks Those using nicotine inhalers have reported coughs, rhinitis, and irritation of the mouth and throat, which usually decline over time, while headache, heartburn and nausea have also been reported. As with the gum, acidic beverages interfere with the buccal absorption of nicotine, so eating and drinking anything except water should be avoided for 15 minutes before an during inhalation Mouthpiece is reusable
53	Schematic of the Nicotine Inhaler
54	Nicotine Nasal Spray Available since 1996 as an 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
55	Nicotine Nasal Spray To activate the spray, press the bottom of the spray container a few times. Tilting the head back, the nosepiece of the spray is placed into the nostril. To administer the spray press the bottom of the container. It is recommended that one or two sprays be used each hour as required for the first eight weeks. For the following two weeks this amount should be halved and then reduced to zero over a further two weeks. No more than two doses per hour should be used for a maximum of 16 hours per day. One bottle of spray contains about 100 doses The use of nicotine nasal sprays is associated with a greater number of side effects, which may be worse at the earlier stages of treatment. Headaches and nausea associated with using the nasal spray usually decline over time. Irritation of the nose and eyes, nose bleeds and sore throats are more frequently reported while palpitations, sweating and cold extremities occur less frequently.
56	Nicotine Lozenge Available since 2002 as an 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 Cost $6.00+ per day
57	Nicotine Lozenge Place in your mouth and allow it to dissolve slowly. Don’t chew or swallow it – you won’t absorb the correct dose of medication if you do. Consuming the lozenge too fast could also lead to heartburn or indigestion. You may feel a warm or tingling sensation as nicotine is released and makes contact with your mouth tissues. That’s the medicine going to work. Occasionally move the lozenge from one side of your mouth to the other, just like you would any lozenge. It will take about 20-30 minutes for the lozenge to dissolve completely. Do not eat or drink 15 minutes before using, or while the lozenge is in your mouth. Do not use more than one lozenge at a time or continuously use one lozenge after the other. Doing so may cause hiccups, heartburn, nausea or other side effects. Do not use more than 5 lozenges in 6 hours, or more than 20 lozenges total per day
58	Zyban An atypical antidepressant (Wellbutrin) with dopaminergic and noradrenergic activity First FDA approved non-NRT Can be used in combination with NRT Is effective in those with no current or past depressive symptoms
59	Zyban Exact mechanism of action unknown Active ingredient in Wellbutrin® Dosing: 300 mg (150 mg initially) Begin therapy while still smoking
60	Zyban 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)
61	Zyban 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
62	Effectiveness of Bupropion for Tobacco Dependence Swallow this medication whole. Do not crush or chew them or the sustained activity of the drug will be destroyed and the chances of side effects occurring may be increased. Take as directed, usually twice daily for 7 to 12 weeks. Do not take more or less medication than prescribed. Since this drug can cause sleeplessness at first, it is best not to take near bedtime. It is advised to continue smoking for the first week after starting this drug until it reaches higher levels in your blood. Do not smoke if using any nicotine products with Zyban. Too much nicotine can cause serious side effects. This drug is excreted into breast milk. Because of the potential risk to the infant, BREAST-FEEDING WHILE USING THIS DRUG IS NOT RECOMMENDED. Zyban is generally well tolerated. Dry mouth, headache, increased sweating, constipation, anxiety and fatigue may occur. MAO inhibitors (e.g., isocarboxazid, phenelzine, tranylcypromine, pargyline, selegiline, furazolidone), levodopa, theophylline, corticosteroids (e.g., prednisone), seizure medications, sedatives, ritonavir, tranquilizers/psychiatric drugs (e.g., chlorpromazine), other antidepressants (e.g., amitriptyline), salicylates (e.g., aspirin, salsalate), isoniazid, chlolinesterase inhibitors (e.g., tacrine, donepezil), morphine, and adrenaline-like drugs (e.g., pseudoephedrine). Excess caffeine intake can increase the chance of seizures with this drug.
63	Chantix www.chantix.com/ The latest FDA-approved prescription drug is varenicline. Data showed that the odds of quitting successfully at the end of 12 weeks of treatment using 1 mg twice a day were 4 times greater than those taking placebo and 2 times greater than those taking bupropion.
64	Chantix Patients may continue for a further 12 weeks if they so wish. The FDA does not recommend that it be used with any other stop-smoking drug. Most common side effect was nausea.
65	“Smoking will no more be fun, as Chantix cuts off the usual thrill and the kick that nicotine induces in your brain. And withdrawal symptoms of quitting smoking won't be anymore a bitter pill to swallow, as it eases and soothes the symptoms.” In discussion about medication…
66	Chantix Varenicline, the main ingredient of Chantix, behaves differently from the other quit smoking medicaments. It surprisingly operates in a way that is way similar to the working of nicotine. When a person smokes, nicotine goes straight to the brain and binds with the nicotine receptor cells, thereby activating the pleasure cells. It is an agonist and it acts just like nicotine, as it gets attached with high intensity to the a4ß2 neuronal nicotinic acetylcholine receptors when it is consumed. It gives the same feel good factor that nicotine gives. However, it blocks nicotine from binding with the receptors and prevents it from aggravating the cells further. It doesn't have any of the addictive features of nicotine.
67	Chantix- Important Note to Dental Professionals: Manufacturer has recently added a warning that patients who are attempting to quit smoking by taking Chantix should be observed by a physician for serious neuropsychiatric symptoms like changes in behavior, agitation, depressed mood, suicidal ideation and suicidal behavior. Thus the dental team will want to have the drug prescribed and monitored by the patient’s physician.
68	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
69	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
70	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
71	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
72	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.
73	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
74	General References Current list of all state quitlines: www.askadviserefer.org National Cancer Institute’s Quitline: 1-877-44U-QUIT Cancer Information Service Website: http://cis.nci.nih.gov/ Web based cessation program: http://smokefree.gov/ or http://www.quitnet.com *** For Other National and State References: see WSDHA Website on Tobacco Cessation
75	Additional References Davis JM: Tobacco Cessation for the Dental Team: A Practical Guide Part II: Evidence-based Interventions. Journal of Contemporary Dental Practice 2005 November;(6)4:178-186 (see http://www.thejcdp.com/issue024/davis/01davis.htm). Diefenbacher LJ, et al. What is the most effective nicotine replacement therapy? Journal of Family Practice. 2003 Jun;52:492-4. Fiore MC, 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.
76	Additional References Lancaster T, et al. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. British Medical Journal 2000; 321: 355-8. Rigotti, N. Treatment of tobacco use and dependence. New England Journal of Medicine 2002; 346: 506-512. Silagy C, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Systemic Review. 2002; CD000146. US Department of Health and Human Services. The Surgeon General’s Report. Women and Smoking, , 2001, The Health Consequences of Smoking, 2004, The Health Consequences of Involuntary Exposure to Tobacco Smoke, 2006. Zhu, SH, et al. Evidence of real-world effectiveness of a telephone Quitline for smokers. New England Journal of Medicine. 2002; 347: 1087-1093.
77	Thank you