Still as important as it was 100 years ago
By Pamela J. Myers, RDH
Our first impression of others is their bright white smiles. It is our invitation to connect with others, as well as the portal to our overall health and well-being. Another way to view the mouth is as the gatekeeper for the rest of the body.
History of tobacco
When Columbus discovered tobacco in 1492, it was as a gift of dried tobacco leaves from the natives, and they were promptly discarded. Early in history, tobacco was smoked in pipes. As early as 1527, Bartolome de Las Casas documented that tobacco was addictive. Sir Walter Raleigh persuaded Queen Elizabeth to try smoking in 1600.
Massachusetts passed the nation’s first no-smoking law in 1683. It forbade the smoking of tobacco outdoors, because of fire hazard. Within months, Philadelphia lawmakers voted for a ban on smoking on the street. The fines collected for violation of the law were used to buy fire equipment.
The U.S. Congress passed the first federal excise tax on tobacco in 1794. As a part of the temperance movement in 1830, the first antitobacco movement began.
The Tennessee Supreme Court upheld a total ban on cigarettes in 1898. The ruling stated that cigarettes are “not legitimate articles of commerce, being wholly noxious and deleterious to health. Their use is always harmful.”
Tobacco companies spend and spend on advertising. By 1940, adult Americans were smoking 2,558 cigarettes per capita per year, twice the amount from 1930. In 1971, TV advertising for tobacco was banned. The law stated the ban was to begin on January 1st, but was delayed for one day so the tobacco companies could air their final ads for the college bowl games on New Year’s Day.
In 1989, the Philip Morris Tobacco Company discovered how to circumvent the 1971 ban on TV advertising by sponsoring the Marlboro Grand Prix in which the Marlboro name appeared 5,933 times or 43 minutes in total. Sponsorship of sporting events became the primary means of circumventing the 1971 law banning TV advertisements.
Smokeless tobacco has been historically documented as far back as 3500 B.C. in Peru and Mexico where it was considered a valuable trading commodity. Historical records indicate that snuff was in Jamestown, Va., as early as 1611. In the 1800s and early 1900s, snuff was thought to alleviate toothaches, whiten teeth, reduce decay, cure bleeding gums, scurvy, and even neuralgia.
In 1761, a London physician, John Hill, reported the occurrence of nasal polyps in patients who inhaled tobacco. The United States did not initiate epidemiological studies on tobacco use until the early 1950s even though physicians had been reporting increasing numbers of oral and nasal cancers in patients using tobacco since 1915.
The Centers for Disease Control and Prevention in 2002 estimated the annual smoking productivity and health costs to reach $150 billion. As of September 2011, the CDC reported that “smoking costs the U.S. about $96 billion each year in direct medical costs and $97 billion from productivity losses due to premature death. For every smoking related death, another 20 people suffer with a smoking related disease.” In 2010, 19.3% of adults (or 45.3 million) smoked, according to the CDC. “Approximately 443,000 Americans die of smoking or exposure to secondhand smoke each year.”
The bright side to recent statistics is that adult smoking is down from 20.9% in 2005 to 19.3% in 2010 or 3 million fewer smokers.
Combatting denial
More than 100 years after tobacco’s use was legally recognized as harmful, many Americans are still in the throes of denial!
In 1998, major U.S. tobacco companies settled litigation with states in what was known as the Master Settlement Agreement. This settlement required tobacco companies to pay $206 billion to the states over 25 years, but the agreement did not compel states to spend the money on tobacco cessation or treatment of tobacco-related conditions.
After less than 12 years, most states have shifted the money away from tobacco-related programs and to college scholarships, roads and bridges, and to cover budget shortfalls. Some states had increased tobacco taxes even before the Master Settlement. The average state tax on cigarettes was $1.45 a pack in 2010, with the highest state tax being $4.35 a pack in New York. Even though the CDC recommends spending an average of $12.34 per resident on tobacco prevention programs, most states spend an average of $2 per resident.
In September 2011, the CDC Vital Signs published a report outlining the adult smoking problem in the United States. According to the report, 21.5% of adult males and 17.3% of adult females smoke. Almost 29% of adults who smoke live below the poverty level, while only slightly over 18% live at or above the poverty level. It is evident that those who can least afford it use tobacco. Alabama, Ohio, Kentucky, West Virginia, Arkansas, Mississippi, Louisiana, and Oklahoma have the highest prevalence of adult smokers.
A higher percentage of smokers have an educational level of high school or less, while those adults 25 years of age and older who have an associate’s degree or above have the least percentage. Education is a factor in the prevalence of tobacco usage.
The ethnic group with the largest percentage who smoke is American Indians or Alaskan Natives. The smallest percentage who smoke by racial/ethnic group is non-Hispanic Asians.
The CDC reported that more than half of the adult smokers in America have made at least one attempt to quit in the previous year. The majority of would-be quitters did not use medication or counseling to aid them in their efforts and therefore failed.
In November 2011, Major League baseball and the players’ union announced that Major League players, coaches, and managers will no longer be permitted to carry tobacco tins or packages in their uniforms at games or anytime fans are in the ballpark. Additionally, professional players were prohibited from using smokeless tobacco during televised interviews, at autograph signings, team-sponsored events, and meet-and-greets. This was a major victory for Oral Health America, the ADA, and ADHA.
Beginning in September 2012, the FDA was to require larger, more prominent health warnings on all cigarette packaging and advertisements in the United States. These warnings and advertisements were to carry graphic images.
In early November 2011, U.S. District Judge Richard Leon issued an injunction stating that the five tobacco companies (R.J. Reynolds, Lorillard, Liggett Group, Commonwealth Brands, Inc., and the Santa Fe Natural Tobacco Company) that are suing the federal government over being required to carry the warning images. The companies claimed they will “suffer irreparable harm,” and the injunction barred the images from appearing on packs until a full “judicial review of the constitutionality of the FDA’s rule” is carried out. The tobacco companies stated that it would cost $20 million to redesign their packaging. Tobacco companies reap over $24 billion in sales each year; $20 million would be twelve one-hundredths of the sales in 2010.
The American Lung Association (ALA) released a report card on states and the fight against tobacco in January 2012 that was abysmal. Only four states — Delaware, Hawaii, Maine, and Oklahoma — received an “A” in all areas. The areas the ALA reviewed were cigarette taxes, smoke-free legislation, and sufficient funding for quit smoking and tobacco prevention programs.
On March 30, 2012, the FDA released draft guidance implementing provisions in the Family Smoking Prevention and Control Act. The guidance requires tobacco companies and importers to report quantities of harmful and potentially harmful constituents (HPHCs) found in tobacco products. The FDA released a list of 20 harmful HPHCs that will be reported in the coming year. The second draft guidance released on March 30 will require companies that sell modified risk tobacco products to submit applications for the sale and distribution of these products which claim to reduce harm or the risk of tobacco-related disease.
Effects of tobacco use on health
Tobacco use costs a half million lives each year and is the leading cause of preventable and premature death in the United States.
Nicotine is a drug. Physiological and behavioral processes are similar for cocaine, heroin, and nicotine. Nicotine is as addicting as those common “street drugs.” Surprised? Addiction to nicotine is a chronic relapsing disease. Should we treat it just like other chronic diseases such as hypertension and diabetes?
Tobacco has over 4,000 toxic ingredients. Tobacco specific nitrosamines (TSNAs) are cancer-causing chemicals found in tobacco products. These include polycyclic aromatic hydrocarbons (PAHs), Carbon monoxide, hydrogen cyanide, nicotine, and tar just to name a few.
PAHs destroy retinal cells and photoreceptors, contributing to macular degeneration.
Smokers have two to four times the risk of developing heart disease and twice the risk of sudden death than nonsmokers.
Premature birth and low birth weight are higher among smokers. The nicotine causes the uterine blood vessels to narrow, which results in a slowing of overall fetal growth and impediment of brain development.
Impaired healing is evident in smokers as a direct result of decreased oxygen levels. Lower oxygen levels impair fibroblasts (cells that help tissues heal).
Researchers have recently noted that middle age males who smoke may be at greater risk for rapid cognitive decline. Smoking equates to 10 years of aging on cognition and executive function in males, which may lead to dementia.
For years, tobacco use has been linked to multiple respiratory problems such as emphysema, asthma, chronic bronchitis, lung cancer, and chronic obstructive pulmonary disease (COPD). The destruction of lung tissue in emphysema is mediated by antigen-presenting cells (APCs) that appear to be activated by cigarette smoke. In addition to inadequate oxygenation or impaired breathing ability, COPD causes increased muscle fatigue and skeletal muscle dysfunction. Eventual loss of muscle mass, decreased strength, and lower endurance are the end result.
Smoking is detrimental to oral health. In a smoker, the patient will have reduced blood flow, altered neutrophil functions, increased cytokine production, inhibition of fibroblast growth and attachment, decreased collagen production, and reduced vascularity, which directly impact periodontal disease.
In my part of the country (Texas), dipping or chewing tobacco is very common. These forms of tobacco have additional dangers for the oral cavity. Sugar in smokeless tobacco increases the decay rate, especially in areas where exposed cementum is present. The gingiva recedes in areas where the product is held or placed in the mouth. Normally the tobacco is placed and held for hours next to the buccal mucosa on the mandibular arch. White leathery patches and red sore areas are very common in the oral cavity of a smokeless tobacco user. These abnormal changes in the tissue of the oral cavity can be precancerous. High incidence of oral cancer has been found in persons who dip or chew tobacco. Holding a dip of tobacco (about a tablespoon) in the mouth for 30 minutes releases as much nicotine as smoking three cigarettes. Using two cans of snuff a week equates to as much nicotine absorption as smoking 1½ packs of cigarettes a day.
What can be done?
The Tobacco Products Scientific Advisory Committee (TPSAC) was created as a result of the federal legislation Family Smoking Prevention and Tobacco Control Act of 2009. One section of the law was devoted to exploring and developing tobacco product standards, specifically concerning:
- “the risks and benefits to the population as a whole, including users and nonusers of tobacco products, of the proposed standard;
- the increased or decreased likelihood that existing users of tobacco products will stop using such products; and
- the increased or decreased likelihood that those who do not use tobacco products will start using such products.”
The law also addresses dissolvable tobacco products. The TPSAC is required to review and provide recommendations to the FDA regarding the “nature and impact of the use of dissolvable tobacco products on the public health, including such use among children.”
Tobacco cessation strategies
As a caregiver, you should follow the Five A counseling program developed by the Agency for Healthcare Research and Quality of the U.S. Public Health Service. The Five A’s are:
- Ask about tobacco usage at every visit and record the response.
- Advise all tobacco users to quit using very strong precise language.
- Assess readiness to quit.
- Assist tobacco users with a plan to quit.
- Arrange for follow-up visits to review progress.
When asking a patient about tobacco consumption use very specific wording. If you ask the patient if he/she smokes; the only response you get will be related to smoking. The patient may use snuff or chewing tobacco and would respond “no” to your inquiry. The question should be, “Do you or have you ever used tobacco in any form?” You will get a more accurate response from the patient. Always document the query and the response.
Advise all users to quit by personalizing your message. The word “you” is important when addressing the issue with your patient. “The most important thing you can do to protect your health and your family’s health is to quit!” Your conversation with your patient should be strong, to the point, and honest. Words such as should, could, and maybe are not strong words. Consider your language and use strong action words.
Assessing a person’s readiness to quit may be more difficult than you think. You can ask them, “Are you ready to quit?” or “Would you like to quit?” Again, how you word the question is extremely important. If the patient is ready or wants to quit, then it is your professional responsibility to provide resources and assistance. If the patient is not ready or willing to make an effort, then it is your professional responsibility to motivate the patient. You should provide positive reasons to quit in a supportive manner.
Assisting the tobacco users with a plan to quit includes a number of factors. Setting a quit date is the most important — ideally, the quit date should be within two weeks. Removing all tobacco products from the patient’s environment aids the impulse users — people with little self-control. The patient should obtain support from family, friends, and co-workers. Review past attempts to quit as this will assist with what worked, didn’t work, or what led to their relapse. Be prepared for nicotine withdrawal and other challenges facing your patient in the critical first few weeks. Communicate with the patient important reasons for quitting as well as the benefits of quitting.
Your patients treasure your opinion and advice. Be positive and upbeat when discussing what will result in successfully quitting. Advise the patient that total abstinence is essential! Even one puff can be disastrous. Advise the patient that drinking alcohol or consuming caffeine associated with tobacco use is strongly linked to relapse. That first cigarette each day is usually with a cup of coffee. Encourage the patient to not allow others to smoke in the car or house as this can lead to a relapse.
Encourage the use of aids to quit such as medication. Over-the-counter products such as nicotine patches, gum, or lozenges can be extremely helpful for some patients. Others may require prescription drugs such as varenicline, bupropion SR, nicotine inhaler, or nasal spray.
There is even an app for smartphones, which will provide support and encouragement. SmokefreeTXT is a free mobile service designed for young adults and provides 24/7 encouragement, advice, and tips for smokers. Signing up is easy:
- Text the word QUIT to IQUIT (47848) from the mobile phone, answer a few questions, and the messages will begin.
- Or, go to www.smokefree.gov, search smokefreeTXT, then click on the button indicated on the screen and answer a few questions and the patient will begin receiving text messages to help them quit.
If the patient pays for individual text messages, this might be expensive for them. Have them check with their mobile providers.
Advise the patient that counseling plus medication is more effective than medication alone. Encourage the patient to start or increase their daily physical activity as this provides an alternative behavior to the midmorning coffee and tobacco break or the lunch cigarette and cola. Take a walk instead of a smoke! This will also keep the patient from putting on those extra few pounds.
Eating bananas can also help people trying to quit smoking. The B6 and B12 as well as the potassium and magnesium contained in bananas can help the body recover from the effects of nicotine withdrawal.
For those patients who just are not ready to quit and comment that they have smoked for many years without side effects, be ready to educate and motivate them. Inform them that about half the people who smoke will die from a tobacco-related illness and that the average smoker lives 10 years less than a non-smoker. Smoking ages a person about 10 years. Inform your female patients that the heat and chemicals from cigarette smoking can harm the skin and increase wrinkles. Appeal to their vanity. Remember, it is time to pull out all the stops!
The American Dental Hygienists’ Association’s Smoking Cessation Initiative and the Ask, Advise, Refer programs are both aids for dental hygienists to actively become advocates for smoking cessation. “Quit Now” cards are available through the ADHA and are sponsored by William Wrigley Jr. Company. The “Quit Now” cards offer tobacco users interested in quitting access to the first national toll-free quit line number: (800) QUIT-NOW (800-784-8669). For more information about the William Wrigley Jr. Company’s Oral Health Program, visit www.wrigleydentalcare.com. Visit the ADHA’s website at www.adha.org to explore the Smoking Cessation Initiative.
Clinical use of medication for tobacco cessation
There are at least two commonly used over-the-counter options available to your patients. One OTC option is nicotine gum (Nicorette) that comes in 2 mg. or 4 mg. and has been proven to be effective. This is not a good option for denture wearers because it adheres to the prosthetic appliance. Another cautionary factor to advise the patient of is that it is recommended that the person not drink anything 15 minutes prior to or during chewing the gum. The nicotine gum can cause mouth soreness and stomach discomfort. The recommended dosage is one piece every one to two hours up to 15 pieces a day. The gum may require usage up to 12 weeks or as needed.
Nicotine lozenges also come in the same strength as the gum. The patient should be advised not to drink or eat 15 minutes before or during use of the lozenges. The lozenges can cause hiccups, cough, and heartburn, and should be used for three to six months.
Nicotine patches (Nicotrol or Nicoderm CQ) can be OTC or prescription. Patients cannot use these products if they have severe eczema or psoriasis. The patches can cause local skin reaction and insomnia. Adding nicotine patches to behavioral programs for pregnant women did not improve the rates of cessation in smokers, according to a recent randomized study. Pregnant women who tried nicotine replacement therapy during pregnancy had a higher incidence of babies with colic. Nicotine patches are being used in nonsmokers to improve memory in patients with mild cognitive impairment. Normally, this product is taken for eight to 12 weeks.
Prescriptions available for use in a tobacco dependence treatment program are nicotine inhalers, nicotine patches, and nicotine nasal sprays. Oral medications such as varenicline or bupropion SR are also very effective.
Nicotine inhalers (Nicotrol) may be used for six months, tapering toward the end of the specified time frame. At first, local irritation of the mouth and throat is common, but usually subsides with continued use. It is prescribed with directions for using six to 16 cartridges a day, inhaling 80 times per cartridge.
Nicotine nasal spray should not be prescribed for patients with asthma as it causes nasal irritation. Patients are instructed not to inhale the product. Long-term use may cause dependence. It is usually prescribed for three to six months with instructions to use one “squirt” per nostril at one to two doses per hour, not to exceed 40 doses a day.
Bupropion SR 150 (Zyban, Wellbutrin SR, or generic) can cause insomnia and dry mouth. It is not to be prescribed for patients who currently use monoamine oxidase (MAO) inhibitor, or use bupropion in any other form. Patients who have a history of seizures or eating disorders should not be prescribed bupropion SR. The FDA warnings include an increase in suicidal and depressive behaviors in young adults or adolescents who have used the medication.
Varenicline (Chantix) has many side effects, but is by far the most promising prescription drug available for a tobacco cessation program. Chantix should be used with caution in patients with significant renal impairment, are undergoing dialysis, or with serious psychiatric illness. The FDA warning states that patients have reported depressed moods, agitation, and changes in behavior, suicidal ideation, and suicide. Side effects include nausea, insomnia, abnormal, vivid, or strange dreams, changes in behavior, hostility, aggression, agitation, constipation, gas, and vomiting. Recommended dosage is a graduated dosing starting at .05 mg. each morning on the first three days, then 0.5 mg. twice a day on the fourth through seventh day, followed by 1 mg. a day twice daily until completed. The patient is instructed to smoke, dip, or chew for the first week that Chantix is taken and then quit. Chantix® is now being tested for use in reducing alcohol-drinking behaviors. The drug is recommended to be taken for three to six months.
Some combinations of drugs have also been prescribed. For example, nicotine patch plus bupropion, or the patch and gum, or the patch plus lozenge plus inhaler.
Buyer beware
E-cigarettes or smokeless cigarettes are one of the newer products on the market espousing pure nicotine with no chemicals (no tar, no ash, and no smell). They come in packaging that looks like a cigarette, a USB stick, or a pen, all of which might appeal to adolescents and young adults. They have a rechargeable battery, which powers a heating element that vaporizes pure nicotine in a replaceable cartridge. What is inhaled looks like smoke.
The claims of some e-cigarette manufacturers are that the devices are safer. The companies even claim that their products help smokers quit. These claims are unproven.
Recently, the FDA issued a warning after tests showed chemicals such as diethylene glycol and nitrosamine were found in some e-cigarettes. They are not regulated. Other countries such as Australia, Hong Kong, Israel, and Canada have already banned this product. New York City is currently trying to ban e-cigarette sales.
Snus is a smokeless tobacco product that claims to be healthier. Some of the Snus products have high amounts of TSNAs (remember, these are cancer-causing chemicals). Bacc Off is an herbal product that is used like smokeless tobacco or snuff. Neither of these products are recognized tobacco cessation products even though manufacturers claim they are.
So, again, buyer beware!
Recently, some health insurance companies have implemented tobacco cessation programs. Many will cover the entire cost of prescription smoking cessation products. Some insurance plans offer free online counseling, instant messaging, or professional counseling via telephone. Many insurance companies charge an additional premium for smokers.
Celebrate quit anniversaries. Next time your patient tells you they quit smoking, note the date they quit and send them an anniversary card monthly, annually or whatever time frame works for you. Many offices send birthday cards; why not a card for recognizing one of the most important dates in their health history? Tell the patient how proud you are of their monumental achievement! If patients slip, encourage them not to give up.
If the average state would designate an additional $1 million to fighting smoking, it would result in 1.4 million fewer packs of cigarettes being smoked and would ultimately save $7 million in health-care costs, $7 million is lost productivity, and approximately $2 million in Medicaid payments. If those figures were multiplied, the savings/benefits would also increase about 16 fold. An example would be an expenditure of $50 million could reap a benefit of $737 million. It is obvious that the benefits would far outweigh the costs.
It is as our professional responsibility to actively be involved in a tobacco cessation program with our patients. RDH
Pamela J. Myers, RDH, has been a practicing dental hygienist for 36 years and is currently the Dental Hygiene Program Manager for the University of Texas Medical Branch – Correctional Managed Care in Huntsville, Texas.
Tobacco Cessation resources
www.who.int — World Health Organization
www.fda.gov — U.S. Food & Drug Administration
www.cdc.gov/OralHealth — Centers for Disease Control and Prevention
www.thevisualmd.com/wellness — Really well done videos carefully researched
www.ada.org — American Dental Association
www.adha.org — American Dental Hygienists’ Association
www.nidcr.nih.gov — National Institute of Dental and Craniofacial Research
www.PfizerHelpAnswers.com — Pfizer Drug Company
www.nlm.nih.gov/medlinesplus/smoking.html — National Institutes of Health
www.nlm.nih.gov/medlinesplus/smokingandyouth.html
www.cancer.org — American Cancer Association
www.lung.org — American Lung Association
www.MedPageToday.com — This site is free and provides daily reports on a myriad of topics, research, and publications
www.women.smokefree.gov/pubs/Clearing_the_Air_508
In its Sept. 2011 guide, “Adult Smoking in the U.S., the Centers for Disease Control and Prevention suggested community involvement with the following steps:
State and community leaders can:
- Fund comprehensive tobacco control programs at CDC-recommended levels. The CDC recommends that states spend an average of $12.34 per resident on tobacco prevention efforts.
- Enact 100% smoke-free indoor air policies that include workplaces, restaurants, and bars.
- Increase the price of all tobacco products.
- Implement hard-hitting media campaigns that raise public awareness of the dangers of tobacco use and secondhand smoke exposure.
- Use the World Health Organization’s (WHO) MPOWER strategies to prevent and reduce tobacco use and make tobacco products less accessible, affordable, attractive, and accepted:
M = Monitor tobacco use and prevention policies
P = Protect people from tobacco smoke
O = Offer help to quit
W = Warn about dangers of tobacco use
E = Enforce restrictions on tobacco advertising
R = Raise taxes on tobacco
Parents and nonsmokers can:
- Make your home and vehicles smoke free.
- Not start, if you are not already using tobacco.
- Quit if you smoke; children of parents who smoke are twice as likely to become smokers.
- Teach children about the health risks of smoking and secondhand smoke.
- Encourage friends, family, and coworkers to quit.
Health care providers can:
- Ask their patients if they use tobacco; if they do, help them quit.
- Refer patients interested in quitting to 1-800-QUIT-NOW, www.smokefree.gov, or other resources.
- Advise patients to make their homes and vehicles 100% smoke free.
- Advise nonsmokers to avoid secondhand smoke exposure.
Employers can:
- Establish a policy banning the use of any tobacco products indoors or outdoors on company property by anyone at any time.
- Provide all employees and their dependents with health insurance that covers support for quitting with little or no copayment.
Retailers can:
- Learn new Food and Drug Administration (FDA) restrictions on youth access to tobacco products and tobacco marketing to youth, and closely follow them.
- Never sell any tobacco products to customers younger than 18 years of age (or 19 in states with a higher minimum age requirement).
- Check photo ID of any customer trying to buy tobacco products who appears to be 26 years of age or younger.
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