Puff, puff, Thats enough

Sept. 1, 2000
Dental hygienists should become familiar with the tools to assess, educate, and motivate patients who use tobacco and are pregnant and/or mothers. In the Clinical Practice of the Dental Hygienist, eighth edition, Esther Wilkins has included many pages of valuable information on this topic for the hygienist to digest.

A new program is designed to help mothers and pregnant women stop using tobacco.

Valerie Kimbell, RDH

Dental hygienists should become familiar with the tools to assess, educate, and motivate patients who use tobacco and are pregnant and/or mothers. In the Clinical Practice of the Dental Hygienist, eighth edition, Esther Wilkins has included many pages of valuable information on this topic for the hygienist to digest.

Wilkins reports tobacco use has a "moderate to severe influence on the developing fetus as well as the child after birth." Wilkins also states, "All involuntary smoke from the mother, or environment, can adversely affect the behavioral, mental, and physical health of unborn and born children."

In utero, the transplacental passage of harmful smoke components can increase risks for adverse pregnancy outcomes. Low birth weight, still birth, fetal neonatal death, placenta abruptio, placenta previa, premature/prolonged membrane rupture, preterm labor, preeclampsia, growth retardation, and sudden infant death syndrome (SIDS) are reported associations with maternal tobacco use. Higher incidences of cleft lip, cleft palate, and delayed tooth formation have also been reported.

Chemicals are passed to the baby in the breast milk of mothers who smoke. Respiratory tract illness and risk of SIDS is increased. Young children experience decreased lung function and more chronic respiratory symptoms, as well as increased chances of asthma and ear infections. These illnesses can lead to behavioral problems and poor academic achievement because of increased absenteeism.

Science has shown us that before you can solve a problem, you must first understand it. Understanding the dangers posed to the fetus and child are the first steps in our understanding of this problem.

My enthusiasm for this problem was sparked in Oakland, Calif., where I attended a seminar titled, "Make Yours a Fresh Start Family," sponsored by the American Cancer Society. This was a new approach to tobacco control, specifically designed for targeting pregnant women and mothers.

This seminar increased my awareness of a problem I had not spent much time thinking about. In my dental practices, it seemed that I did not meet many pregnant mothers who use tobacco, specifically cigarettes. Now I am wondering if I ever thought to ask pregnant women or mothers if they smoke. Did I feel it was unprofessional to enter this territory? Did I assume most women already knew the dangers of smoking while pregnant or around young children? Did I assume most women listen to the advice of their physicians during their pregnancies and nurturing years? Did I allow my personal feelings and inexperience to dissuade me from going down the path of enlightenment with those patients? Was I afraid I would offend the patient? Perhaps I was uninformed about how to go about the task of suggesting tobacco control.

This seminar provided me with the tools necessary to provide tobacco-control assistance to female patients. The presenters discussed many important facts that were new to me. During this seminar, I wrote down four pages of notes, some of which are included in the sidebar on this page.

Understanding the facts about quitting and why cessation should be encouraged is the first step. The second is understanding how to use this program. What do we need to know about it? What makes it work? The motivational strategies create the confidence that will carry us through. Realizing the "Fresh Start" program has been tested on - and has effectively treated - 2,000 women is evidence of the program`s ability to reach those women who perhaps need it most. The program has been established as a safe environment for smokers.

Before we start, we must realize that smoking is a habit, a psychological dependency, and a physical addiction. The responsibility for tobacco control lies with the smoker, and the supporting facilitator is the hygienist.

Encourage cessation by saying, "The only failure is not to try." Encourage taking baby steps by saying, "Inch by inch, life`s a cinch." Active learning through participation results in success.

The facilitator must understand that people smoke for different reasons, and quitters must make significant lifestyle changes. "Fresh Start" identifies problems and "forces." The program builds up positive forces and eliminates negative forces. External forces include health issues, role models, money, and peer pressure. Internal forces are health issues, image, self-mastery, awareness, and, hopefully, adoption of cessation. Identifying these "forces" assists the smoker in making decisions. Values are often the key, and money is the motivating factor for the smoker to make the decision to quit.

Three conditions must be met in order to make the cessation process a success:

? Establishing the "I want to" feeling is 75 percent of the process.

? The smoker must realize the first 72 hours will be uncomfortable.

? The smoker must avoid behaviors and people connected with smoking.

As facilitators, we must realize how nicotine affects the mind. Tobacco can alter the smoker`s mood in seven seconds, while heroin takes 14 seconds. Nicotine is an appetite suppressant. Smoking can relax or stimulate. Smokers must realize they can live and function successfully without nicotine addiction ruling their minds.

Smokers must be taught that they can alter their lifestyles successfully. Thinking "outside the box" is a new concept they must learn to live by. For example, smokers must believe they can drive to work without a cigarette. Change is possible and healthy.

How does "Fresh Start" work? The first step teaches the facilitators to assess the readiness of the smoker to quit the habit. The instructional video, included in the packet of information, walks the facilitator through the steps of recognizing the signs of a smoker: precontemplating, contemplating, preparing, or having already quit and maintaining cessation. Pamphlets are included and are designed to work with whichever phase the smoker is experiencing at the time of assessment.

A "ladder" diagramming the stages of change illustrates the phases a smoker goes through prior to and during cessation. This ladder is helpful, because it shows which phases a smoker is encountering, as well as outlined strategies for use during a possible relapse.

Characteristics of the Four Stages of Behavioral Change are also included and explain the stages of "hanging on," "letting go," "starting over," and "restabilizing." When you understand these stages, you can help the smoker understand where she stands in the quitting game.

Identifying smokers and recent quitters is the first phase in the "stage" process, which consists of five steps.

(1) Survey - This step assesses the nicotine dependence and barriers to quitting.

(2) Tailor - This is the health message and acknowledgement of the difficulty of quitting. Dispensing information about the effects of smoking on the fetus/child, the client herself, the stress and benefits of quitting, and clear recommendations about how to quit happen at this point.

(3) Assess readiness to quit - Tell her she can be successful with help. If she does not want to quit, try to interest her in learning more. Remind her of the effects on the baby.

(4) Give - The appropriate "Fresh Start Family" magazine is given to the client with the plan of action. Open the magazine and show her the section most appropriate for her assessed stage. For example:

Not ready/Not interested

Y Client will think about the effects of smoking and reasons to stop

Y Have the pregnant woman read "Having a healthy baby"

Y Have the mother read "Healthy family" and "Nicotine"

Not ready but willing to learn more

Y Client learns what to do to be ready to quit

Y Pregnant woman reads "Three steps to quitting"

Y Mother reads "Four steps to quitting"

Ready to quit

Y What to do to get ready and how to set the "quit day"

Y Pregnant woman reads "Three steps to quitting" and "Staying stopped"

Y Mother reads "Four steps to quitting" and "Staying stopped"

Recent quitter

Y Client identifies and addresses problems associated with continuing cessation.

Y Pregnant woman reads "Staying stopped" and "Baby is home"

Y Mother reads "Staying stopped" and "A healthy future"

Evaluate - Evaluate progress at follow-up visit and praise positive actions.

This program is fun, easy to follow, and fulfilling to implement. To be successful, I suggest following Wilkins` advice on establishing a cessation program within the dental office:

Y Establish group agreement

Y Appoint a program coordinator

Y Establish a tobacco-free environment and get rid of the ashtrays

Y Set an example

Y Gain the patient`s confidence

Y Present questions without judgment

Y Motivate

Y Personalize reasons to quit

Y Show willingness to help

Y Relate oral findings

Y Do not antagonize and remain calm

Y Respect the patient

Y Provide educational materials

Wilkins believes "interventions and their outcomes will depend on the motivation

and experience of the clinician and the acceptance and adherence of the

individual." Even minimal intervention by a clinician may help a patient (and

child) become tobacco-free.

I challenge my profession to support this effort and actively combat the effects of tobacco on current and future generations. Public health agencies have voiced an interest in enlisting the input and energy from the American Dental Hygiene

Association. Please contact your local public health department or the AmericanCancer Society for more information regarding the "Fresh Start Family Program." Remember: It only takes three minutes to enhance the lives of innocent victims.

For further information, contact the American Cancer Society at (800) ACS-2345 or visit www.cancer.org. The author can be reached at [email protected].

Seminar notes

Y Smoking is the most addictive behavior

Y One in four women in the United States smokes (peak ages are 24-44)

Y 20 percent of pregnant women smoke, and 38 percent of those are heavy smokers

Y 25 percent of women quit smoking when pregnant, but 70 percent start again

after pregnancy

Y Smoking incidence rises with lower education status

Y Smoking incidence rises with lower income status

Y Smoking rises with increased divorce and separation rates

Y Smoking increases bronchitis and pneumonia incidence

Y Children of smokers fill emergency rooms because of chronic coughing

Y Wellbutrin/Zyban is not recommended for pregnant women

Y 42 mg transdermal patches may be recommended by a physician

Y Smoking causes increased vasoconstriction, which means less oxygen for the fetus

Y Smokeless tobacco is equivalent to smoking

Y 3,000 people become smokers each day (from age 13)

Y New mothers return to smoking to lose weight

Y Heavy smokers smoke more than 20 cigarettes per day and have the most trouble quitting

Y Smoking is not related to breast cancer, but is related to cervical cancer

Y 15 percent of smokers are diagnosed with lung cancer

Y Nicotine is extracted by the bladder

Y Oncologists report every patient experiencing bladder cancer used tobacco

Y It takes three minutes to suggest tobacco cessation

Y Smokers avoid looking at smoking data

Y Teens do not know that smoking harms the fetus

Y 90 percent of quitters quit by themselves, while the 10 percent who seek assistance from the public health department are the most hardcore addicts and most difficult to assist to quit

Y Two people, each smoking a pack a day, will pay $67 a week to smoke

Y People should eat less when they quit smoking because their metabolism will slow down after three months

Y Average weight gain from quitting tobacco ranges from four to nine pounds

Y Mothers who smoke use baby bottles more often to feed their babies

Y Smokers should start exercising when quitting

Y The most successful quitters make several attempts to quit

An example of the

"Make Yours a Fresh Start for Families" program in progress

A returning 18-year-old patient, who has a 3-year-old child, came to the operatory for her six-month checkup and prophylaxis.

Radiographs were taken, and the prophy was performed. Afterward, we were watching the child when I noticed he exhibited a reddened left eye. The grandmother and mother were discussing what could have caused the reddened eye when the talk turned to tobacco usage by the mother.

Soon we discussed the use of tobacco and the exposure to the child from the second-hand smoke. Both women were very familiar with the types of cancer and other medical problems associated with this habit.

An intraoral exam of the child revealed a reddened, irritated throat. The women knew about the increased incidence of ear infections and asthma to children exposed to second-hand smoke, and both became concerned about the child`s throat.

I mentioned my recent training in facilitating a tobacco-control program for mothers of young children. Both women were interested and requested an additional appointment where I could share this valuable information.

I planned to call the mother at her home the following Monday and appraise her desire to quit smoking. She seemed to be in the precontemplative stage. After my assessment, I gave the patient the proper reading materials, hoping she will progress to the contemplative stage where she will think about assigning a "quit date."

We discussed that, prior to her quitting, she will need to tell all of her tobacco-using friends and family that she indeed intends to quit the habit and that she will request their help. We also talked about the weight gain and the initial 72 hours of being uncomfortable. The patient understands that the only failure is not to try.

This facilitation was amazingly simple and easy to implement! I anticipated a possible delay in the decision to quit. I understand that I must mention the cessation at each dental visit to convey to the patient my earnest concern for the health outcomes for her and her child.

If this cessation is successful, I anticipate immense fulfillment and pride in providing a service that can ultimately spare this family major health concerns.