Tobacco Dependence Interventions

by Cathleen Terhune Alty, RDH

Statistics show that one out of every four adult patients you treat is a smoker. As a hygienist, you know the importance of performing a thorough oral cancer exam on every patient. You may even find yourself being extra diligent in the examination when you know that a patient is a smoker. But do you say anything to the patient about quitting? Do you document and offer treatment to every tobacco user? You may not know that 70 percent of current smokers express a desire to quit, and that many tobacco cessation programs are very effective.

Tobacco dependence is a chronic condition that often requires repeated intervention, but effective treatments exist that can produce long-term or even permanent abstinence. Even brief tobacco dependence treatment is effective, and every patient who uses tobacco should be offered at least brief treatment.

The dangers of tobacco have been explained in detail for years. Lung disease, stroke, heart disease, cancers, low-birth-weight babies, and early menopause are just a few in the long list of health hazards associated with tobacco use. According to the U.S. Department of Health and Human Services, tobacco use is the single greatest cause of disease and premature death in America today. More than 430,000 tobacco users die prematurely each year, and it costs society more than $100 billion to treat tobacco-related death and diseases.

Compelling evidence about the damage smoking can do to oral tissues has been recently released. Research reported in the June 2004 British Journal of Cancer found that smoking destroys protective antioxidant molecules in saliva and transforms it into a dangerous mixture of chemicals that increases the risk of oral cancer. The researchers found the mixture of saliva and cigarette smoke is actually more lethal to cells in the mouth than cigarette smoke alone. "Our study shows that once exposed to cigarette smoke, our normally healthy saliva not only loses its beneficial qualities, but it turns traitor and actually aids in destroying the cells of the mouth and oral cavity," said Dr. Rafi Nagler, of the Technion-Israel Institute of Technology in Haifa, Israel.

So how do we approach this health issue with our patients? Because effective tobacco dependence treatments are available, every patient who uses tobacco should be offered one of these treatments: Patients willing to try to quit tobacco use should be provided with treatments that are identified as effective, and patients unwilling to try to quit tobacco use should be provided with a brief intervention that is designed to increase their motivation to quit. Patients who have quit smoking need encouragement to continue to be smoke-free.

The U.S. Department of Health and Human Services has created a step-by-step guideline for clinicians to follow to help smokers quit.

The first and most important step in the process is identification and assessment of tobacco usage. As hygienists, we are in a frontline position to help patients by asking two key questions: Do you smoke? and Do you want to quit?

The first step in this process — identification and assessment of tobacco use — separates patients into three treatment categories:

1) Patients who use tobacco and are willing to quit should be treated using the five A's (ask, advise, assess, assist, and arrange).

2) Patients who use tobacco but are unwilling to quit at this time should be treated with the five R's for motivational intervention (relevance, risks, rewards, roadblocks, and repetition).

3) Patients who have recently quit using tobacco or former smokers should be provided relapse prevention treatment and encouragement to continue abstinence.

Tobacco users willing to quit — the five A's

The five A's are designed to be used with the smoker who is willing to quit. Tobacco use status stickers can be placed on charts of smokers with their assessment. Advise the patient that quitting is indeed possible and is an important thing for them to do right now. Also, advise the patient of current health risks (like precancerous changes to oral tissues that are visible in the mouth), the economic costs of smoking, and the impact of secondhand smoke on children and others in the family.

Next, assess the willingness of the patient to quit within the next 30 days. If they are willing, provide information and assistance to help the patient succeed.

Assist the patient to come up with a quit plan, including a quit date, ideally within the next two weeks. Tell the patient to enlist the help of family and friends by sharing the quit date with them. Emphasize to the patient that total abstinence is essential. Not even a single puff after the quit date! Discuss triggers or challenges the patient may face after quitting, including commuting, social drinking, and other situations that could cause a relapse. Identifying and anticipating events that may lead to relapse prior to the situation occurring is important. Help the patient think of ways to overcome or avoid these events, such as driving a different route to work, not drinking socially for a few weeks, etc. Remind the patient that withdrawal typically peaks one to three weeks after quitting.

Arrange a follow up contact with the patient about 1 week after the quit date.Congratulate success, ask for a recommitment if the patient lapsed and assess pharmacotherapy usage and problems.Arrange further follow up dates as needed. Click here to view Pharmacotherapies Chart and Treatment Chart

Encourage the patient by telling them it is possible to quit for good, even if they have not been completely successful in the past. Studies show that one-half of all people who have ever smoked have quit, and so can they. Mail encouraging notes to the patient during the first couple of weeks. For adult smokers who smoke more than 10 cigarettes per day, suggest effective quitting aids, such as nicotine patches, to help get them over their addiction. Be sure to follow up with the patient after thequit date to see how they are doing.

Tobacco users unwilling to quit — the five R's

The five R's are designed to motivate smokers who are unwilling to quit at this time. Smokers may be unwilling to quit due to misinformation, concern about the effects of quitting, or demoralization because of previous unsuccessful quit attempts. Therefore, after asking about tobacco use, advising the smoker to quit, and assessing the willingness of the smoker to quit, it is important to provide the five R's motivational intervention.

Encourage the patient to indicate why quitting is personally relevant, being as specific as possible. Motivational information has the greatest impact if it is relevant to a patient's disease status or risk, family or social situation (having children in the home), health concerns, age, gender, and other important patient characteristics (prior quitting experience, personal barriers to cessation).

Ask the patient to identify potential negative consequences of tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. The clinician should emphasize that smoking low-tar/low-nicotine cigarettes or use of other forms of tobacco (smokeless tobacco, cigars, and pipes) will not eliminate these risks. Examples of risks include shortness of breath, infertility, heart attacks, stroke, cancers, low-birth-weight babies, etc.

Ask the patient to identify potential benefits of stopping tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. Examples of rewards include improved health, improved sense of taste and smell, saving money, no worry about exposing others to smoke, feeling better physically, reduced facial skin aging, etc.

The clinician should ask the patient to identify roadblocks — barriers or impediments to quitting — and note elements of treatment (problem solving, pharmacotherapy) that could address barriers. Barriers may include withdrawal symptoms, weight gain, fear of failure, depression, missing the enjoyment of smoking, social interaction of smokers, etc.

This can be repeated every time an unmotivated patient visits the office. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful. Always encourage and never lecture!

Former smokers — preventing relapse

Most relapses occur soon after a person quits smoking, yet some people relapse months or even years after the quit date. We need to help the patient to prevent relapse. Every patient who has quit recently should be asked how they are doing with being smoke-free. Every ex-tobacco user undergoing relapse prevention should receive congratulations on any success and strong encouragement to remain abstinent. When encountering a recent quitter, use open-ended questions designed to initiate patient problem solving ("How has stopping tobacco use helped you?"). The clinician should encourage the patient's active discussion of the benefits they have noticed from quitting and anticipated threats to remaining smoke-free.

During relapse prevention, a patient might identify a problem that threatens his or her abstinence, such as lack of support at home, weight gain, feeling deprived, etc. Reassure the patient that this is normal and offer encouragement to continue abstinence from smoking. Referral to a medical specialist or family physician may be indicated.

Tobacco dependence is a chronic disease that deserves treatment. Effective treatments have now been identified and should be used with every current and former smoker. Dental personnel have a great opportunity to help patients quit smoking for good.

∞ Five first-line pharmacotherapies were identified that reliably increase long-term smoking abstinence rates:

• Bupropion SR
• Nicotine gum
• Nicotine inhaler
• Nicotine nasal spray
• Nicotine patch

∞ Two second-line pharmacotherapies were identified as efficacious and may be considered by clinicians if first-line pharmacotherapies are not effective:

• Clonidine
• Nortriptyline

∞ Over-the-counter nicotine patches are effective relative to placebo, and their use should be encouraged.