Smoking deterrents can help kick the habit, but side effects need to be closely monitored

June 1, 1996
We often discuss the adverse effects of tobacco with patients who smoke. We are the ones they hate to face as we examine the lingual aspects of their teeth, easily seeing the heavy tobacco stain not visible to the rest of the world.

Cynthia R. Biron, RDH

We often discuss the adverse effects of tobacco with patients who smoke. We are the ones they hate to face as we examine the lingual aspects of their teeth, easily seeing the heavy tobacco stain not visible to the rest of the world.

Even though the patient has access to the facial aspects of their teeth - possibly resorting to some rather unorthodox methods of stain removal in order to face the public - they are well aware of the stain left for us to remove. Frequently, they are self-conscious and embarrassed about opening their mouths for us since they know we are seeing what we saw six months ago. They told us then it was the last time we`d see them with so much stain - they were determined to quit smoking.

Stained teeth is certainly the least detrimental of the adverse effects of smoking. What concerns us more are the effects on the cardiovascular, pulmonary, gastrointestinal, renal, skeletal, and nervous systems and, yes, an area we can address with more expertise - the oral cavity, especially the periodontium. Dental professionals are knowledgeable enough about all bodily systems to discuss the adverse effects of smoking. We still find the general public, however, thinking that teeth are a separate entity - sort of like the typodonts tied to a chair in dental hygiene preclinics. Patients think that our interest in their health, like the dental practice, is limited to teeth.

Perhaps it is more difficult for us to educate our patients about the most detrimental effects of smoking because the patient is thinking to himself, "She really finds my stained teeth and tobacco breath offensive or she wouldn`t be telling me about heart disease!"

Perhaps we need to preface our discussion of the adverse effects of smoking with a statement such as, "I don`t mind removing tobacco stain from your teeth. It feels like I`m really doing something productive. I`m just concerned about your overall health."

Before we answer patients` questions about pharmacological smoking deterrents, we need to know how and if these drugs effectively break the smoking habit, the contraindications to using them, their adverse effects, and if they have consulted with their physicians about their smoking habit.

Just what are smokers enjoying?

If we understand the pleasurable effects of smoking, we can be more understanding to the reasons our patients cannot seem to give it up very easily. Quitters say it was the most difficult thing they have ever had to do and that they mourn the loss of their friend, the cigarette.

Nicotine is the substance smokers are addicted to. In addition to the addiction to the substance, a group of psychomotor habits become comforting to the smoker, such as doing something with the hands like holding a cigarette and placing it in the mouth. There is the oral gratification of puckering up the lips and drawing in on the cigarette to achieve first the taste and then the feeling of the surge one gets when the nicotine binds to the acetylcholine receptors at the autonomic ganglia, in the adrenal medulla, at the neuromuscular junctions, and, ultimately, the brain.

Two effects of nicotine make smokers keep going back for more - first, stimulation evidenced by increased alertness and cognitive performance and, secondly, a mildly euphoric effect from the pleasure system of the brain.

How do smoking deterrents work?

The actual drug derived from smoking cigarettes (nicotine) is provided in smaller doses to the patient in the form of chewing gum or skin patches. Two naturally occurring alkaloids, nicotine and lobeline, are the drugs used as smoking deterrents. Lobeline is much weaker than nicotine, and controlled studies have shown that it only has a placebo effect in reducing the craving for cigarettes.

The combined effects of smoking - oral gratification, psychomotor habits, and nicotine effects - make quitting more difficult for some people than other addictions. Quitting one aspect of the habit at a time may be easier than to give up the entire combination at once. If smoking deterrents are prescribed for a patient to ease the craving for cigarettes, behavior modification can be employed to reduce the psychomotor and oral gratification part of the habit.

The preparations of nicotine are in the forms of chewing gum and transdermal patches.

Nicotine polacrilex (Nicorette, Nicorette DS). Nicotine polacrilex is the ingredient in chewing gum that is bound to an ion exchange resin. Nicotine is released only during chewing, and the blood level of nicotine is greater when chewing is more vigorous.

A cigarette produces twice the amount of nicotine to the blood stream than one 2 milligrams (mg) piece of Nicorette (nicotine gum). Dosages of nicotine gum are available in 2 mg and 4 mg pieces. The 4 mg pieces are recommended for highly dependent smokers (one package of cigarettes or more per day). The 2 mg pieces are recommended for those who had smoked less than one package of cigarettes per day.

Patients must be instructed to chew slowly. This allows for slower buccal absorption of the nicotine. Rapid chewing results in rapid absorption, leading to the side effects of "oversmoking," which include oropharyngeal irritation, hiccups, and nausea. Patients are also instructed to avoid eating and drinking for 15 minutes before and during the gum chewing. Acidic beverages such as juices, coffee, wine, and soft drinks should be avoided since they change the pH of the saliva, interfering with absorption of the nicotine through the buccal mucosa.

Nine to 12 pieces should be chewed per day. The intake is limited to one piece per hour that is chewed slowly for 30 minutes. Patients are more successful with the therapy if they have a fixed schedule of taking one piece of gum every one to two hours than if they wait until they have a tremendous craving for a cigarette. The 2 mg pieces should not exceed a maximum of 30 pieces per day but 4 mg pieces should not exceed a maximum of 20 pieces per day.

Gradual withdrawal from the nicotine gum avoids a return to the smoking habit. Patients control withdrawal through a reduction in the number of pieces per day, as well as the length of time spent chewing. If the nicotine gum is effective, it usually will be within three months of therapy. The therapy of nicotine gum is not recommended to last longer than six months. In controlled trials, nicotine gum doubled the success rate of smoking cessation.

The nicotine gum is noteworthy in dental treatment because it may worsen dental problems. The mechanical effects of chewing may cause TMJ pain and/or traumatic injury to the oral mucosa or teeth. The irritating effects of nicotine gum can cause gingivitis, stomatitis, glossitis, aphthous ulcers, and changes in taste and salivary flow.

Transdermal nicotine (Habitrol, Nicoderm, Nicotrol, ProStep). The transdermal system involves a patch which contains a pouch of nicotine in varying dosages. The dosages are usually either 21 mg, 14 mg, or 7 mg. An initial starting dose is usually 21 mg. The 14 mg and 7 mg doses are employed to wean the patient off the nicotine.

Each patch is placed on the upper body or outer arm of the patient and kept in place for 24 hours. The patient`s systemic circulation consumes 68 percent of the nicotine released from the patch.

Patients are instructed to remove the patch every night, replacing it with a new patch every morning. A new patch should be placed in a different location on the skin to avoid irritation.

In a controlled study, 22 percent of the patients wearing the nicotine patch abstained from smoking for 52 weeks. Only 11 percent of those using a placebo abstained from smoking for the full 52-week period.

The patch is only recommended for a three-month time span of therapy. Nicotrol has been recommended for up to five months.

What are the adverse effects of deterrents?

Nicotine causes cardiovascular effects such as increased heart rate, vasoconstriction, and elevated blood pressure. In the initial period of inhalation, the cardiovascular effects are quite noticeable to smokers, who often describe the sensation as a feeling of dizziness along with a euphoria. The smoker builds up a tolerance to the nicotine, and more nicotine is necessary to provide the same effect.

Nicotine`s long-term effects on the cardiovascular system causes hypertension and associated cardiovascular disease.

Accordingly, a patient wearing or chewing a deterrent must be warned of the toxic effects that can occur from smoking while having a higher blood level of nicotine that is provided by the patch or the chewing gum. A few cases of myocardial infarction have occurred when patients using deterrents decided to smoke cigarettes anyway, since they still experienced a craving.

It is inadvisable to prescribe smoking deterrents to any patient who has hypertension or any underlying cardiac condition. Their smoking habit must be dealt with, but the risk factors should be carefully weighed. Unless the patient is really committed to the smoking cessation program, a smoking deterrent that creates a blood level of nicotine is not the treatment of choice.

The flow of drugs during cessation

The effects produced from nicotine through the smoking process can also result when using prescribed smoking deterrents. The transdermal system, for example, has been known to cause allergy and/or irritation at the site of administration (the patch).

When anyone quits smoking and the level of nicotine in the blood is decreased or eliminated, drugs that used to be somewhat blocked by nicotine are now available at a higher blood level. Theophylline, oxazepam, pentazocine, propranolol, imiparamine, acetaminophen, furosemide, and even caffeine will have greater efficacy in the non-smoker. Patients taking these drugs and many others may need to have dosages adjusted when they quit smoking.

Smokers may need dosages to be increased when lower levels of nicotine are provided by prescribed smoking deterrents. Adrenergic agonists and adrenergic blockers need to have dosage adjustments during the use of smoking deterrents and after smoking cessation.

It is wise to always keep in mind that no single drug elicits only one effect. That is why doctors prescribe the mildest treatment that will be effective and move to a more aggressive treatment as necessary.

Unfortunately, it frequently takes a life-threatening scare to make a patient determined to quit smoking. It is frightening to see the emphysema patients who have to take off the nasal cannula and turn off their portable oxygen tank to have a cigarette. If you have never been a smoker, be thankful, and be sympathetic to those who are addicted to smoking. Most of them really want to quit smoking just as much as 75 percent of the people in our country want to lose weight. Stress is replete in our lives and willpower is submissive to stress.

Cynthia R. Biron, RDH, is chair of the dental hygiene program at the Tallahassee Community College. She is also a certified emergency medical technician.