Helping Tobacco Users Quit: Dental Hygienists Leading the way ...

Helping Tobacco Users Quit:

Dental Hygienists Leading the way as Effective Cessation Counselors

Presented By:Tavia Rauch, BA, CRT

Funded by NYS’s Tobacco Control Program to provide free services to healthcare providers

Training, technical assistance, and follow up to healthcare institutions and providers on addressing tobacco dependence with patients and helping them quit

Eight counties served: Albany, Schenectady, Rensselaer, Columbia, Green, Schoharie, Delaware, Otsego

Center for Smoking Cessation atSeton Health

• Trainings, free supplies & educational resources for hygienists and their practices…

• Fun contests and other incentive-based promotions – check for updates often on our website: www.Quitsolutions.org

Program Overview:

Forward: What you should know about nicotine addiction

Rationale: Why address tobacco use and encourage cessation in dental practices?

Communication: Effective counseling principles and techniques to assist you in providing effective interventions with patients who use tobacco

Continuity: A systems approach to permanently translate evidence based methods into practice

Folder contents

Evidence-based Practices:Strategies that Work in Tobacco Control

Increases price of tobacco Clean Indoor Air (Smoking

bans & restrictions) Mass Media campaigns

with interventions (i.e., part of comprehensive tobacco control programs)

Availability of treatment for tobacco dependence

– Provider reminder systems*****

– Telephone counseling and support

– Reducing patient costs for treatment

Source: Guide to Community Preventive Services , Systematic Reviews & recommendations

New York’s Tobacco Cessation Environment

Media

Policy

Community Action

Health Care System

Self-Quit

Tobacco Dependence Treatment

•Health Care Providers & Organizations

•Community Programs

New York State Smokers’ Quitline

•Counseling & NRT

•Information & self-help Materials

•Referral

Tobacco

Users

Why Are Cigarettes So Dangerous?

Tobacco & NicotineTobacco & Nicotine

• Tobacco was cultivated and used since 6000 BC• Nicotine makes up 5% of the tobacco plant• One cigarette contains 8-20mg of nicotine• When a cigarette is smoked, 1mg is absorbed into

the body• Delivered through skin, lungs and mucous

membranes

Cigarettes Are PoisonCigarettes Are Poison

• Nicotine is sold commercially as a pesticide• Consuming one cigarette will make a

toddler very ill• 60 mg, about 3-4 cigarettes, if

consumed will kill an adult

A BURNING CIGARETTE is a small chemical manufacturing plant, that produces over 4,000 chemicals including:• 43 Carcinogens• 400 toxins• Nicotine

Chemicals in Chemicals in Tobacco SmokeTobacco Smoke

• Butane – lighter fluid• Cadmium – batteries• Toluene – solvent• Ammonia – cleaner

• Acetic acid – vinegar

• Methane – sewer gas

• Arsenic - Poison• Carbon Monoxide –

poisonous gas• Methanol – rocket fuel• Formaldehyde –

embalming fluid

The Cold, Hard Facts about The Cold, Hard Facts about Spit.Spit.

Placed inside of the user’s mouth [‘wad’] for a continuous high from the nicotine– CHEW: a leafy form of tobacco sold in pouches.

Users keep the chew between the cheek and gums for several hours at a time.

– PLUG: chew tobacco that has been pressed into a brick.

– SNUFF: a powdered, moist form of tobacco sold in tins. Users put the snuff between the lower lip or cheek and the gum. As well, some users will sniff it. Using snuff is also called “dipping.”

Smokeless ≠ Safe.

8 – 10 chews/dips per day [2 cans per week] is equivalent [in nicotine content] to 30 – 40 cigarettes per day

Made from a mixture of tobacco, nicotine, sweeteners, abrasives, salts and chemicals

Contains more than 3000 chemicals, about 28 known carcinogens; more addictive than cigarettes because it contains higher levels of nicotine

U.S. Dept. of Health and Human Services, National Institutes of Health, NIH Publication No. 03-3270, July 2003

Laced with the Same Kinds of Toxic Chemicals…

Polonium 210 (nuclear waste) Tobacco-specific N-nitrosamines or TSNAs Formaldehyde Nicotine Cadmium Cyanide Arsenic Benzene Lead

Leading Causes of Preventable Death:

1. Tobacco Use

3. Obesity

5. Secondhand Smoke

Secondhand Smoke-Did You Know That:

Children are twice as likely to develop cavities in baby teeth

¼ would not have developed cavities 50% of children in the U.S. are exposed to

secondhand smoke

There is No Safe Level of Exposure to Secondhand Smoke.

It is a known cause of SIDS

Children are more likely to have lung problems, ear infections, and severe asthma

Even a brief pass through drifting tobacco smoke can be harmful

What the Science Says

Most children breathe SHS in their homes

Almost 3 million children in the U.S. under the age of 6 breathe SHS at home at least 4 days per week

40-59% of all youth in the U.S. live in homes where others smoke in their presence

38,000 – 65,000 people die each year from heart disease and lung cancer caused by passive smoking

In the United States:

Tobacco Industry Marketing

$516 million annually is spent on cigarette advertising and promotion in NYS

Point-of-purchase ad

Magazines Ad’s in Clinical or Residential Areas

The Brain and NicotineThe Brain and Nicotine

Nicotine and other Nicotine and other Addictive DrugsAddictive Drugs

Nicotine stimulates an increase in the release of dopamine, a neurotransmitter associated with feelings of pleasure.

Studies show that brain changes during withdrawal from nicotine are similar to those that occur when withdrawing from heroin, cocaine and alcohol.

Once inhaled, nicotine goes to the lungs and is easily absorbed into the blood stream, and routed directly to the brain.

This takes 7 seconds!

EASY COME

EASY GO

Liver, Lungs, Kidney’s……….

Mutant Enzymes

Neurotransmitter Neurotransmitter

Neuron Neuron Neuron

Neurons typically release a small amount of acetylcholine

Nicotine mimics the effects of the brain chemical acetylcholine

Within 10 seconds of inhaling a cigarette the brain is flooded with nicotine and a large release of acetylcholine.

Receptor Sites

Acetylcholine

The flood of nicotine signals the brain to release dopamine.

This happens with all addictive drugs. The brain becomes adjusted to high

levels of nicotine, dopamine and acetylcholine.

The problem: The brain can no longer be content with normal levels of acetylcholine.

Without nicotine the smoker experiences withdrawal, increased nervousness, lack of concentration and craving.

These symptoms subside within a month

Nicotine activates the release of dopamine and then deactivates it’s release.

The first cigarette of the day is the most enjoyable but as more are smoked enjoyment subsides.

This is called tolerance. It fades overnight. The next morning the dopamine cells are once again kicked up a notch and then kicked down.

ToleranceTolerance

The Cycle:

Nicotine use for pleasure, enhanced performance,mood regulation

Tolerance and physicaldependence

Nicotine abstinence produces withdrawal symptoms

Nicotine use to self-medicate withdrawalsymptoms

Benowitz NL. Med Clin North Am. 1992; 76: 423.

Nicotine Affects Brain Emotions

Regulating mood

Controlling anger and anxiety

Acting as a stimulant or relaxing a person depending on the situation

Providing a sense of control

Nicotine Affects the Body

Increasing metabolism

Decreasing appetite

Dulling the sensation of pain

Producing a slight high

Physical Withdrawal Symptoms

Sweating Weight gain Cough Nausea Fatigue Drowsiness

Constipation / diarrhea Muscle aches / cramps Excessive saliva Warmer hands and feet Runny nose Sensory changes in the

mouth and nose

Psychological Withdrawal Symptoms

Anxiety Irritability Restlessness Depression Anger

Intense cravings Reduced coping ability Feeling weepy Listlessness Trouble concentrating

The Cycle Triggers

The longer one smokes, the more dependent he / she becomes; the occasional cigarette becomes 20 to 30 each day

Positive effects [physical, social] reinforce smoking behavior

Repetition of use in specific situations create strong associations [triggers]

– After meals -While driving -Talking on the phone– Breaks during the work shift -Morning cup of coffee

Tobacco dependence demonstrates features of a chronic disease

Long term disorder Periods of relapse and remission Requires an ongoing rather than acute care

Tobacco Dependence as a Chronic Disease

Nicotine Addiction Is Classified As Nicotine Use Disorder in DSM-lV

***Criteria Includes Any 3 During a 1-year Time Span***

Tolerance to nicotine with decreased effect and increasing dose to obtain same efficacy

Withdrawal symptoms after cessation Smoking more than usual Persistent desire to smoke despite efforts

to decrease intake Extensive time spent smoking or

purchasing tobacco Postponing work, social, or recreational

events in order to smoke Continuing to smoke despite health

hazards

The 12 Truths The 12 Truths About SmokersAbout Smokers

What Every Hygienist Needs to Know for Treating Patients Who Smoke

Truth # 1 People don’t start smoking, they have one or two.

Most addictive substance on the planet More addictive than heroin and cocaine It is harder to quit than heroin Dopamine: ‘Dopaminergic Effects’

Percent of Those Ever Using Who Become Addicted

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

Alcohol Cocaine Heroin Tobacco

Abstinent Rate at One Year for Heroin, Smoking & Alcohol

0%

5%

10%

15%

20%

25%

30%

35%

Heroin Alcohol Smoking

Truth # 2People who smoke wish that they didn’t

No one ever says, “I’m glad I started this.” 70% state they want to quit American Cancer Society did a study and

reported that 95% of smokers wished to have their smoking removed

Truth # 3Smokers feel like second class citizens

Corralled outside to smoke Comments/complaints from others They feel weak-minded: “I can’t do this.” Even more so for pregnant women who

smoke

Truth #4Ex-smokers do not “go back” to smoking, they have “just one.”

Why can’t an ex-smoker have “just one?” Because it’s 100x easier to have the next

“just one.” “Therein lies the rub.” Increases

exponentially

Truth #5But if you do have one…

Slips are normal, if not expected Many quitters who slip experience extreme

guilt Does not mean relapse Prepare ahead of time and create a “slip

plan.”

Truth #6When a smoker quits it’s a miracle

There is no success formula Motivators are different for everyone Seasoned cessation counselors have

learned not to predict

Truth #7Smokers do fear the harm that cigarettes cause

They often will not verbalize it, but smokers know it’s potentially causing harm

Important to be sensitive to this Denial

– Psychologically Protects– Perpetuates compulsion

Truth # 8People smoke because it is too uncomfortable not to. It is an addiction.

Physical dependency– Interacts with CNS receptors.– Facilitates release of neurotransmitters: dopamine,

norepinephrine, acetylcholine, glutamate & serotonin.– Produces pleasure, arousal, relaxation, improves

concentration, reduces anxiety & prevents weight gain– Dependence produced is similar to that of opiates & cocaine– Psychoactive effects causes smoking behavior to be

reinforced

Truth # 9Cigarette smoking is a habit the size of Texas!

Let’s do the math – for the patient who smokes 1 ppd:

1 cigarette = 12 drags

20 cig./day x 12 = 240 drags/day240 x 365 days = 87,600 drags/year87,600 x 20 years = 1,752,000 drags

Truth # 9Cont’d

For the patient who smokes 2 ppd:1 cigarette = 12 drags

40 cig./day x 12 = 480/day480 x 365 days = 175,200/year175,200 x 20/years = 3,504,000

*Each smoking event is connected to the smoker’s daily rituals*

Truth # 9Cont’d

When a smoker quits they are literally bombed with triggers.

“It’s time to smoke.... No, I quit.”

Truth #10Cigarette smoking is a psychological dependency

People smoke when they are happy, sad, angry, lonely, tired, excited…

Smokers consider their cigarettes a friend; a friend who is always there and never talks back.

They have a smoking voice in their head.

Truth # 11Smokers hate being controlled by cigarettes

Smokers don’t have a choice – they have to smoke. If they don’t, they feel awful

Smokers know they are owned by the pack of cigarettes

The addiction demands a certain amount of cigarettes be smoked every day.

Truth # 11Cont’d

The expense of smoking is motivational for many younger smokers

1 pack = $5.00/day $35/week = 4 bags of diapers $280/month = ½ rent $1,825/year = buy a used car $36,500/20 years = college education

Truth #12To allow is to teach

Health care professionals have significant impact on a patient’s smoking

Smoking must be addressed at every patient visit

Sharpen Your Pencils…!

Morning Break

Effects of Tobacco on Teeth and Oral Health

What Every Dental Hygienist Should Be Familiar With

Esthetics:

– Discoloration of teeth, dentures, and restorations– Excessive wear on teeth– Halitosis – Cleft lips and palates are twice as common

amongst children born to mothers who smoked during pregnancy

– Overgrowth of the papilla of the tongue surface– Higher levels of calculus formation

Christen AG, Klein JA. Tobacco and Your Oral Health. Quintessence Book, Illinois; 1997

More Effects on Teeth and Oral Health

Periodontal diseases– Periodontitis– Gingivitis– Acute necrotizing ulcerative gingivitis (ANUG)

Dental implants– Damaging to both the initial and long-term

success of…– Delayed wound healing / less favorable treatment

outcomes

Bain CA, Moy PK. The association between the failure of dental implants and cigarette smoking; Int J Maxillofac Implants. 1993; 8:609-15

More Effects on Teeth and Oral Health

Dental caries Salivary changes Candidasis Leukoplakia Malignancies

Oral Leukoplakia

Most common potentially malignant lesion defined as a predominantly white lesion of oral mucosa that cannot be characterized as any other definable lesion

Site Of The Oral Cavity Affected By Leukoplakia

Lateral tongue and floor of mouth in cigarette smokers

Palate in pipe smokers and reverse smokers …. smokers palate

Commissures in bidi smokers

Site Of The Oral Cavity Affected By Leukoplakia

Buccal groves in tobacco chewers where they park the chew

Lower or upper labial mucosa in snuff dippers

Oral Cancer Facts

Survival rate has not changed significantly in over 40 years

Late detection: 70% of oral cancer lesions are identified in stages III and IV

50% 5-year survival rate; poor quality of life

Oral Cancer Risk by Patient Profile

High risk– Patients age 40 and older– Tobacco users (any type, any age, within 10

years)

Highest risk– Patients age 40 and older who use tobacco

Consumption of alcohol increases risk 15x

– Patients with history of oral cancer

High Risk Sites for Oral Cancer

Lateral tongue Lip Anterior floor of the mouth Soft palate, including anterior and posterior

tonsillar pillars and uvula

How Does Oral Cancer Present?

A lump on the lip, or in the mouth, or in the throat

A sore on the lip, or in the mouth, or on the tongue, that does not heal

How Does Oral Cancer Present?

A white or red patch or black spots on the gums, tongue, or lining of the mouth Unusual bleeding, pain, or numbness in the mouth A sore throat that does not go away or a feeling that

something is 'caught in the throat'

Silverman Oral Cancer 5Silverman Oral Cancer 5thth Ed. Ed.

How Does Oral Cancer Present?

Difficulty or pain while chewing or swallowing Swelling of the jaw that causes dentures to

fit poorly or fall off or become uncomfortable. A change in the voice or pain in the ear

These symptoms can also be caused by other less serious problems

It is important that a health care professional determine the cause of these symptoms early as possible

Tobacco Intervention

The Dental Office is an Excellent Venue for Providing Tobacco Intervention Services

Dental Hygienists / Dentists are in a prime position to show patients the health effects of tobacco use

You can be as effective – if not more so – than primary care physicians in helping patients quit tobacco

“Cold Turkey” 2 – 4% quit rate Brief Advice [1 – 3 minute intervention by a

clinician] 3 – 6% quit rate Behavioral Counseling:

– Dose related: Quit rate increases with time spent– 10 – 15% quit rate

Pharmacotherapy + Counseling 20 – 30% quit rate

Interventions are Powerful:Provider Intervention Quit Rates

The Good News:

More than 50% of patients who smoke make an annual visit to the dentist

Dental hygienists / dentists are more likely to see adults for routine care on an annual basis

Patients do have increased success rates with tobacco cessation with brief interventions from dental hygienists / dentists

Tobacco Interventions

75% of health care providers THINK it is a good idea

However, only 10% routinely do it—Why ?

Common Reported Barriers for Not Helping Patients Quit

Not enough time / too busy Lack of knowledge No financial incentive Many tobacco users cannot / will not quit Stigmatizing tobacco users Respect for Privacy Fear of scaring patients away Personal beliefs / smoking habits

Precontemplation Contemplation Preparation Action Maintenance Relapse

Behavior Change: A Process, Not a Single Act

Not interestedThinking about it

I’m ready Doing it Living it Try again

Stages of Change

Movement through stages

The progression through stages are not necessarily forward.

2 steps forward, one back. Any progress increased the likelihood of future

success. The circle is more like an upward spiral.

American Cancer Society, Living Well, Tobacco Free

Goal of Treatment

Goal is to move people along the stages.

Even if people do not quit, our interventions can move them to the next stage.

Movement = success

Both the Hygienist and the Patient Bring Things to the Table:

Hygienist:– Medical information– Statistics– Research Results– Experience– Community resources /

“tools” for the patient

Patient:– Unique circumstances/

personal experiences– Values– Life priorities

1. Identify patients who use tobacco

2. Talk with them briefly

3. Provide assistance with quitting or a motivational intervention

Components of a Brief Intervention

Focus on the patient’s strengths Respect the patient’s autonomy & decisions Make interventions individualized Use empathy, not authority or power Recognize that addiction exists along a continuum Accept treatment goals that involve incremental

steps toward the ultimate goal

Motivation is a Key to Change

It’s How You Approach Patients About Their Tobacco Use

In the “spirit” of gentle guidance

Why Patients May Become Resistant/ Defensive When You Address Their Tobacco Use:

Causes:– Take control away– Misjudge importance,

confidence, or readiness– Meet force with force,

lecturing

Strategies:– Emphasize personal

choice and control– Reassess readiness,

importance, confidence– Avoid arguing; use

reflective listening

Motivational Interviewing

“On a scale of 0 – 10, how important is it for you to make a quit attempt?”

On that same scale, how confident are you?

(2) (1) (3)

0 1 2 3 4 5 6 7 8 9 10

Just Remember – Avoid the following Assumptions:

The patient wants to change The patient ought to change – in a particular

way Health is the prime motivating factor If the patient doesn’t decide to change during

this visit, the practitioner has failed

Public Health Service Guidelines: The 5 ‘A’s

Ask your patient if he / she uses tobacco Advise the patient to quit Assess the patient’s readiness to quit Assist the patient with the quitting process Arrange for follow up

“Do you use tobacco in any form?” “Have you ever used tobacco in the past?” “How many cigarettes / cigars / bowls of pipe

tobacco do you smoke per day?” If the patient uses spit tobacco:

– “How many cans of snuff do you use per day?”– “How many pouches of chew do you use per

week?” “Do others in your household use tobacco?”

Ask

Asking Youth About Tobacco:Starting the Conversation

Interview pre-teens privately and explain that you ask all patients the same questions

Start with open-ended, less personal questions, then progress to more difficult ones

Consider age and risk factor when shaping the discussion

First, ask about attitudes / tobacco knowledge / friends’ use / peer pressure to experiment, then ask about actual use / history

Advise

The Advice Should Be:– CLEAR– Strong– Personal

“I think you should ______” Emphasize that tobacco use is bad for their health,

and focus on short-term risks:– Makes clothes / breath / hair stink– Will not allow you to perform in sports as

well– Talk about the cost factor $$$

Discuss ways to resist peer pressure Offer free educational materials Reinforce positive messages within the office

Advising Youth

ASSESS

Ask every patient if they are willing to make a quit attempt

Not all patients are ready quit, you can assist those patients with the motivational interviewing

Assist

“Whether or not you are ready to quit, I can help you. Let me give you the phone number for the statewide quitline. You can receive free counseling on how to quit and remain tobacco-free

Arrange

Schedule follow-up contact, either in person or via telephone

An Abbreviated, Approach

Ask the patient if he / she uses tobacco Document tobacco use status at each visit

Advise the patient to quit Refer the patient:

– NYS Smokers’ Quitline– Fax-to-Quit Program– Group Support Programs– Medications

Motivational Interviewing Summary

It is important for dental hygienists to routinely address tobacco use with patients

It can sometimes be difficult to intervene effectively It’s critical to meet patients ‘where they are at’ A patient-centered approach like MI can improve the

effectiveness of reaching out to patients in this area The New York State Smokers’ Quitline should be

included in all tobacco dependence interventions

Lunch Time…Enjoy

Resources to Help Tobacco Users Quit:

-Services of the NYS Smokers’ Quitline-Medications

Free and confidential program that provides evidence-based tobacco cessation services to New York State residents who want to stop cigarette smoking or other forms of tobacco.

What is the New York State Smoker’s Quitline?

In operation since 2000 Based at Roswell Park Center Institute,

Buffalo Serviced ~400,000 calls

– Hours of Operation: Live Specialist Support

– Monday – Friday: 9am – 9pm– Saturday – Sunday: 9am – 1 pm

Taped Message Library: 24 hours / 7 days Tip of the Day: 24 hours / 7 days

Quitline Overview

A Brief Video Brought to You by the New York State Smokers’ Quitline

Free and confidential services Free NRT starter kit for eligible callers Resources for all healthcare settings Evidence-based services Referrals to local community supports /

programs Information on NYS health plans’ cessation

coverage

Services of the Quitline

Quitline “Dos and Don’ts”

Print or write legibly on the referral form

Complete all blank sections on the form whenever possible

Refer patients as often as they request

Advise patients that they can call as often as needed

Expect a faxed progress report sent back on the patient’s tobacco use status

Do NOT limit the number of patients a health care provider may refer

Do NOT refax forms or information that was previously submitted

Do NOT “promise” patches or confirm eligibility – this will be done by a Quitline Specialist

NRT: Nicotine Replacement Therapies

Medications to treat tobacco dependence

Reduce withdrawal symptoms

Steady dose or self-administered

Scheduled basis tapered discontinued

Nicotine Replacement Therapy (NRT)

Did You Know…

There are seven first-line pharmacotherapies available to help tobacco users quit

Pharmacotherapy is safe and highly effective

Dentists can prescribe NRT

By Definition, the Scope of Dentistry Says:

§ 6601. Definition of practice of dentistry. The practice of the profession of dentistry is defined

as diagnosing, treating, operating, or prescribing for any disease, pain, injury, deformity, or physical condition of the oral and maxillofacial area related to restoring and maintaining dental health. The practice of dentistry includes the prescribing and fabrication of dental prostheses and appliances. The practice of dentistry may include performing physical evaluations in conjunction with the provision of dental treatment.

Nicotine Replacement Therapy

No evidence of increased cardiovascular risk

Medical contraindications: Immediate myocardial infarction [< 2 weeks] Serious arrhythmia Serious or worsening angina Accelerated hypertension

OTC– Nicotine Patch, Gum, Lozenge

Prescription– Nicotine Inhaler, Nasal Spray– Bupropion, Varenicline [non-NRT medications]

Nicotine Replacement Therapies

Nicotine Transdermal Patch

Use:– Apply to clean skin [upper trunk / arms / back]– 24 hours or 16 hours– Rotate sites– Taper dosage over 4 – 6 weeks [21mg; 14mg; 7mg]

Advantages:– Over the counter– Place and forget

Disadvantages:– Passive– Local irritation [treat with steroid cream]

Nicotine Gum

Use:– Chew and park [oral absorption]– PRN or fixed schedule [every 1 – 2 hrs, no more than 24

pieces/day] Advantages:

– PRN use [active]; less weight gain Disadvantages:

– Avoid food / beverage around use– Hard to chew – jaw pain– Nausea

Dosing – based on time of first cigarette (TTFC)– Within 30 minutes: 4 mg– Over 30 minutes: 2 mg

Use: 9 – 15 lozenges / day for 6 weeks; taper over the next 6 weeks

25% higher blood nicotine levels than gum, otherwise similar

Allow to dissolve – don’t chew

Nicotine Lozenge

Use:– ‘Puff’ [oral absorption]– PRN or fixed schedule [max. of 16 cartridges/ day]– 1 cartridge = 30 minutes of puffing

Advantages:– PRN use (active)– Oral / hand behavior

Disadvantages:– Throat irritation / cough – first few days– Visible

Nicotine Oral Inhaler

Use:– Spray [do not sniffle / inhale]– PRN or fixed schedule [1 – 2 doses / hour]

Advantages:– Rapid onset– PRN use [active]

Disadvantages:– Irritations; caution with sinusitis, rhinitis

– Some potential for dependence

Nicotine Nasal Spray

AKA Zyban or Wellbutrin SR Dopaminergic effects Reduces cravings, withdrawal Less weight gain while using Use:

– Start 7-10 days prior to quit date– Continue for 7-12 weeks or longer (>6 months)

Bupropion SR

Contraindicated: seizure disorder, eating disorders, electrolyte abnormalities, MAO use

NOT dangerous to smoke while taking Monitor blood pressure Side effects:

– Insomnia (2nd dose early evening helps)– Dry mouth; headaches; rash

Bupropion Precautions

FDA approved May, 2006 Mechanism: Partially activates nicotine receptor in

brain Blocks reinforcing effects if patient smokes during

treatment Compared to Bupropion: Nearly doubles chances of

quitting Compared to placebo: Nearly quadruples chance of

quitting

Varenicline (ChantixTM)

Use:– 0.5 mg/day – days 1-3– 0.5 mg twice / day – days 4-7– 1 mg twice / day – day 8 until end of treatment– Course of treatment – 12 weeks; may be extended for an

additional 12 weeks Side effects:

– Nausea, changes in dreaming, constipation, gas, vomiting Not recommended for patients under age 18 FDA does not recommend this be used with any

other stop-smoking drug

Varenicline (ChantixTM)

Pharmacotherapy should be considered only when they have been unable to quit without it

The healthcare provider and patient must weigh the risks and unknown efficacy of NRT in pregnant women against the substantial risks of continued smoking

Assisting Special Populations:Pregnant Women who Smoke

Health care providers may consider NRT when other behavioral treatments have failed

No evidence that NRT is harmful for adolescents

Bupropion and Varenicline are not recommended for adolescents

Adolescents

Multiple Pharmacotherapy

Bupropion may be combined with any of the NRTs; Varenicline should not be combined with NRT

Combination NRT– Patch + gum or patch + nasal spray is more

efficacious than a single NRT– Encourage in patients unable to quit using

single agent– Caution patients on risk of nicotine overdose– Combined NRT not currently FDA approved

Off-Label Dosing and Use of NRT

Use of a drug “off-label” does not require FDA approval

Off-label use of NRT is common and may be essential for effective medical management of treating tobacco dependence– Typical: Advising a patient to use 2 patches if

he/she smokes 2+ ppd

JAMA 1995;274:1347,1353,1390. N Engl J Med 1995;333:1196. Arch Intern Med 1995;155:1933.

NRT does not cause cancer! Be aggressive with NRT to evaluate what works best

for the patient Most patients are under-medicated Consider combining medications Targets to achieve:

– Relieve Withdrawal– Control Cravings– Abstinence

NRT: In Summary

Preventing Relapse

Most relapses occur within the first 3 months Relapse interventions for patients who have

recently quit:– Congratulate patient on successes– Discuss health and benefits & success of

cessation– Discussion of threats to maintaining abstinence

Frequently Asked Questions

Relevance Risk Rewards Roadblocks Repetition

What if my Patient Doesn’t Want to Quit?

Encourage the patient to indicate why quitting is personally relevant

Provide motivational information that is relevant to the patient’s status, risk, family or social situation, health concerns

Explain that tobacco use is not the social norm

Relevance To Each Patient

Ask patients to identify potentially negative consequences of tobacco use that are relevant to the patient

RiskOf Continued Smoking / Tobacco Use

Ask patients to identify potential benefits/rewards of stopping tobacco use

Highlight those that seem most important to your patients

RewardsOf Quitting

Ask patients to identify barriers to quitting and note treatment options to address barriers [i.e. pharmacotherapy, group support, etc]

RoadblocksAddress Barriers

Motivational interventions should be repeated every time a patient visits the clinic setting. Tobacco users who have previously relapsed should be told that most people make repeated attempts before long-term cessation success occurs

RepetitionAt Every Visit

Do Insurance Companies Cover the Different Nicotine Replacement Medications?

New York Medicaid covers all stop smoking medications except the lozenge. Patients must have a prescription and a pharmacist will fill it

Capital District Physician Health Plan [CDPHP] covers Inhalers, Nasal Spray, and Zyban

[January 2006] Medicare covers all medications

Blue Shield covers all medications including OTC – prescription needed. Must show proof of enrollment in a cessation program.

MVP covers Zyban, patches, gum, & lozenge. They will cover 2 cessation courses per year, and patients must have a drug rider on their policy

Medications Coverage Con’t

Can We Refer a Patient Who Has no Health Insurance?

Absolutely!

Fax-to-Quit is for any resident of New York State who would like to stop using tobacco

Once they receive the signed consent form, they will contact the patient within 3 days; they will then send your practice a progress report on the patient via fax

How Can My Practice Incorporate a System So That We Continue to Address Tobacco Dependence?

Consistent tobacco user identification and treatment

Dedicate staff to provide tobacco dependence treatments

Provide education, resources, and feedback to promote provider intervention

Clinical Case Studies:

How would you help the following 3 patients quit tobacco?

Evidence Shows

Advice works Systems in place support behavior change Patient satisfaction increases Cessation medications increase quit rates Cessation is cost-effective

We need to encourage a culture of health care in which failure to treat tobacco use – the chief cause of preventable death and disease – constitutes an inappropriate standard of care. If every physician, dentist, nurse, dental hygienist…across America uses this tool, we would double quit rates, from one to at least two million new quitters each year.

Michael Fiore, MD, Principal author, Clinical Practice Guidelines, Treating Tobacco Dependence. 2000.

Taking <1 minute to refer patients to the quitline might be the most effective way to help save lives

Tobacco dependence treatment is effective, doable, and of service to patients

It’s good customer service It’s good medicine…and it’s the right thing to

do.

In Summary…

For More Information, Questions or Comments, Contact the ‘Empire Challenge’ Initiative:

Tavia Rauch, BA, CRTProject Coordinator

Seton Health’s Center for Smoking Cessation849 2nd Ave Troy, NY 12182

Ph: 518-268-6165 Cell: 518-810-4903Fax: 518-268-5864

E-mail: [email protected] the Dental Pages on our Website:

www.Quitsolutions.org

Wrap Up

Questions?

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Thank you for your time…and thank you for helping to save lives