Tobacco Cessation

What makes smokeless tobacco 'safer' than smoked tobacco?

Takes longer to cause cancer (but still causes cancer) since there is a lack of combustion products, but the silicates used to cut mucosa means that everything enters the bloodstream more quickly

What should you warn your patient about when recommending nicotine gum?

The gum is hard to chew, if the patient has TMJ problems then this likely isn't a great choice

Why is tobacco cessation important?

Smoking related issues are the leading preventable cause of premature death in the US -Average years lost of life is 10 -1 person dies every hour from oral cancer -4 people per hour are diagnosed with head and neck cancer

Bupropion SR

Monocyclic antidepressant approved by the FDA for smoking-cessation

Is smokeless tobacco a safe alternative to smoking?

NO

How does physical addiction occur when using tobacco?

Nicotine binds to nicotinic receptors in the brain causing release of dopamine and other NTs which produce reinforcing effects of pleasure, appetite suppression, stimulation, arousal, cognitive enhancement, mood modulation and improved memory

What is the only long acting nicotine replacement therapy?

Nicotine patch

Is there any evidence of increased cardiovascular risk with NRT (excluding acute disease)?

No

Assist (ADA's 5 A's)

Offer medication and counseling, use if-then planning

1 can of dip or chew contains how many mg of nicotine? What is this equivalent to in terms of cigarettes?

-144 mg of nicotine -1 can of dip = 80 cigarettes (4 packs)

Chantix MOA

-Antagonist which blocks nicotine from binding (makes smoking less pleasurable) -Agonist which causes release of dopamine to ease cravings and withdrawal symptoms

How is the dental team in a good position to promote tobacco cessation?

-Appeal of esthetics in conjunction with the practice of dentistry for some patients -22-40 year old population are more likely to have regular dental visits than physician visits -Recurrent dental visits provide opportunities to discuss and evaluate cessation -Tobacco prevention and cessation improves oral health

ADA's 5 A's

-Ask -Advise -Assess -Assist -Arrange

Advantages of Bupropion SR

-Available generic -Can be combined with NRT -Attenuates weight gain during treatment -Works well in patients who struggle with depression, anger or irritability

Smoked Tobacco Products

-Cigarettes -Cigars -Hookah

What should you educate your patient about when they are taking Chantix?

-Common side effects include nausea, insomnia, headache and abnormal dreams -If allergic reactions occur, discontinue use and contact health care provider

Things to Avoid in Motivational Interviewing

-Confrontation -Education -Authority

Disadvantages of Bupropion SR

-Contraindications and drug interactions (lowers seizure threshold) -Side effects include headache, dry mouth, insomnia and weight loss -If allergic reactions occur, discontinue use and contact health care provider

Factors to Consider for Pharmacotherapies

-Contraindications for individual patients -Patient preference -Patient previous experience with medications -Co-morbidities (alcohol or drug use, history of depression, concern of weight gain, etc.)

Nicotine Withdrawal Effects

-Difficulty concentrating -Irritability -Insomnia -Increased appetite -Weight gain (~5 pounds in the following months) -Depression -Drowsiness -Nervousness -Fatigue -Headache

What issues are associated with tobacco use?

-Diseases of the heart -Malignant neoplasms -Chronic lower respiratory diseases -Cerebrovascular diseases

Patient Instructions for Nicotine Lozenge

-Do not chew or swallow the lozenge -Move the lozenge to different areas of the mouth -Lozenge dissolves in 20-30 minutes -Do not consume acidic food or beverages 15 minutes before or during use

Principles of Motivational Interviewing

-Goal is to elicit change talk -Express empathy -Develop discrepancy -Roll with resistance -Support self-efficacy (pt must believe change is possible) -Collaboration -Evocation -Autonomy

Patient Instructions for Nicotine Gum

-Have the patient chew the gum then place it in the vestibule -Gradually increase the interval between doses

Advantages of Chantix

-Highest abstinence rates of any mono-therapy -Helps patients reduce alcohol use

Lung Injury and E-Cigarettes

-If devices are altered to include different products then it can cause issues -Vaping-related pneumonia

Major Medical Contraindications for Pharmacotherapies for Tobacco Cessation

-Immediate myocardial infarction (<2 weeks) -Serious arrhythmia -Serious or worsening angina pectoris -Accelerated hypertension

Nicotine Effects

-Increase in HR and BP -Enhances information processing -Reduces fatigue -Sedative action -Reduces anxiety -Induces euphoria

Evidence on E-Cigarettes

-Increases likelihood that a person will smoke -Limited evidence on long-term health risks since they are relatively new products

Chantix Length of Therapy

-Minimum 3 months -Higher abstinence rates for some patients at 6 months

Main Points on Cessation

-Most patients WANT to quit -Counseling + medications is the most effective treatment -Utilize resources such as Quitline and TTP -1 can of dip = 4 packs of cigarettes -Ambivalence in motivational interviewing (develop discrepancies) -Dental visits provide unique opportunities to approach cessation talks

Nicotine Replacement Therapies (NRT)

-Nicotine gum (OTC) -Nicotine lozenge (OTC) -Nicotine inhaler (Rx) -Nicotine nasal spray (Rx) -Nicotine patch (OTC)

Tips to Promote Successful Cessation Interactions

-Non-threatening, caring interpersonal atmosphere -Approach questions like any other routine health history question -Address benefits of cessation -Establish eye contact and verbalize concerns for well-being -Present findings in a gentle, informative manner -Assure patient condition will likely improve after quitting -If patient is not interested, drop it and let them know to contact you if anything changes

Advantages of NRT

-Provides addictive substance w/o toxic and carcinogenic agents -Does not introduce a new drug -Allows flexible dosing and gradual reduction -Attenuates weight gain during treatment -Much lower addiction potential than cigarettes -Minimal side effects ensure proper usage

Precautions for Chantix

-Screen for psychiatric illness or self-harm behaviors -Screen for severe renal impairment -Use restricted in certain professions

The tars are _____________________ and the nicotine is _________________

-Tars = carcinogenic -Nicotine = addictive

How many years does it take after cessation for the risk of lung cancer to decrease to the same amount as a non-smoker?

15 years

When is NRT not recommended?

Adolescents or women who are pregnant/breastfeeding

Chantix

Alpha-4-beta-2 nicotinic acetylcholine receptor partial agonist

Ambivalence

Arises when there is a discrepancy between values and behaviors, must be resolved in order for behavior change to occur

Arrange (ADA's 5 A's)

Arrange follow-up

Assess (ADA's 5 A's)

Assess readiness to quit and past quit attempts -Reinforce reasons they may be ready to quit, explore their reasons as part of motivational interviewing -Ask about what went wrong with past quit attempts

Nicotine Lozenge Dosage

Based on the time to first cigarette -1st cigarette more than 1 hour after waking is 2 mg -1st cigarette within 30 minutes of waking is 4 mg

Would you expect dosage of nicotine replacement therapies to be higher in people who use smoked or smokeless tobacco?

Smokeless tobacco

Disadvantages of Chantix

Cannot be used with NRT

Motivational Interviewing

Client-centered collaborative approach to enhance intrinsic motivation to change by exploring and resolving ambivalence

D1320

Code for tobacco counseling for the control and prevention of oral disease

What is the standard of care for tobacco cessation?

Counseling + NRT combination or Chantix

What is the most effective treatment for tobacco cessation? (likely test question)

Counseling + medication -Pharmacotherapy plus counseling doubles quit rates

Silicates in Smokeless Tobacco

Cut the mucosa to allow the products to enter the bloodstream more quickly -Why smokeless tobacco is said to give a better high than smoked tobacco

Nicotine Transdermal Patch Dosage

Determined by cigarettes per day or cans/patches per week

Nicotine Gum Dosing

Dosage is dependent on the tobacco use of the patient, heavier smokers require more drug during withdrawal

How much nicotine can a cigar contain in comparison to a cigarette?

Due to the wider diameter, one cigar can contain as much nicotine as an entire pack of cigarettes

(T/F) Both Chantix and Bupropion SR can be combined with NRTs to make them more effective

False -Chantix cannot be combined with an NRT

E-Cigarettes

Heats a liquid solution into an aerosol

Ask (ADA's 5 A's)

Identify and document tobacco use status and amount for every patient at every appointment

What are some examples of if-then planning?

If I feel stressed and want to smoke, then I will practice deep breathing instead

Alcohol and Smoking

Two behaviors are often associated with each other, using both at greater amounts doubles the risk of oral cancer -Alcohol alone is weaker factor in oral cancer, but when combined with tobacco it increases risk

Advise (ADA's 5 A's)

Use a strong, clear and personalized message urging them to quit -Important to let them talk to get background information that can be useful in future conversations

When doing a history and your patient states they quit using tobacco, what would your next question be?

What was the quit date (years, months, or days ago?)