M7- The Patient Who Uses Tobacco

coronary heart stroke lung cancer coronary heart

1 year after quitting, _____________________ disease is half that of a smoker's 5 years after quitting, _________ risk is reduced to that of a non-smoker After 10 years, the _____________ death rate decreases by almost half After 15 years, the risk of ___________________disease is that of a non-smoker

100-200 times

45 min. - 1 hr. of smoking hookah is equivalent to inhaling _________________ the volume of smoke from one cigarette.

nicotine patch 50% Insomnia// vivid dreams

A ________________ is a transdermal patch that releases nicotine into the body through the skin Side effects Skin reactions: Up to ____% of patients experience a local skin reaction Reactions are usually mild _______________ and/or ______________

nicotine lozenge lining // blood vessels nausea, hiccups, and heartburn

A __________________ is a tablet (usually flavored) that contains a dose of nicotine which dissolves slowly in the mouth to release the nicotine The nicotine is absorbed through the ___________ of the mouth and enters the _______________ Side effects The most common side effects are _____________, ____________, and ________________

80% / cotinine Lungs

About 80% of nicotine is broken down to _____________ by enzymes in the liver The rest is metabolized in the _________

30%

About _____% of patients are current smokers

46%

About _____% of smokers try to quit in a given year The majority of smokers try to quit on their own

buccal absorption 15 $5

Acidic beverages (e.g., coffee, juices, soft drinks) interfere with the ____________________ of nicotine, so eating and drinking anything except water should be avoided for _____ minutes before or during chewing Cost Approximately $____/day for average usage during the first six weeks of use

tobacco cessation program

Advice from health professionals has been shown to be a powerful influence on patients' decisions to stop or not begin using tobacco Dental hygiene professionals are in an ideal position and have a responsibility to provide patients who use tobacco with the opportunity to enter a _____________________

caring, compassionate stains, calculus, periodontal disease, and abnormal lesions future health / others existing conditions

Advise Advise every patient about tobacco use Present the advice in a ______, ____________________ manner so patients realize you are interested in their health and well-being Show patients existing conditions such as __________, ______________, _____________________, and ________________ These serve as strong motivators in getting a patient to quit Generally, patients are not impressed by a discussion of possible ________________ problems or of the effect of tobacco use on ____________ Advice needs to be relevant to __________________

8 // carbon monoxide circulation // lung coughing, sinus congestion, fatigue and shortness of breath

After 8 hours, the level of _________________ in the blood drops to normal Between 2 weeks and 3 months of quitting, _______________ improves and _____ function increases up to 30% Within 1 to 9 months of quitting, ____________ , ___________________, __________ and ___________________ decrease

oral, pharyngeal, and esophageal

All forms of tobacco (smoking or smokeless) are associated with ________, ___________________, and __________________ cancer

gingival recession hyperkeratosis

Almost half of spit tobacco users have ___________________ and ______________________ of the vestibular mucosa associated with use.

Ask Advise Refer

American Dental Hygienists AssociationAsk Advise Refer Model Simplifies tobacco cessation to a 3-step process ______ about tobacco use at every visit __________ tobacco users to quit ________ tobacco users to a state or national tobacco quitline 1-800-QUIT-NOW http://www.tobaccofreeflorida.com/

extraoral/intraoral examination That means your examination!

An _________________________ is the most efficient and effective method for detecting tobacco-related conditions in and around the mouth

calendar // reminder Following-up

Arrange Provide the patient with a _______________ page or other _________ showing the quit date Suggest posting it in a suitable place in the patient's home such as refrigerator door or bathroom mirror _________________ is essential A telephone call or e-mail assures the patient that your interest is sincere Ask if there are any questions

ethically obligated

As oral healthcare providers, dental hygienists are ______________________ to address clients' tobacco use and its relationship to their oral health and overall well-being.

moral and/or social issue Defensive Confidence ETS //children

Ask Ask all patients about tobacco use Address tobacco use as a health issue, not as a _________ and/or _______________ Obtain facts without placing the patient on the _______________ Obtain Patient's _____________ Many minors use tobacco without their parents' knowledge or consent Social disapproval of tobacco use is increasing, and patients may hesitate to disclose their habit Ask parents about tobacco use in the home Discuss effects of ______ on the health of their ____________

Are you ready to quit

Assess Ask the patient: "_______________________?" If the patient is ready: Determine if the patient could best be treated in your practice or necessitates a referral If treatment is to be provided in your office, go to the assist step

Quit Plan quit date 2 weeks understanding and support challenges / few weeks home and work sites

Assist Establish a _____________ Set a ___________ Preferably within ____ weeks Have the patient tell family, friends, and co-workers about quitting and request their __________________ and _________ Warn the patient to anticipate _________________ to the planned quit attempt, particularly during the first _______________ This includes nicotine withdrawal symptoms Ask the patient to remove all tobacco-related products from ___________ and ____________

eating // glass (8 ounces) of water twelve weeks Day 1-3 days // one tablet (0.5 mg) X1 a day Day 4-7 // one tablet (0.5 mg) X2 a day Day 8 // one blue tablet (1mg) x2 a day

Chantix Chantix is taken after ___________ and with a full ______________ Treatment is up to ___________ weeks Days ___-_____ one white tablet each day Days ___-____ one white tablet twice a day- one in the morning and one in the evening Days ___ - the end of the treatment ________________ twice a day- one in the morning and one in the evening

coarsely shredded tobacco leaf.

Chewing tobacco is a more ___________________ tobacco leaf Tobacco chewers place a "chaw" of loose leaf tobacco, or a "plug" of compressed tobacco, in the cheek.

kidneys tobacco passive or ETS (environmental tobacco smoke)

Cotinine is excreted via the ___________ in urine Urine can be tested to assess whether a person uses _____________ Urine testing can assess the level of exposure of nonsmokers to __________ or ________

nine 20 12

Dosage Generally, smokers should use at least ______ lozenges per day but no more than _____ lozenges per day in the first 6 weeks The lozenge should be used for up to _____ weeks

studied unknown

E-cigarettes have not been fully ___________ and the potential risks are unknown.

lower-cost (approx ½ the cost). smoking cessation lingering smoke smell social stigma

ENDS Provides a ______________ alternative to traditional smoking Used as a self-administered __________________ therapy. Does not result in ______________________ Carries less _________________ than smoking

FDA regulated/approved.

ENDS devices are not _______________

450,000

Each year, more than ________________ people die as a result of tobacco-related diseases.

higher amounts addictive \\ difficult

Eventually, however, because of nicotine dependence, many need to use products with _______________ of free nicotine. Brands with high levels of free nicotine are very _______________, making it _____________ for individuals to quit.

recall & record learning experience pharmacotherapy

Follow-up Congratulate and praise patients who have remained tobacco free If relapse has occurred, ask the patient to __________ and ___________ the circumstances that led to reuse Encourage the patient to set another quit date, reminding the patient that a lapse can be a ___________________ Review the use of _________________

1st End of 1st, 2nd, and 3rd

Follow-up Contact the patient once within the _____ week after the quit date when the patient's physical withdrawal symptoms are most intense, and again at the end of the ______, ______, & ______ months More than 4 contacts help to increase long-term abstinence

no less harmfu

Hookah smoking is ___________ harmful than other forms of tobacco use.

Relevance Rewards Roadblocks Repetition

If the patient is not ready to quit, use the "5 R's": __________________ : Pt identifies personal importance of quitting Risks: Pt identifies negative consequences of continued use ___________: Pt identifies personal benefits of quitting ______________: Pt identifies barriers to quitting (clinician helps address barriers) _____________: Reinforce the motivational message at every visit

Tobacco Master Settlement Agreement (MSA)

In 1998 there was a settlement entitled The ______________________________ It was between the four largest US tobacco companies and the attorney generals of 46 states The tobacco companies agreed to curtail or cease certain tobacco marketing practices, as well as to pay various annual payments to the states to compensate them for some of the medical costs of caring for persons with smoking-related illnesses This money also funds anti-smoking groups The settlement agreed to pay a minimum of $206 billion over twenty-five years

80,000

In 2014, an estimated ______________ high school students used dissolvable tobacco.

alkaline buffering agents.

Manufacturers control the amount of free nicotine available by adding ___________________ agents

"peppery" or "flavored" taste emerges // parked chewed and parked // 30

Nicotine Gum Chewing technique Gum should be chewed slowly until a ____________________, then "____________" between cheek and gum to facilitate nicotine absorption Gum should be slowly and intermittently "__________ and __________" for about _____ minutes or until the taste dissipates

tissues of the mouth Mouth soreness, hiccups, indigestion, and jaw ache

Nicotine Gum The nicotine is delivered to the bloodstream via absorption by the ___________________ Side effects ___________________, ____________, _________________, and ______________

4mg // 80 inhalations 6-16 cartridges 6 months six

Nicotine Inhaler Dosage Each cartridge delivers ____ mg of nicotine over _____ inhalations Recommended dosage is ___-_____ cartridges/day Recommended duration of therapy is up to ___ months Instruct the patient to taper dosage during the final 3 months of treatment Best effects are achieved by frequent puffing of the inhaler and using at least _____ cartridges/day

nicotine-containing nicotine aerosol oropharyngeal membranes pulmonary inhaler

Nicotine Inhaler It looks like a small cigarette holder and contains a chamber into which a _________________ cartridge is placed The cartridge is punctured when placed in the holder, making the ____________ available The nicotine becomes an ____________ when the individual inhales strongly on the holder The nicotine is then deposited on the ______________________ and is transferred into the bloodstream, similar to the gum It is not a true ___________________

40°F 15 mins $45.00

Nicotine Inhaler Prescribing Instructions The delivery of nicotine from the inhaler declines significantly at temperatures below ____°F In cold weather, the inhaler and cartridges should be kept in an inside pocket or other warm area, or should just be used indoors Eating and drinking anything except water should be avoided for ____ minutes before or during use Cost Approximately $_________/package (42 cartridges)

irritation Coughing and rhinitis mild// declines

Nicotine Inhaler Side Effects Local ____________ in the mouth and throat _________________ and ______________(irritation and inflammation of the mucous membrane inside the nose) Severity is generally ________, and the frequency of symptoms usually ____________ with continued use

more than 30 min within 30 minutes

Nicotine Lozenge Dosage Available in 2-mg and 4-mg (per piece) doses 2 mg for patients who smoke their 1st cigarette ________ minutes after waking 4 mg for patients who smoke their 1st cigarette _________ of waking

15 mins chew into small pieces / swallow fixed schedule $6 $12

Nicotine Lozenge Prescribing Instructions Same as gum, eating and drinking anything except water should be avoided for ____ minutes before or during use Allow lozenge to dissolve slowly; do not _______ and do not __________ the lozenge Similar to the gum, use the lozenge on a ________________ Cost Approximately $___/day for average usage (12 doses) and up to $____/day for maximum usage (20 doses) during the first six weeks of use

0.5 (1 mg total) 1-2 doses 8 // 40 100 3-6months

Nicotine Nasal Spray Dosage A dose consists of one ________-mg dose delivered to each nostril Initial dosing should be ___-____doses per hour, increasing as needed for symptom relief Minimum recommended treatment is ___ doses/day, with a maximum limit of ____ doses/day. Each bottle contains approximately _______ doses Recommended duration of therapy is ___-____ months

nasal irritation smell and taste reactive airway disease

Nicotine Nasal Spray Side effects Moderate to severe ___________________ especially in the first few days of use Nasal congestion and transient changes in the sense of ________ and _________ Nicotine nasal spray should not be used in persons with severe _______________________

faster overwhelming urges combination therapy

Nicotine Nasal Spray The nasal spray delivers nicotine to the brain ____________ than any other NRT It is particularly useful in patients with ________________________ It can be used with other nicotine replacement therapies in _________________________

rotating the site remove 16 hr (designed for use while the patient is awake)

Nicotine Patch Prescribing instructions At the start of each day, a new patch is placed on a relatively hairless location, typically between the neck and waist, ________________ to reduce skin irritation Patches should be applied as soon as the patient wakes With patients who experience sleep disruption, have the patient ___________ the 24-hour patch prior to bedtime, or use the ____-hour patch

Constant craving of cigarettes Insomnia Irritability Anxiety Frustration Anger Depression Difficulty concentrating Restlessness Decreased heart rate Increased appetite Fatigue

Nicotine Withdrawal Symptoms

12-24 2-4

Nicotine Withdrawal Symptoms Withdrawal peaks within ___-_____ hours and lasts ___-____weeks

dependence Nicotine dependence can occur with cigarette, cigar or pipe smoking, as well as smokeless tobacco use

Nicotine __________________ is nicotine tolerance combined with withdrawal symptoms if nicotine is removed

1 to 2 hrs 24 fixed schedule

Nicotine gum Smokers should use at least one piece every ___ to ___ hours for the first 6 weeks with no more than _____ pieces to be used per day Chewing the gum on a __________________ is more beneficial than using the gum when a person thinks he or she needs it

2mg / 4mg 2mg 4mg

Nicotine gum is available in __-mg and ___-mg doses ___-mg gum is recommended for patients smoking less than 25 cigarettes per day ___-mg gum is recommended for patients smoking 25 or more cigarettes per day

psychoactive (one that produces feelings of pleasure and well-being)

Nicotine is tobacco's _________________ agent, and its use leads to nicotine tolerance, dependence, and addiction

smoking smokeless brain body

Nicotine readily diffuses through the lungs (______________) and mucous membranes (________________) It moves into the small blood vessels in these tissues and travels through the bloodstream to the ________, and is then delivered to the rest of the _________

Bupropion hydrochloride (Zyban) non-nicotine Wellbutrin insomnia and dry mouth still smoking //quit date 7 to 8

Non-Nicotine Drugs ________________________________ was approved in 1997 to help smokers quit It is a ________________ pill which reduces craving for nicotine The drug is also sold as an antidepressant under the name __________________ Common side effects include ________________ and _____________ Treatment with this begins while the user is________________, one week prior to the _____________ Treatment is then continued for ____ to ______weeks

Verenicline (Chantix) neurochemical effects nausea, vomiting, and constipation one week Chantix

Non-Nicotine Drugs ______________________ is the newest drug (2006) approved by the FDA Binds to nicotine receptors to block the _______________________ Common side effects include _____________, _________________, and ______________ Treatment begins _____________ before the quit date This allows __________ build up in the body

20-25

On average, 50% of smokers lose ________ years of life expectancy.

one pack of traditional tobacco cigarettes.

One ENDS refill cartridge is roughly equivalent to ?

10 to 20%

Only ____ to _____% plan to quit in the next month

spit (or smokeless) loose tea bag-like sachet

Oral snuff and chewing tobacco, are also called _______ tobacco Snuff is a finely ground tobacco leaf, packaged either ____________ (A) or in a ____________________ (B) Snuff users place a small amount of snuff between the cheek and gum

tolerance

Over time, a given level of nicotine has less of an effect on the brain and a larger dose is needed to produce the same rewarding effects. This means the user needs more and more to achieve the same desired feeling of well-being. This is called ___________________

4 to 6

Overall, self-quitters have a success rate of ___ to ___% Half of all smokers eventually quit

4 weeks - 21mg 2 weeks - 14mg 2 weeks - 7mg

Patches of different doses are available Regimens are based on the amount smoked, the degree of dependence, etc. The average regimen; ___ weeks ____mg/24hrs ___ weeks ____mg/24hrs ___ weeks ___mg/24 hrs

types of tobacco (smoking and/or smokeless) and the amount (e.g. 1/2 pack a day) how long since quitting

Patient History The basic history form should include one or two questions to determine whether the patient currently uses tobacco and, if so, the ___________ and ___________ If a patient has stopped using tobacco (smoking or smokeless), note in the assessment tab ____________________

aldehydes ketones amines

Pesticides, __________________ (such as formaldehyde), ____________ (similar to solvents used in paint), and ____________ (derivatives of ammonia) are found in processed tobacco

Nicotine gum Nicotine patch Nicotine lozenge Nicotine inhaler Nicotine nasal spray Oral

Pharmacotherapies Over the Counter (OTC) ________________ _________________ __________________ Prescription __________________ ___________________ ___________

sniff, swallow, or inhale tilted slightly back $5 (13 doses) $15 (40 doses)

Prescribing Instructions Patients should not _____, _________, or __________ through the nose while administering doses, as this increases irritating effects The spray is best delivered with the head ____________________ Cost Approximately $____/day for average usage and up to $___/day for maximum usage

abstinence quit attempt challenges/triggers relapse another smoker

Provide Practical Counseling Total ________________ is essential: "not even a single puff or dip after the quit date." Review past _______________ and identify what helped and what factors contributed to relapse Discuss _______________\_____________ and how the patient will overcome them successfully Because alcohol can cause _____________, limit/abstain from alcohol use Quitting is more difficult when there is ________________ in the household Tobacco using housemates are requested to avoid use in the presence of the patient attempting to quit

pharmacotherapy Educational

Recommend the use of approved ______________________ Provide _______________ Materials Materials should be culturally and ethnically appropriate as well as targeted for different levels of education and differences in age Keep a supply of these materials in the office for distribution to patients

lower respiratory illness, middle ear infections, asthma, and sudden infant death syndrome (SIDS)

Results of epidemiologic studies provide strong evidence that exposure of infants and children to environmental tobacco smoke is associated with increased rates of __________________________, _________________________, ____________ ______ and _______________________________ (_________)

87%

Smoked tobacco is responsible for ______% of lung cancers.

environmental tobacco smoke (ETS)

Secondhand smoke, also known as _____________________________, is a general term for any smoke that non-smokers are exposed to

cold turkey tobacco exposures / lower nicotine patches, gum, or lozenges family member or friend

Self-Help Intervention Methods Go ___________ Reduce the number of daily ______________ and/or purchase a brand with ________________ content Select over-the-counter nicotine replacement ____________, ________, or ________________ Join a __________________ or ________________ in the tobacco cessation effort

20 mins blood pressure temperature

Smokers will start to see the benefit of quitting within _____ minutes of their last cigarette when ________________ drops and the _________________ of hands and feet increase to normal

1.9 // $481.2

States are continuing to spend only a miniscule portion of their tobacco revenues to fight tobacco use. In 2014, the states will collect $25 billion in revenue from the tobacco settlement and tobacco taxes, but will spend only ____ percent of it - $__________ million on programs to prevent kids from smoking and help smokers quit. http://www.tobaccofreekids.org/what_we_do/state_local/tobacco_settlement/

"Do you use tobacco?" If no: "Have you every used tobacco in the past?" Determine whether patient is a current or former tobacco user or has never used tobacco Determine the form, frequency, and duration of tobacco use Document tobacco use status in the dental record

Step #1 ASK

In a clear, strong, and personalized manner, urge every tobacco user to quit. Employ the "teachable moment," link oral finding with advice. Tobacco users who have not succeeded in previous attempts should be told that most people try repeatedly (on average 3-8 times) before permanent quitting is achieved

Step #2 ADVISE

Ask patient if he/she is willing to make a quit attempt at this time. If unwilling, reassess his/her willingness at the next visit. If patient is willing to make a quit attempt, refer patient to the National Network of Tobacco Quitline, 1-800-QUIT-NOW Trained tobacco cessation experts will assist the patient in setting a quit date and coach him/her through the quitting process Use reactive referral; provide patient with a 1-800-QUIT-NOW wallet card and urge patient to call the tobacco quitline Schedule a follow-up telephone call

Step #3 REFER

Ask Advise Assess Assist Arrange

The "5 A's" provide the basis for a brief, simple, but effective tobacco dependence intervention

corrugated white disappears

The ____________________ lesion associated with smokeless tobacco placement is called snuff keratosis, snuff patch, or tobacco pouch keratosis Often ________________ if tobacco use is terminated at an early enough stage

oral cancer

The combined use of alcohol with tobacco increases the risk of _____________ tenfold

Phone-based Face to face Group Internet-based

The four primary ways in which stop-smoking counseling can be delivered are:

20 seconds

The lungs are lined with millions of alveoli, the tiny air sacs where gas exchange occurs These alveoli provide an enormous surface area for nicotine to enter the body when smoking Once in the bloodstream, nicotine is delivered to the brain in less than _____ seconds.

Nicotine stomatitis Melanin pigmentation Hairy or coated would healing 3-6

The numerous oral conditions that are attributed to tobacco use vary with the type of tobacco used (smoking or smokeless) The numerous oral conditions that are attributed to tobacco use vary with the type of tobacco used (smoking or smokeless) ____________________ (smoking) ___________of the gums (smoking) ____________ or _____________ tongue Delayed ________________ Smokers are _____ times more likely than nonsmokers to develop periodontal disease

Self-help Assisted strategies

Tobacco cessation methods or treatment for nicotine addiction fall into two categories:

DHCP 1/3

Tobacco cessation programs Addressing tobacco use is an essential component of the ________ for all tobacco-using patients The majority of users admit that they would like to quit or "know" that they should About ______ of them are willing to try Even a minimal intervention conducted by a clinician may help a patient become tobacco free

preventable illness

Tobacco use is the number one cause of ___________________________ and death in the U.S.

health awareness Specific health family role model ETS Cost Social//restrictions nicotine addiction //control

Typical reasons to quit include: General _________________ ________________ problem directly or indirectly related to tobacco use Effect on ____________ Need to act as a _____________ Awareness of effects of _________ _________ __________ pressure and ________________ on smoking Personal recognition of the dangers of ________________ and the desire to regain ___________ of one's life

nicotine toxicity (nausea and vomiting)

Usually new users start with products with low amounts of free nicotine to avoid the unpleasant side effects of __________ (e.g., ____________ and ________________)

one in five

Vaping is on the rise with ________________ adult smokers stating that they have used an ENDS device.

addictive

While nicotine is the most ________________ substance in tobacco, other chemicals are just as, if not more, harmful than nicotine

bloodstream brain free nicotin For example, at a neutral pH of 7.0, there is no free nicotine available; however, at a pH of 8.0, about 60% of the nicotine is ionized and available for use by the body to create dependence.

Why is smokeless tobacco so addictive? Free nicotine is ionized nicotine that passes rapidly through the oral mucosa into the ______________ and the _______. The higher the pH the more available ________________

70%

______% of smokers say they are "interested" in quitting

Electronic Nicotine Delivery System (ENDS) Devices

____________ devices, are battery-powered vaporizers designed to deliver nicotine, flavor and other chemicals without the adverse effects of tobacco.

Addiction

_________________ is characterized by compulsive use of a sub substance The effects result in physical, psychological, and/or social harm to the user, but use continues despite that harm

Counseling // pharmacotherapy Alternatives : Acupuncture Hypnosis Laser

__________________ combined with ____________________ has been shown to be the most effective in helping patients to quit using tobacco Alternative Therapies (3)

Seventy-five

__________________ percent of oral and pharyngeal cancers are attributed to tobacco and/or heavy alcohol use

Secondhand smoke charcoal

___________________ poses a serious risk for nonsmokers, not only from the toxic chemicals in tobacco but also from the ______________ used as a heat source.

Documentation type and amount interest/motivation

____________________ of tobacco use is part of each patient assessment Include ________ and ____________ of tobacco typically used Record patient ___________\__________________ to quit

Counseling

______________________ helps people plan to quit smoking in a way that will increase their chances of success