Post on 16-Jul-2015
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
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
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
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
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.
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
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
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
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
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
“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
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
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
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
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
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: trauch@setonhealth.orgVisit the Dental Pages on our Website:
www.Quitsolutions.org