Smoking Cessation Practice Guidelines for Registered Dental Hygienists

1. Smoking Cessation Practice Guidelinesfor Registered Dental Hygienists Carol Southard, RN, MSNSmoking Cessation Specialist

2. Presentation Objectives At the conclusion of this program, the participant will be able to: • Describe trends and issues regarding smoking cessation • Discuss tobacco cessation intervention using the AAR model • Review treatment options in the management of smoking cessation • Explain current guidelines on smoking cessation intervention • Summarize appropriate cessation pharmacotherapy

3. “The use of tobacco…conquers men with a certain secret pleasure so that those who have once been accustomed theretocan hardly be restrained therefrom” Sir Francis Bacon Historica Vital et Mortis 1622

4. “…a custome lothsome to the Eye, hatefull to the Brain, dangerous to the Lungs, and in the black stinking fume thereof, nearest resembling the horrible, stigian smoke of the pit that is bottomlesse”“My position on the use of tobacco”King James I, 1604

6. Tobacco Facts • #1 public health problem in the United States • Most preventable cause of morbidity and mortality • Causes more deaths each year than alcohol, motor vehicle accidents, suicide, AIDS, homicide, illicit drugs and fires combined • Proven risk factor for heart disease, malignant neoplasms and stroke • One-third of all tobacco users will die prematurely

7. ComparativeCauses of Annual Deaths in the United States Number of Deaths (thousands) AIDS Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced Source: CDC

8. Impact of Smoking • Smoking is now conclusively linked to acute myeloid leukemia and cancers of the cervix, kidney, pancreas and stomach • Smoking is now also known to cause pneumonia, abdominal aortic aneruysm, cataracts and periodontitis • Smoking harms nearly every organ of the body, damaging a smoker's overall health even when it does not cause a specific illness

9. Cardiovascular Risks • 30% of chronic heart disease deaths • 21% of deaths from other cardiovascular disease •  risk of sudden death •  risk of atherosclerotic abdominal aneurysm •  risk of atherosclerotic peripheral vascular disease •  risk of coronary heart/Cerebrovascular disease

10. Oral Cavity Risks • The most significant risk factor in the development and progression of periodontal disease • Major risk factor for oral and pharyngeal cancer • Tobacco use responsible for about 75% of all oral cavity cancers - mouth, tongue lips, throat, nose, larynx • Smokers have 6 times the risk for mouth cancer as nonsmokers

11. Oral Cavity Risks • Tobacco users have from 3 to 17 times as much larynx cancer as nonsmokers • Smoking is a key risk factor for gum disease • Smoking while pregnant linked to cleft palate and cleft lip • Children who are exposed to secondhand cigarette smoke are more likely to develop cavities in their baby teeth

12. Risk Factor for Periodontitis • Cross-sectional and case-control studies demonstrate a moderate to strong association between smoking and periodontitis • Smokers are almost three times as likely to have severe periodontitis compared to non-smokers • In general, current smokers have deeper probing depths, greater attachment loss, more bone loss, and fewer teeth • Smokers exhibit more supragingival calculus, and a majority of studies show a trend toward decreased clinical signs of inflammation

13. Impact on the Periodontium • Some studies report that subgingival bacteria associated with periodontitis were higher among smokers • Smoking is associated with significantly increased levels of proinflammatory cytokines in crevicular fluid tipping the balance in favor or tissue breakdown • The vasoconstrictive properties of nicotine may impair gingival blood flow

14. Effects on Periodontal Therapy • Smoking slows healing after non-surgical and surgical periodontal therapy • Numerous studies have shown that smoking compromises probing depth and/or attachment gain outcomes following non-surgical or surgical therapy • Studies show that probing depth reduction and clinical attachment level improvements in smokers are 50% to 75% those of non-smokers following periodontal therapy • Evidence suggests that subgingival pathogens are more difficult to eliminate in smokers following scaling and root planing (adjunctive antimicrobial therapy may help) • Smoking is significantly associated with implant failure • The majority of implant failures in smokers occur prior to prosthesis delivery

15. ETS = second hand smoke, or passive smoking The smoke generated from a single cigarette in a large room causes the air to fail the national minimum standard set by the Clean Air Act of 1994 ETS is comprised of Sidestream smoke emitted by a burning tobacco product Mainstream smoke exhaled by the smoker 1986 Surgeon General’s Report: ETS causes disease, including lung cancer, among healthy nonsmokers Separating smokers from nonsmokers in same space may reduce ETS exposure but does not eliminate it ETS: A Known Human Carcinogen

16. Diseases Associated with ETS in Non-Smoking Adults • Short-term exposure: eye, nose, and throat irritation; headaches; nausea; and dizziness • Persistent exposure: increased risk for lung cancer and other diseases • 3,000 US deaths from lung cancer among nonsmoking adults • Increases risk of heart disease and lung conditions •  Annually, ETS is thought to cause: • 35,000 to 40,000 US deaths from heart disease among current nonsmokers

17. Impact of Secondhand Smoke • Many millions of Americans are still exposed to secondhand smoke • Secondhand smoke exposure causes disease and premature death • Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma. respiratory symptoms and slows lung growth children • Exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer • The scientific evidence indicates that there is no safe level of exposure to secondhand smoke • Eliminating smoking in indoor spaces fully protects people from exposure to secondhand smoke - separating sections, air cleaning systems, and ventilating buildings cannot eliminate the risk of exposure

18. Smoking Statistics • About 44.5 million Americans are current smokers – 20.9% • 23.4% of men and 18.5% of women smoke in US • Prevalence • Native Americans & Alaskan Natives (33.4%), • Persons reporting two or more races (31.0%) • Caucasians (22.2 %) • African Americans (20.2 %) • Hispanics (15.0 %) • Southeast Asians (11.3 %)

19. Smoking Incidence & Scope • The annual toll on the nation’s health and economy is staggering: 440,000 deaths, 8.6 million people suffering from at least one serious illness related to smoking • $75 billion in direct medical costs; $92 billion in lost productivity • The Department of Health and Human Services has set a goal of reducing smoking prevalence to 12% or less by 2010

20. Smoking Trends • Since 1974, the smoking prevalence in men has decreased by about 1% a year, in women 0.33% • Prevalence has remained fairly constant since 1992 • Children raised in households where one or both parents smoke are 2 to 5 times more likely to smoke • 1/3 of households with children under 6 years old contains at least one smoker • 90% of smokers begin smoking before age 21

21. Tobacco is Not an Equal OpportunityKiller • Smoking affects young, the poor, depressed, uninsured, less educated, blue-collar, and minorities most in the US • Addiction affects those with the least information about health risks, with the fewest resources to resist advertising, and the least access to cessation services • Those below poverty line are >40% more likely to smoke than those above poverty line

22. 38% of persons with 9-11 yrs education 40% of cooks/truckers 1/3 of service workers covered by smoke-free policies Social norm for low SES different from high SES 13% of persons with college degree or higher 3% of lawyers ½ of white collar workers covered by smoke-free policies Higher SES less likely to be exposed to parent/peer smokers Unequal Patterns of Use and Exposure

24. Smoking Population Trend Lines The Department of Health and Human Services has set a goal of reducing smoking prevalence to 12% or less by 2010.

25. Cessation Facts • About 30% of patients are current smokers • 70% of smokers say they are “interested” in quitting • Only 10 to 20% plan to quit in the next month • About 43% of smokers try to quit in a given year • The majority of smokers try to quit on their own • Overall, self-quitters have a success rate of 4 to 6% • Half of all smokers eventually quit

27. Prevention, Tobacco Control, and Cessation Henningfield & lade, 1998

28. Tobacco Intervention • 75% of health providers THINK it is a good idea • 10% routinely do it - not confident about subject - questionable goals - afraid of negative reaction from patient - feel patient might be offended - not enough reimbursement - not enough time

29. Dental Intervention • 30% of smokers report visiting a dentist annually • 40% of dentists do not routinely ask about tobacco use • 60% do not advise tobacco users to quit

30. Practice Implications • Up to 90% of smokers report being asked about smoking status; more than 70% report having been counseled to quit • Providers not consistently intervening despite the substantial evidence that even brief smoking cessation counseling can be effective • Tobacco use status assessment, documentation and intervention by RDH and/or DDS would have a huge impact on cessation efforts

31. History of the SCI • 14 member task force met September 2003 • Summit sponsored by the RWJF SCLC • Grant awarded in November 2003 • A nationwide campaign designed to promote smoking cessation intervention by dental hygienists "The advice of a dental hygienist can be a major motivation for a quit attempt by a patient who smokes.“ -- Tammi O. Byrd, RDH, ADHA President 2003-2004

32. ADHA Tobacco Cessation Task Force Tammi O. Byrd, RDH Katie L. Dawson, RDH, BS Jacquelyn L. Fried, RDH, MS JoAnn R. Gurenlian, RDH, PhD Kirsten Jarvi, RDH, BS C. Austin Risbeck, RDH Rebecca Wilder, RDH, BS, MS Lisa M. Esparza, RDH, BS Maria Perno Goldie, RDH, MS Barbara Heckman, RDH, MS Kathleen Mangskau, RDH, BS, MPA Margaret M. Walsh, MS, Ed.D

33. The Objective • Baseline and Target: • Increase to 50 the percentage of dental hygienists that screen their clients regarding tobacco use (rate, type and amount) by 2006.Baseline 25% in 2001 Journal of Dental Hygiene study • (Winter 2001)

34. Main Elements of the SCIYear One Educational Program: Ask. Advise. Refer. SCI Liaison Program: Designate a liaison in each state Dedicated Website: www.askadviserefer.org

35. SCI Year Two • Grant renewed November, 2004 • SCI Project Manager, January, 2005 • SCI Administrative Assistant • SCI Liaisons in-state support • Six state presentations

36. SCI Year Three • Grant renewed November, 2005 • SCI Project Consultant • SCI Administrative Assistant • SCI Liaison education support • Twelve district presentations

37. SCI Year Four • Grant renewed November, 2006 • Webcasts • National survey results • Complete district presentations • ADHA Tobacco Cessation Forum • Presentations per request

38. Three Minutes or Less Can Save Lives • The advice of a health care professional can more • than double smoking cessation success rates. • Tobacco dependence is a chronic disease • that demands treatment. • Effective interventions have been established and • should be utilized with every current and former • tobacco user. • There is no other clinical practice that has more • impact on reducing illness, preventing death, and • increasing quality of life.

39. Does patient/client now use tobacco? If NO: If YES: Did patient once use Is patient now willing tobacco? to quit? If NO: If YES: If YES: No intervention required. If NO: Provide appropriate Prevent Relapse Encourage continued Promote motivation to quit. referral. abstinence. Ask. Advise. Refer. Systematic Approach

40. Ask. Advise. Refer. = 5 A’s Ask Ask. Every patient/client about tobacco use. Advise Assess Assist Advise. Every tobacco user to quit. Arrange Refer. Determine willingness to quit. Provide information on quitlines. Refer to Quitlines ADHA Smoking Cessation Initiative (SCI)

41. SCI Protocols Step 1: Ask 1 min • Systemically ask every client about tobacco use at every visit. • Determine if client is current, former, or never tobacco user. • Determine what form of tobacco is used. • Determine frequency of use. • Document tobacco use status in the dental record.

42. SCI Protocols Step 2: Advise 1 min • In a clear, strong, and personalized manner, urge every tobacco user to quit. • Tobacco users who have not succeeded in previous quit attempts should be told that most people try repeatedly (on average 3 to 8 times) before permanent quitting is achieved. • Employ the teachable moment: link oral findings with advice.

43. SCI Protocols Step 3: Refer 1 min • Asses if client is interested in quitting. • Assist those interested in quitting by providing information on: • Statewide or national quitlines, websites and local cessation programs. • Use proactive referral if available • Request written permission to fax contact information to a cessation quitline or program. Inform the client that cessation program staff will provide follow-up. • Document referral on dental record. • Use reactive referral – provide client with contact information • Arrangefollow-up at periodontal maintenance visit and/or schedule a phone call

44. What are Quitlines? Tobacco Quitlines are telephone-based tobacco cessation services available in all states and are accessed through a new federal toll-free number. They provide callers with a number of services: • Individualized telephone counseling • Educational materials • Referrals to local programs

46. Refer to: Current list of all state quitlines: www.askadviserefer.org Department of Health and Human Services Quitline: 1-800-QUITNOW (784-8669) Information Service Website: http://www.smokefree.gov Web based cessation program: http://smokefree.gov/ or http://www.quitnet.com

47. Online Smoking Cessation Assistance • On-line smoking cessation services now available for smokers who prefer using computers over telephones • Anonymity is a plus, as with telephone quitlines • Early studies show promising efficacy • www.quitnet.com • www.smokeclinic.com • www.tobaccoschool.com

48. SCI Scripts If the client uses tobacco: “How many cigarettes per day do you smoke” “How many cigars per day do you smoke?” “How many bowls of pipe tobacco do you use per day?” “How many dips of chewing tobacco do you use per day?” “Do others in your household use tobacco?”

49. SCI Scripts For the client who never regularly used tobacco: “Congratulations, you have made a wise decision to protect your health.” “Congratulations on being a non-smoker.”

50. SCI Scripts For the client who quit using tobacco: “Congratulations, you made a wise decision.” “Congratulations on quitting tobacco use. We have some good programs to help you remain tobacco-free. I can give you the contact information for the program.”