1 / 55

Smoking Cessation Practice Guidelines for Registered Dental Hygienists

Smoking Cessation Practice Guidelines for Registered Dental Hygienists. Carol Southard, RN, MSN Smoking Cessation Specialist.

ronda
Download Presentation

Smoking Cessation Practice Guidelines for Registered Dental Hygienists

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

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

  2. “…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

  3. 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

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

  5. 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

  6. 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

  7. Smoking Statistics • Almost one in four Americans are current smokers • 28% of men and 23.5% of women smoke in U.S. • Prevalence is highest among Native Americans & Alaskan Natives (37.1%), then 35.0 percent among persons reporting two or more races African Americans (25.3 %), Hispanics (23.0 %), Caucasians (26.9 %) and lowest among Southeast Asians (17.7 %) • 90% of smokers begin smoking before age 21 • 1/3 of households with children under 6 years old contains at least one smoker

  8. Smoking Incidence & Scope • An estimated 71.5 million Americans reported current use (past month use) of a tobacco product in 2002, a prevalence rate of 30.4 percent for the population aged 12 or older • Among that same population, 61.1 million (26.0 percent of the total population aged 12 or older) smoked cigarettes, 12.8 million (5.4 percent) smoked cigars, 7.8 million (3.3 percent) used smokeless tobacco, and 1.8 million (0.8 percent) smoked tobacco in pipes. • By age group, the prevalence of cigarette use was 13.0 percent among 12 to 17 year olds, 40.8 percent among young adults aged 18 to 25 years, and 25.2 percent among adults aged 26 or older. • Higher proportion of males than females aged 12 or older smoked cigarettes in 2002 (28.7 vs. 23.4 percent).

  9. Smoking Trends • Since 1974, the smoking prevalence in men has decreased by about 1% a year, in women 0.33% • Prevalence has remained constant since 1992 • Smoking is more common among persons with 11 years of education or less • Smoking among adolescents has been decreasing slightly (girls still exceeding boys) • Children raised in households where one or both parents smoke are 2 times more likely to smoke

  10. Smoking Population Trend Lines

  11. 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 46% of smokers try to quit in a given year • In the past, 90 to 95% of smokers quit on their own • Currently, 1/3 of smokers now use a medication • Overall, self-quitters have a success rate of 5 to 10% • Half of all smokers eventually quit

  12. Practice Implications • Only half of smokers report being asked about smoking by their MD in the past year • Only a minority report being advised to quit • There is 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

  13. Nicotine Dependence • The most powerful of all addictions to overcome • Nicotine acts on nicotinic acetylcholine receptors in both the central nervous system and the peripheral nervous system resulting in a physical and biologic basis for physical dependence • Psychological dependence • Habitual dependence

  14. Treatment Facts • The efficacy of several smoking cessation therapies is well established • All proven treatments appear to be equally effective: quit rates are doubled • Early evidence suggests allowing smokers to choose treatment produces better outcomes • The Agency for Health Care Policy and Research (AHCPR) published updated smoking cessation guidelines in 2000 for primary care clinicians

  15. Practice Guideline Changes • All tobacco products exact devastating costs on the nation’s health and welfare • For most users, tobacco use results in true drug dependence comparable to opiates, amphetamines and cocaine • Chronic tobacco use warrants repeated clinical intervention just as do other addictive disorders

  16. Pharmacotherapy • Six first-line FDA approved therapies reliably increase long-term smoking abstinence rates • All approximately double the rate of cessation when compared to placebo • Typical rates of smoking cessation are 40 to 60% at end of drug treatment vs. 20 to 30% on placebo • At one year, 25 to 30% success rates are reported compared to 10 to 15% on placebo • All help with symptoms of withdrawal • Two second-line drugs have been identified as efficacious

  17. Medications • Nicotine Replacement Therapy • Gum • Patch • Inhaler • Nasal Spray • Lozenge • Non-Nicotine Medications • Buproprion • Clonidine Hydrochloride • Nortriptyline Hydrochloride

  18. Nicotine Replacement Therapy • Goal is to replace nicotine from cigarettes in order to reduce or eliminate physical withdrawal symptoms • Pharmacokinetic properties differ but none deliver nicotine to the circulation as fast as does inhaling cigarettes • Effectiveness of all are broadly similar • Few health interventions have such overwhelming evidence of effectiveness

  19. Plasma Nicotine ConcentrationsCigarettes versus NRT Cigarettes • 1 cigarette produces rapid surge of plasma nicotine •  by about 25 ng/ml in minutes; declines rapidly NRT • No form achieves plasma nicotine concentrations as high as those from smoking 20 cigarettes/day • Does not reproduce immediate effect of smoking Tang JL, Law M, Wald N. BMJ. 1994; 308: 22.

  20. Nicotine Gum • Available since 1984 • OTC 1995 • 2 mg recommended for patients smoking less than 1 pack per day • 4 mg for patients smoking over 1 pack/day • Full dose absorbed in about 20 minutes • Cost $6.00+ per day

  21. Nicotine Patch • Available since 1994 • OTC 1996 • 21 mg recommended for patients smoking 1 pack per day • 14 mg for patients smoking 1/2 pack/day • Full dose absorbed in about 2 hours • Cost $4.00+ per day

  22. Nicotine Inhaler • Available since 1998 - Rx • Each cartridge delivers 4 mg of nicotine over 80 inhalations • Full dose absorbed in about 20 minutes • Cost $10.00+ per day • Designed to combine pharmacological and behavioral substitution

  23. Schematic of the Nicotine Inhaler Sharp point that breaks the seal Cartridge Air/Nicotine Mixture Out Sharp point that breaks the seal Mouthpiece Air In Porous Plug Impregnated with Nicotine Aluminum Laminate Sealing Material

  24. Nicotine Nasal Spray • Available since 1996 - Rx • Each spray delivers 0.5 mg of nicotine • Full dose absorbed in less than 5 minutes • Minimum recommended treatment is 8 doses per day • Cost $5.00+ per day

  25. Nicotine Lozenge • Available since 2002 - OTC • 2 mg recommended for patients who smoke more than 30 minutes after waking • 4 mg for patients who smoke within 30 minutes of waking • Full dose absorbed in about 20 minutes

  26. Non-Nicotine MedicationsBuproprion • An atypical antidepressant with dopaminergic and noradrenergic activity • First FDA approved non-NRT • Risk of seizure is 0.1% or less • Can be used in combination with NRT • Is effective in those with no current or past depressive symptoms

  27. Bupropion for Tobacco Dependence Features • Atypical antidepressive substance (amfebutamone) • Exact mechanism of action unknown: dopaminergic/ noradrenergic/other • Active ingredient in Wellbutrin® Dosing • 300 mg (150 mg initially) • Begin therapy while still smoking Zyban™ prescribing information, 2001.

  28. Bupropion for Tobacco Dependence Side effects • Dry mouth and insomnia • Risk of seizure: approximately 1 in 1,000 • Contraindicated for patients with seizure disorder or predisposing factors that increase seizure risk (head injury, active substance abuse) Zyban™ prescribing information, 2001.

  29. Effectiveness of Bupropion for Tobacco Dependence • Significantly higher abstinence rates than placebo during treatment and at 6-,12-month follow up • Combination therapy (with step-down, 24-hour nicotine patch) • Approved indication • Provided slightly higher abstinence rates than bupropion alone Holm, KJ, Spencer, CM. Drugs. 2000; 59: 1015. Zyban™ prescribing information, 2001.

  30. Dose-Response Trial

  31. Comparative Trial

  32. Non-Nicotine MedicationsSuggested/Not FDA Approved • Clonidine • Reduces symptoms of withdrawal • Effective for smoking cessation • High frequency of adverse effects limits use • Nortriptyline • Effective for smoking cessation in 2 small studies • No other antidepressant has had demonstrated efficacy

  33. Psychosocial Therapies • Behavioral therapy is the only proven psychosocial treatment for smoking cessation • Usually administered in a group setting • Can also be conducted on an individual basis • Major disadvantage is limited availability and acceptability

  34. AHCPR Guidelines • Ask every patient at every visit if he or she smokes • Record patients’ smoking status with vital signs • Ask patients about their desire to quit • Motivate patients who are reluctant to quit • Help motivated smokers to set a quit date • Prescribe nicotine replacement therapy • Help patients resolve problems from quitting • Encourage relapsed smokers to try quitting again

  35. Five A’s • Ask - initial step is to identify if client uses tobacco • Advise - deliver clear, strong, personal, and straightforward advice about the importance of quitting; emphasize four R's: risks, relevance, rewards, repetition • Assess - willingness to make a quit attempt • Assist - set quit date, offer pharmacologic and behavioral support • Arrange - follow-up to prevent relapse

  36. The Five “A”s of a Three-Minute Intervention (continued) • Ask about tobacco use • Every patient on every visit • Past/present tobacco use • Smoking as a vital sign • WT_____HT_____BP_____TEMP_____P_____ • Tobacco Use: Current Former Never WT_____HT_____ BP______ TEMP______P______ CC: ________________________________________ Tobacco Use (circle): Current Former Never Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June 2000. Page 28.

  37. Advise patient to quit Stress importance of quitting Personalize advice Example: “This is the third time you have had bronchitis this year. Your smoking is affecting your health.” Deliver strong, firm message Example: “Quitting smoking is the best way to reduce your health risk.” The Five “A”s of a Three-Minute Intervention (continued) Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June 2000. Page 28.

  38. Assess willingness to make quit attempt now, e.g., within next 30 days “On a scale of 1 to 10, how motivated are you?” If patient is willing to quit Provide assistance Offer intensive treatment or refer patient If patient is unwilling to quit Provide motivational intervention Relevance, risks, rewards, roadblocks and repetition Special populations (adolescents, pregnant smokers) The Five “A”s of a Three-Minute Intervention (continued) Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June 2000. Page 29.

  39. Assist by helping patient formulate quit plan Set quit date within 2 weeks Tell family and friends for support Anticipate challenges Withdrawal during first few weeks Remove all tobacco products and alcohol from environment The Five “A”s of a Three-Minute Intervention (continued) Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June 2000. Page 29.

  40. Arrange follow-up contact (in person/by phone) Timing Preferably during first week Second follow-up contact within first month Actions during follow-up contact Congratulate success Assess pharmacotherapy use; consider more intensive treatment If tobacco use has occurred, review circumstances and elicit recommitment to total abstinence Remind patient a lapse can be a learning experience The Five “A”s of a Three-Minute Intervention (continued) Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. June 2000. Page 31.

  41. Relapse Considerations • Encourage quit attempt as soon as possible after relapse • Adequacy of nicotine replacement therapy dosage • Length of treatment • Follow up contact is vital • Relapse rates are highest during first few days of cessation • Referral to smoking cessation specialist after 2 to 3 relapses

  42. State of the Art Programs • Setting of specific quit date • Interruption of conditioned responses • Identification and preparation of plans for coping • Attention to relapse episodes • Encouragement of continued nonsmoking • Follow up contact • Social support for quitting and abstinence

  43. Session 1 Session 2 Session 3 Session 4 Orientation & Introductions Understanding addiction Preparation_________________ Benefits of Quitting Withdrawal Symptoms Cessation Strategies__________ QUIT DAY_________________ Motivation Reinforcement Support Systems Program Agenda

  44. Session 5 Session 6 Session 7 Session 8 Lifestyle issues: Nutrition/Weight Exercise____________________ Stress Management Relaxation Skills New Self-image______________ Ex-smokers panel_____________ Graduation & Celebration Relapse Prevention Program Agenda

  45. Health Care Costs • Roughly 46 million Americans report regular tobacco use • Tobacco is responsible for approximately 1 in 5 deaths each year • The estimated cost to the American health care system is $80 billion in direct costs and $50 billion in indirect costs

  46. Power of Intervention • The costs of providing brief interventions is $3 per smoker • Implementing such interventions could quadruple the national annual cessation rate, translating to roughly 4.8 million quitters • Adding brief behavioral counseling and medication can increase the cessation rate sixfold, translating to roughly 7.2 million quitters

  47. Why Bother? • Single most effective step to lengthen and improve patients’ lives • Quitting smoking has immediate and long-term benefits and is well worth the difficulty, both for patient and clinician

  48. The Benefits Of Quitting Smoking • At 1 year excess risk of coronary heart disease decreases to half that of a smoker • At 5 years stroke risk reduces to that of people who have never smoked

  49. The Benefits Of Quitting Smoking • At 10 years the risk of lung cancer drops to one-half that of continuing smokers • At 15 years the risk of coronary heart disease is now similar to that of people who have never smoked and the risk of death returns to nearly the level of people who have never smoked

More Related