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Smoking Cessation Practice Guidelines for Registered Dental Hygienists. Carol Southard, RN, MSN Smoking Cessation Specialist. Presentation Objectives. At the conclusion of this program, the participant will be able to: Describe trends and issues regarding smoking cessation

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smoking cessation practice guidelines for registered dental hygienists

Smoking Cessation Practice Guidelinesfor Registered Dental Hygienists

Carol Southard, RN, MSNSmoking Cessation Specialist

presentation objectives
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
historica vital et mortis 1622

“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


“…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

tobacco facts
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

ComparativeCauses of Annual Deaths in the United States

Number of Deaths (thousands)

AIDS Alcohol Motor Homicide Drug Suicide Smoking

Vehicle Induced

Source: CDC

impact of smoking
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
cardiovascular risks
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
oral cavity risks
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
oral cavity risks11
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
risk factor for periodontitis
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
impact on the periodontium
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
effects on periodontal therapy
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
ets a known human carcinogen
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
diseases associated with ets in non smoking adults
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
impact of secondhand smoke
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
smoking statistics
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 %)
smoking incidence scope
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
smoking trends
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
tobacco is not an equal opportunity killer
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
unequal patterns of use and exposure
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
smoking population trend lines
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.

cessation facts
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
tobacco intervention
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

dental intervention
Dental Intervention
  • 30% of smokers report visiting a dentist


  • 40% of dentists do not routinely ask about tobacco


  • 60% do not advise tobacco users to quit
practice implications
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

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


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


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)

Main Elements of the SCIYear One

Educational Program:

Ask. Advise. Refer.

SCI Liaison Program:

Designate a liaison in each state

Dedicated Website:

sci year two
SCI Year Two
  • Grant renewed November, 2004
  • SCI Project Manager, January, 2005
  • SCI Administrative Assistant
  • SCI Liaisons in-state support
  • Six state presentations
sci year three
SCI Year Three
  • Grant renewed November, 2005
  • SCI Project Consultant
  • SCI Administrative Assistant
  • SCI Liaison education support
  • Twelve district presentations
sci year four
SCI Year Four
  • Grant renewed November, 2006
  • Webcasts
  • National survey results
  • Complete district presentations
  • ADHA Tobacco Cessation Forum
  • Presentations per request

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.

Does patient/client now

use tobacco?

If NO:


Did patient once


Is patient now willing


to quit?

If NO:



No intervention required.

If NO:

Provide appropriate

Prevent Relapse

Encourage continued

Promote motivation

to quit.



Ask. Advise. Refer. Systematic Approach

ask advise refer 5 a s
Ask. Advise. Refer. = 5 A’s


Ask. Every patient/client about tobacco use.




Advise. Every tobacco user to quit.


Refer. Determine willingness to quit. Provide information on quitlines.

Refer to Quitlines

ADHA Smoking Cessation Initiative (SCI)

sci protocols
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.
sci protocols42
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.
sci protocols43
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
what are quitlines
What are Quitlines?

Tobacco Quitlines are

telephone-based tobacco

cessation services available in

all states and are accessed

through a new federal toll-free


They provide callers with a number of services:

  • Individualized telephone counseling
  • Educational materials
  • Referrals to local programs
refer to
Refer to:

Current list of all state quitlines:

Department of Health and Human Services Quitline:

1-800-QUITNOW (784-8669)

Information Service Website:

Web based cessation program:


online smoking cessation assistance
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
sci scripts
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?”

sci scripts49
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.”

sci scripts50
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.”

sci scripts51
SCI Scripts

For the client who currently uses tobacco:

“Have you thought about quitting?”

“I can help you even if you do not want to quit. Let me give you the phone number for the statewide quitline. You can receive free counseling on how to quit and remain tobacco-free.”

“Quitlines have had proven success in helping people get through the difficult stages of quitting and many people prefer to use them.”

sci scripts52
SCI Scripts

More available scripts for:

  • Pregnant mothers
  • Hospitalized clients
  • Heart Attack clients
  • Parents of children and adolescents
  • Lung, head and neck cancer clients
  • Youth
nicotine dependence
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
neurochemical effects of nicotine
Dopamine Pleasure

Norepinephrine Appetite Suppression

Acetylcholine Arousal, Cognitive Enhancement

Vasopressin Memory

Serotonin Mood Modulation

ß-endorphin Anxiety Reduction

Neurochemical Effects of Nicotine


Benowitz NL. Primary Care. 1999;26: 619.

biology of addiction
Biology of Addiction
  • Addictive drugs stimulate release of dopamine (brain neurotransmitter)
  • Dopamine produces feelings of pleasure
  • Pleasure reinforces repeat administration
  • Tolerance develops
  • Abrupt discontinuation leads to symptoms of withdrawal
nicotine addiction cycle

Nicotine use for pleasure,

enhanced performance,

mood regulation

Tolerance and physical


Nicotine use to self-

medicate withdrawal


Nicotine abstinence produces

withdrawal symptoms

Nicotine Addiction Cycle

Benowitz NL. Med Clin North Am. 1992; 76: 423.

nicotine withdrawal symptoms
Constant craving of cigarettes







Difficulty concentrating


Decreased heart rate

Increased appetite


Nicotine Withdrawal Symptoms

Withdrawal peaks within 24-48 hours and diminishes over 1 to 3 months.

unique qualities of nicotine addiction through smoking
Cigarette is a highly engineered drug-delivery system

Inhaling produces a rapid distribution of nicotine to the brain

Drug levels peak within 10 seconds in the brain

Acute effects dissipate within minutes, causing the smoker to continue frequent dosing throughout the day

Average smoker takes 200-300 boluses to the brain per day

Easy to get, easy to use, and it is legal!

Unique Qualities of Nicotine Addiction Through Smoking

Pleasure and other subjective and cognitive benefits of smoking*

  • Body weight control*
  • Reduced discomfort from tobacco abstinence*
  • Social Pressure
  • Environmental Cues* (conditioning)




  • Cost
  • Health Benefits
  • Social Pressure
  • Freedom

Continued Smoking or Relapse



* Motivation factors that are determined by pharmacologic actions of nicotine

model of addiction
Model of Addiction
  • Classical conditioning – associative learning (cues)
    • Work break
    • Coffee
    • Alcohol
  • Operant conditioning – reinforcement by outcomes (consequences)
    • Social acceptance
    • Cultural norm
  • Observational learning or modeling
    • Parents
    • Peers                     
  • Cognitive factors                         
    • self image
    • coping mechanism
smokers learned helplessness
Smokers’ Learned Helplessness

Low self-efficacy

(“I can’t quit”)


High outcomes expectancies

(“It’s really important that I quit”)


A state of learned helplessness

assessing the degree of addiction
Assessing the Degree of Addiction
  • How many cigarettes are smoked on average per day?
  • How much time typically elapses between waking and the first cigarette?
  • What is the longest period of time between cigarettes before craving?
assessing nicotine dependence
Assessing Nicotine Dependence

1. How soon after you wake do you smoke your first cigarette or take your first dip?

  • <30 minutes 2
  • 31 - 60 minutes 1
  • >60 minutes 0

2. How many cigarettes per day or tins per week do you use?

  • <10 cigarettes or <1 tin 0
  • 11 - 20 cigarettes or 1 - 2 tins 1
  • 21-30 cigarettes or >2-3 tins 2
  • >30 cigarettes or > 3 tins 3

3. Do you find it difficult to refrain from using tobacco in places where it is forbidden (e.g., movies, work, etc)?

Yes 1

No 0

Scoring: 0 - 2 (LOW) 3 - 4 (MEDIUM) 5 - 6 (HIGH)

treatment facts
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
clinical interventions
Clinical Interventions
  • The “5 A’s” for patients willing to make a quit attempt
  • The “5 R’s” for patients unwilling to make a quit attempt at this time
  • Relapse prevention for patients who have recently quit
  • Intensive interventions should be provided when possible
  • Health care administrators, insurers, and purchasers should institutionalize guideline findings
nicotine absorption
Primary routes: respiratory tract, buccal mucosa,


Absorption is pH-dependent

Oral absorption

- mouth is acidic

- oral tobacco products buffered to increase mouth pH to 7.0-8.0

- pH-altering beverages affect absorption

Nicotine Absorption

Benowitz NL. Primary Care. 1999;26: 619.

nicotine absorption68
Lung absorption: ionized & non-ionized

90% absorption across respiratory epithelium

Alkaline form irritates throat

Ionized form allows more nicotine to be dissolved

in the tar droplets

Absorbed in tar, nicotine is less irritating to throat

Nicotine Absorption

Benowitz NL. Primary Care. 1999;26: 619.

rates of absorption
Rates of Absorption

Benowitz NL. Primary Care. 1999;26: 619.

  • Seven first-line FDA approved therapies reliably increase long-term smoking abstinence rates
  • All approximately double the rate of cessation when compared to placebo
  • All help with symptoms of withdrawal
nicotine replacement therapy
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
plasma nicotine concentrations cigarettes versus nrt
Plasma Nicotine ConcentrationsCigarettes versus NRT


  • 1 cigarette produces rapid surge of plasma nicotine
  •  by about 25 ng/ml in minutes; declines rapidly


  • 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.

nrt contraindications
NRT Contraindications
  • No evidence of increased cardiovascular risk with NRT except with acute disease
  • Medical contraindications:
    • Immediate myocardial infarction (< 2 weeks)
    • Serious arrhythmia
    • Serious or worsening angina pectoris
    • Accelerated hypertension
nicotine gum
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
efficacy of nicotine gum n 13 studies
Efficacy of Nicotine Gum (n = 13 Studies)


Abstinence Rate

Odds Ratio

(95%) CI



(reference group)




(1.3 - 1.8)


Nicotine gum

nicorette clinical use and dosing schedule
Proper Chewing Technique

Chew slowly

Stop chewing when peppery taste occurs

Park gum

Chew gum again when peppery taste fades

Dosing Schedule

Wk 1-6 1 piece q1-2h

Wk 7-9 1 piece q2-4h

Wk 10-12 1 piece q4-8h

Max dose: 24 pieces/day

Nicorette®Clinical use and Dosing Schedule
nicotine patch
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
  • 7 mg for patients smoking 5 or less cigarettes a day
  • Full dose absorbed in about 2 hours
efficacy of nicotine patch n 27 studies
Efficacy of Nicotine Patch (n = 27 Studies)

Odds Ratio

(95%) CI


Abstinence Rate



(reference group)




(1.7 - 2.2)


Nicotine patch

nicotine inhaler
Nicotine Inhaler
  • Available since 1998 - Rx
  • Each cartridge delivers 4 mg of nicotine over 80 inhalations
  • Full dose absorbed in about 20 minutes
  • Designed to combine pharmacological and behavioral substitution
nicotine inhaler81
Nicotine is absorbed through buccal membrane

Satisfies hand-to-mouth ritual of smoking

Two-fold increase in quit rates at 12 months


Initial treatment

6 cartridges/day increase prn to max 16 cartridges/day

min of 3 weeks, up to 12 weeks or longer as needed

Gradual dosage reduction

if needed over additional 12 weeks

Nicotine Inhaler
schematic of the nicotine inhaler
Schematic of the Nicotine Inhaler

Sharp point that

breaks the seal



Mixture Out

Sharp point that

breaks the seal


Air In

Porous Plug Impregnated with Nicotine

Aluminum Laminate

Sealing Material

efficacy of nicotine inhaler n 4 studies
Efficacy of Nicotine Inhaler (n = 4 Studies)

Odds Ratio

(95%) CI


Abstinence Rate



(reference group)




(1.7 - 3.6)


Nicotine inhaler

nicotine nasal spray
Nicotine Nasal Spray
  • Available since 1996 - Rx
  • Each spray delivers 0.5 mg of nicotine
  • Full dose absorbed in less than 3 minutes
  • Minimum recommended treatment is 8 doses per day
nicotine nasal spray dosage and pharmacokinetics
Nicotine Nasal SprayDosage and Pharmacokinetics
  • Dosage: 1-2 sprays in each nostril every hour for 6-8 wks
    • 1mg (1 dose) = 1 spray in each nostril
    • max dose: 40 doses/day or 5 doses/hr
  • Pharmacokinetics
    • 1/2 - 2/3 of dose absorbed systemically
    • time to peak: 3-15 minutes
    • absorption is decreased with colds or rhinitis
nicotine nasal spray nicotrol ns
Nicotine Nasal SprayNicotrol NS®
  • Metered dose pump 10mg/ml 10ml (200 sprays)
  • Designed for quick delivery of nicotine
  • Similar efficacy to patches and gum
  • May be most beneficial to highly dependant smokers
efficacy of nicotine nasal spray n 3 studies
Efficacy of Nicotine Nasal Spray (n = 3 Studies)

Odds Ratio

(95%) CI


Abstinence Rate



(reference group)




(1.8 - 4.1)


Nicotine nasal


nicotine lozenge
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
nicotine lozenge89
Nicotine Lozenge
  • Oral NRT
  • Like hard candy, dissolves in mouth
  • One lozenge every 1-2 hours for the first six weeks; one lozenge every 2-4 hours during weeks 7-9; one lozenge every 4-8 hours during the final weeks 10-12.
combination nicotine replacement therapy
Combination Nicotine Replacement Therapy
  • Combining the nicotine patch and a self-administered NRT (either nicotine gum or nicotine nasal spray) is more efficacious than a single form of NRT




Plasma nicotine (ng/mL)















Gum (4 mg)

Gum (2 mg)


Nasal spray


Reprinted with permissionfrom Schneider et al., Clinical Pharmacokinetics 2001;40(9):661–684. Adis International, Inc.

non nicotine medications bupropion
Non-Nicotine MedicationsBupropion
  • 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
bupropion sr
Bupropion SR
  • Available by prescription only (USA)
  • Dosing:
    • Start 1-2 weeks before quit date
    • 150 mg orally once daily x 3 day
    • 150 mg orally twice daily x 7-12 weeks
    • No taper necessary at end of treatment
  • Maintenance: consider as a maintenance therapy for up to 6 months post-cessation
efficacy of bupropion sr n 2 studies
Efficacy of Bupropion SR (n = 2 Studies)


Abstinence Rate

Odds Ratio

(95%) CI



(reference group)




(1.5 - 3.0)


Bupropion SR



(Minimal Contact)

Data adapted from Hughes et al. JAMA 1999;281:72–76.

multiple pharmacotherapy
Multiple Pharmacotherapy
  • Bupropion SR may be combined with any of the NRTs
  • Combination NRT
    • Patch + gum or patch + nasal spray is more efficacious than a single NRT
    • Encourage in patients unable to quit using single agent
    • Combined NRT not currently FDA approved
non nicotine medications varenicline
Non-Nicotine MedicationsVarenicline
  • A partial nicotinic acetylcholine receptor agonist
  • Specifically indicated for use as an aid in smoking cessation
  • Provides some nicotine effects to ease withdrawal symptoms
  • Blocks effects of nicotine
varenicline chantix
Varenicline (Chantix)

Recommended dosage:

  • Start 1 week before quit date
  • 0.5 mg for 3 days
  • Then 0.5 mg BID for 4 days
  • Then 1 mg BID for up to 12 weeks
varenicline chantix101
Varenicline (Chantix)


  • Six clinical trials N=3659
  • Self-report verified by CO measurement
  • 1 in 5 quit at 1 year


  • Nausea reported by 1/3
  • Pregnancy Category C

NO Contraindications

pharmacotherapy for light smokers
Pharmacotherapy for Light Smokers
  • Consider reducing dose of first-line pharmacotherapies
  • Bupropion SR may be prescribed at full strength
extended use of pharmacotherapy
Extended Use of Pharmacotherapy
  • First-line tobacco dependence medications may be considered for extended use, especially in patients with persistent withdrawal symptoms
  • Evidence shows that a minority of patients continue ad libitum NRT agents
  • Does not present known health risks
  • FDA has approved bupropion SR for a long-term maintenance indication
psychosocial therapies
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
alternative therapies
Alternative Therapies
  • Acupuncture
  • Hypnosis
  • Laser
ahcpr guidelines
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
ahcpr guidelines107
AHCPR Guidelines
  • Documenting tobacco use status at every clinic visit will increase rates of clinician intervention and can increase abstinence rates
  • Identification guides effective and appropriate intervention based on patient’s tobacco use status and willingness to quit
vital signs stamp
Vital Signs Stamp


Blood Pressure:




Respiratory Rate:

Tobacco Use:

Current Former Never

(circle one)

elements of a counseling intervention
Quit date:

Set a stop date, preferably within 2 weeks

Starting on the quit date, total abstinence is essential

Past quit experience:

Identify what helped and what hurt in previous quit attempts

Anticipate triggers or challenges in upcoming attempt:

Discuss challenges/triggers and how patient will successfully overcome them

Elements of a Counseling Intervention
elements of a counseling intervention cont d
Elements of a Counseling Intervention (cont’d)
  • Alcohol:
    • Since alcohol can cause relapse, the patient should consider limiting/abstaining from alcohol while quitting
  • Other smokers in the household:
    • Quitting is more difficult when there is another smoker in the household
    • Patients should encourage housemates to quit with them or not smoke in their presence
five a s
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 five R's: relevance, risks, rewards, roadblocks, repetition
  • Assess - willingness to make a quit attempt
  • Assist - set quit date, offer pharmacologic and behavioral support
  • Arrange - follow-up to prevent relapse
the five a s of a three minute intervention continued
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.

the five a s of a three minute intervention continued113
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.

the five a s of a three minute intervention continued114
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.

the five a s of a three minute intervention continued115
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.

the five a s of a three minute intervention continued116
Arrange follow-up contact (in person/by phone)


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.

the 5 r s to enhance motivation for patients unwilling to quit
The “5 R’s” to Enhance Motivation for Patients Unwilling To Quit
  • RELEVANCE: Tailor advice and discussion to each patient
  • RISKS: Discuss risks of continued smoking
  • REWARDS: Discuss benefits of quitting
  • ROADBLOCKS: Identify barriers to quitting
  • REPETITION: Reinforce the motivational message at every visit
stages of change
Stages of Change
  • Precontemplative (not ready to consider quitting)
  • Contemplative (planning to quit in next 6 months, no stop date set, ambivalent)
  • Preparation (planning to quit, stop date set)
  • Action (has quit)
  • Maintenance (has not used for more than 6 months)
  • Termination (no longer any serious temptation)
  • Employ consciousness-raising to help the smoker to think of quitting in next six months
  • Discuss smoker’s feelings about the idea of quitting
  • Review advantages of quitting/inconveniences of smoking
  • Counsel about risks of smoking
  • Adapt message to suit the beliefs, knowledge, and attitudes of the smoker
  • Assure that advantages of quitting will be more significant than inconveniences
  • Offer confidence that the smoker can do it
  • Identify obstacles in quitting and explore solutions
  • Encourage the smoker to picture life as an ex-smoker
  • Reinforce the reasons given by the smoker to change
  • Ask smoker to set quit date
  • Explore the possible behavioral substitutes
  • Discuss the strategies and available resources
  • Help smoker to decide on a plan of action
  • Encourage observation of smoking behavior in order to be aware of patterns/vulnerable times
  • Motivate smoker as the planning takes place
  • Support the smoker and the actions taken for change
  • Discuss any relapses and develop plan to deal with relapses as necessary
  • Ask questions about triggers
  • Strongly suggest to the smoker to keep on using strategies for at least three months
  • Refer to group program or support group as needed
  • As necessary, revise therapies
  • Help to recognize and use strategies to prevent relapses
  • Reevaluate the strategies based on smoker’s knowledge, behavior and modify as needed
  • Reinforce reasons for quitting
  • Reinforce self confidence in quitting
  • Encourage rewards!
  • Reinforce decision to quit - commitment!
  • Most smokers say this never really occurs - desire for a cigarette never disappears
  • Maintenance becomes less vigilant over time
  • Withdrawal is manageable
  • No longer any serious temptation
relapse considerations
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
preventing relapse
Preventing Relapse
  • Relapse prevention interventions should be provided with every smoker who has recently quit
  • Crucial to address relapse the first 3 months after quitting
  • Strategies to use with recent quitters:
    • Encourage continued abstinence
    • Invite discussion of benefits, success milestones, problems encountered or anticipated
    • Use or refer to an intensive intervention as appropriate

Patient’s task to articulate and resolve ambivalence.

Clinician’s role to help him/her examine and resolve ambivalence.

special populations
Special Populations
  • In general, treatments found to be effective in the guideline should be used with all populations
  • Some special populations may have concerns that can be addressed within the context of treatment:
    • Women
    • Racial and ethnic minorities
    • Adolescents
    • Older smokers
pregnant smokers
Pregnant Smokers
  • Augmented interventions approximately doubles abstinence rates relative to usual care
  • Greatest health benefits result from cessation early in pregnancy, however, pregnant women should be encouraged to quit anytime during pregnancy
  • Pharmacotherapy should be considered when a pregnant woman is otherwise unable to quit, and when the likelihood of quitting, with its potential benefits, outweighs the risks of the pharmacotherapy and potential continued smoking
smokers with comorbidities
Smokers with Comorbidities
  • Smokers with a psychiatric comorbidity or chemical dependency should be offered guideline-based treatments:
    • Psychiatric disorders are more common in smokers than the general population and carry a higher rate of relapse
    • Bupropion SR or nortriptyline should be considered in smokers with a history of depression
    • Smoking cessation does not appear to interfere with recovery from chemical dependency
weight gain
Weight Gain
  • Clinicians should openly address postcessation weight gain concerns:
    • Acknowledge weight gain is likely but typically limited
    • Encourage concentration on smoking cessation now, weight control later
    • Recommend healthy diet and physical activity
    • Consider pharmacotherapy, particularly bupropion SR and nicotine gum, shown to delay (but not prevent) weight gain
non cigarette tobacco users
Non-Cigarette Tobacco Users
  • Smokeless/spit tobacco users can be treated successfully using counseling treatments found to be effective in the guideline
  • Brief interventions in a dental setting can effectively treat smokeless/spit tobacco users
  • Users of smokeless/spit tobacco, cigars, pipes should be identified and offered treatment
metabolic effects
Potentiates Metabolism of:




Adrenergic antagonists


Oxazepam (Serax)

Imipramine (Tofranil)

Propoxyphene napsylate

(Davocet, Darvon)


Antagonizes Metabolism of:

Adrenergic agonists

Metabolic Effects
coding for treatment of tobacco use and dependence
Coding for Treatment of Tobacco Use and Dependence


ADA Code 1320 – Tobacco Counseling for the Control and Prevention of Oral Disease

program agenda
Session 1

Session 2

Session 3

Session 4

Orientation & Introductions

Understanding addiction


Benefits of Quitting

Withdrawal Symptoms

Cessation Strategies__________

QUIT DAY_________________

Motivation Reinforcement

Support Systems

Program Agenda
program agenda136
Session 5

Session 6

Session 7

Session 8

Lifestyle issues:



Stress Management

Relaxation Skills

New Self-image______________

Ex-smokers panel_____________

Graduation & Celebration

Relapse Prevention

Program Agenda
power of intervention
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
the benefits of quitting smoking
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
the benefits of quitting smoking139
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
the benefits of quitting smoking140
The Benefits Of Quitting Smoking
  • Children in households will be less likely to become smokers once their parents quit. All family members will be exposed to less second-hand smoke.
  • Former pack-a-day smokers save about $120-190 a month.
oral benefits of quitting
Oral Benefits of Quitting
  • Mortality ratios for oral cancer diminish
  • Premalignant lesions may regress after the discontinuation of smoking or stopping smokeless tobacco use
  • Decreases the risk of second or multiple primary tumors in patients with a previous cancer of the oral cavity or pharynx
  • There is abundant evidence that the rate of bone and attachment loss slows after patients quit smoking
  • Former smokers respond to non-surgical and surgical therapy, including implant success rates, in a manner similar to never smokers
why dental hygienists
Why Dental Hygienists?
  • Have interviewing skills.
  • Have educating skills.
  • Have motivating skills.
  • Have counseling skills.
  • Dental hygiene is the most frequently provided service.
  • Follow-up procedures have always been an important part of the dental hygiene practice.
systems changes
Systems Changes
  • Can reduce smoking prevalence.
  • Makes it easier for dental hygienists to help tobacco users quit.
  • Requires changes in the systems in the profession and in the dental office.
  • A simplified approach is more likely to lead to successful interventions.
  • A simplified approach opens the door to more intensive interventions.
systems changes in the dental office
Systems Changes in the Dental Office

A system in the office can be brief, simple and does not need to disrupt the practice routine.

  • Organize the team and assign team duties and responsibilities.
  • Implement an office-wide tobacco user identification system.
  • Identify and track tobacco use status.
  • Refer tobacco users to a quitline.
program responsibilities
Program Responsibilities

Dentist: Program Director

ADVISE to quit, prescribe pharmacotherapy.

Dental Hygienist: Program Coordinator

Determine willingness to quit, REFER to quitline. Track tobacco use status.

Dental Assistant

Assist front office making follow-up calls concerning quit dates.

Front Office

Update health history and ASK about tobacco use status. Telephone patient/client just before and soon after quit date.

make it a priority
Make it a Priority!
  • 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
  • The health care system’s neglect of the tobacco user exacts costs that sum to thousands of lives and billions of dollars in added health care expenditures
in summary
In Summary
  • Brief tobacco dependence treatment is effective and every patient who uses tobacco should be identified, urged to quit, and offered at least one of these treatments:
    • Patients willing to quit should be provided treatments identified as effective
    • Patients unwilling to quit should be provided an intervention to increase their motivation to quit
  • Nicotine dependence is a chronic condition
  • Every patient who uses tobacco should be offered treatment
  • It is essential that clinicians and health care delivery systems institutionalize the consistent identification, documentation and treatment of every tobacco user
  • Brief tobacco dependence treatment is effective
  • There is a strong dose-response relationship between the intensity of tobacco dependence counseling and its effectiveness
  • Numerous effective pharmacotherapies now exist
  • Tobacco dependence treatments are both clinically effective and cost-effective relative to other medical and disease-prevention interventions
“Lives saved from smoking cessation would swamp all the benefits accrued if each year every person underwent every cancer screening procedure recommended by the American Cancer Society.”–

Steven A. Schroeder, MD

Medical Director

Smoking Cessation Leadership Center


Health professionals shouldn’t grade themselves on how many people they can “get” to quit, but rather how many times they give the messagewhen the opportunity arises.

Under these criteria, there is no reason not to have an intervention success approaching 100%

about the adha website
About the ADHA Website

Available to download for all dental hygienists and their clients:

  • Protocols & Scripts Document
  • PowerPoint Presentations
  • Fact Sheets (for the Consumer & the Dental Hygiene Professional)
  • Ask. Advise. Refer. Flyer
  • Liaison Resource List
  • Quitline Resource List
  • Relevant State & National News and Announcements
  • The Center for Tobacco Cessation
  • Addressing Tobacco in Managed
  • NCI site
surgeon general s web site
Surgeon General’s Web site
  • The full text of the guideline documents and the meta-analyses references for online retrieval are available at:

  • The Clinical Practice Guideline
  • The Quick Reference Guide
  • Consumer Versions
adha s sci project consultant
ADHA’s SCI Project Consultant

Carol Southard, RN MSN

Smoking Cessation Initiative Project Consultant

American Dental Hygienists' Association

444 N. Michigan Ave., Suite 3400

Chicago, IL 60611

1-800-243-ADHA, ext. 220


  • Clinical Practice Guideline Panel and Staff, A Clinical Guideline for Treating Tobacco Use and Dependence. JAMA, 283, 3244-54, 2000.
  • Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence. Rockville, MD.: Department of Health and Human Services, Public Health Service, 2000.
  • Hughes, JR. New treatments for smoking cessation. Cancer Journal for Clinicians 2000; 50: 143-155.
  • Lancaster T, Stead L, Silagy C, Sowden A. Effectiveness of interventions to help people stop smoking: findings from the Cochrane Library. BMJ 2000; 321: 355-8.
  • Rigotti, N. Treatment of tobacco use and dependence. New England Journal of Medicine 2002; 346: 506-512.
  • US Department of Health and Human Services, Clinical Practice Guideline: Treating Tobacco Use and Dependence. US Department of Health and Human Services, Public Health Service, June 2000.
  • US Department of Health and Human Services. The Surgeon General’s Report on The Health Consequences of Smoking. US Department of Health and Human Services, Public Health Service, 2004.
adha s smoking cessation initiative
ADHA’s Smoking Cessation Initiative
  • Ask about tobacco use
  • Advise those who use to quit
  • Refer to a tobacco quitline and/or provide cessation treatment options