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RSBO. 2012 Apr-June;9(2):193-8
Literature Review Article
Tobacco cessation: what role can dental
Abhishek Mehta1Gurkiran Kaur2 Corresponding author:
Dr. Abhishek Mehta
Associate Professor and Head Dept. of Public Health Dentistry, Dr. H. S.
Judge Institute of Dental Sciences and Hospital, Panjab University
Chandigarh (UT)-14
E-mail: [email protected]
¹ Associate Professor and Head, Dept. of Public Health Dentistry, Dr.H.S.Judge Institute of Dental Sciences and Hospital, Panjab University – Chandigarh (U.T.).
² Reader, Dept. of Oral and Maxillofacial Pathology, Gian Sagar Dental College and Hospital – Banur – Distt. Patiala – Punjab.
Received for publication: June 14, 2011. Accepted for publication: November 17, 2011.
Keywords: tobacco
cessation; dental Introduction: Tobacco dependence is classified as a disease by the
professional; nicotine International Classification of Diseases (ICD-10), but, medical and replacement therapy; dental professionals have neither seriously taken this fact nor made oral medicine; smoking any serious attempt to tackle this disease. Apart from supporting wider tobacco control measures, oral health professionals can help
patients to stop using tobacco. This may be the single most important
service dentists can provide for their patients' overall health. Objective:
This review is prepared with the object to help both clinicians and oral health professionals to scale up their involvement in tobacco control activities, including advocacy and smoking cessation programs. Literature review: St
that they want to quit, but a meagre 2�� succeed. The setting provides a unique opportunity to assist tobacco users in
achieving tobacco abstinence. Still, More than 40�� of dentists do
not routinely ask about tobacco use and 60�� do not routinely advise
tobacco users to quit, while 61.5�� of dentists believe their patients
do not expect tobacco cessation services. Conclusion: Interventions
by dentist has been found to be effective in helping people to quit tobacco consumption. A step-wise approach and patience must be adopted while dealing with such patients.
194 – Tobacco cessation: what role can dental professionals play? on quitting tobacco is still neither a routine part of clinical practice for many oral health professionals Currently, there are an estimated 1.3 billion nor are many National Dental Associations (NDAs) smokers in the world. The total global prevalence involved in tobacco control. in smoking is 29�� (4�.5�� of men and 10.3�� of To implement a tobacco cessation program, women over 15 years of age smoke). Of the 1.3 clinicians should systematically identify all billion smokers, more than 900 million live in tobacco users at every visit. A system needs to developing countries out of which 120 million are be implemented in the clinic which ensures that there in India [1]. Tobacco is the second major cause tobacco use status is obtained and recorded at of death in the world. It is currently responsible each patient visit. This may be carried out by for the death of one in ten adults worldwide. Every the clinician or an assistant who may be trained 6.5 seconds one tobacco user dies from a tobacco- accordingly. The forms of tobacco use such as related disease somewhere in the world. Cigarettes cigarettes/beedis/gutkha, frequency and duration kill half of all lifetime users and half of those die of use can be mentioned [9].
in middle age (35-69 years), losing an average Current evidence suggests that even brief advice of 20 to 25 years of life . With current smoking leads to an absolute increase in the cessation rate patterns, approximately 500 million people alive of about 2.5��. This indicates that for every 40 today will eventually be killed by tobacco use. By patients who receive brief advice, one will quit 2030, tobacco is expected to be the single biggest smoking permanently. Given the high prevalence cause of death worldwide, accounting for about 10 tobacco consumption and that �0�� see a clinician million deaths per year [4]. or a dentist at least once a year, interventions As research on the effects of tobacco on health with patients who are tobacco users, can have an continues and the number of affected people enormous impact [�]. As a dentist, one has the increases, the list of conditions caused by tobacco unique opportunity to link the patient's presenting has expanded. There is nowadays evidence that illness to his/her tobacco use, and then prescribe almost every organ in the body is affected by tobacco tobacco cessation therapy. Table I [15] depicts a consumption and now it also includes cataracts, brief guideline on how to advice a patient to quit pneumonia, acute myeloid leukemia, abdominal tobacco.
aortic aneurysm, stomach cancer, pancreatic cancer, cervical cancer, kidney cancer, and periodontitis. Table I – Brief guideline on how to advice a patient to
These diseases add on to the already known such as quit tobacco lung, oesophagus, larynx, mouth and throat cancer, chronic pulmonary and cardiovascular diseases, 1. The timing of advice
as well as negative effects on the reproductive • First and every patient system and sudden infant death syndrome. All • Repetition of advice in each patient visit these diseases are preventable by removing one • Documentation of tobacco cessation advice on single risk factor i.e. tobacco use. Therefore it is the prescription pad/ discharge slip imperative that health care professionals including • If patient visits with an acute illness (e.g. pain dentists must help their patient who are addicted in tooth) then that should be addressed first, and to this habit and want to quit. This review is advice should be given at 1st and all subsequent prepared with the objective to help clinicians and oral health professional to understand in a step- wise approach, how they can help their individual 2. The type of advice
patients as well as general populations to quit habit • Customize the ill effects of tobacco as per tobacco of tobacco consumption.
user profile. Need to emphasize the ill effects of tobacco usage that would be most relevant to each particular tobacco user • The patient's current illness needs to be linked to tobacco use. Clarify that the presenting illness will not resolve unless tobacco usage is discontinued Tobacco cessation and dentist's role • Communicate to the tobacco user that there is help available and that the doctor and his staff are The dental team has a major role to play in there to help if the tobacco user is interested smoking prevention. Evidence suggests that smoking • On the basis of patient co- morbidities, age and cessation interventions are effective [2, �]. A brief motivation quotient, dental clinicians need to intervention will often result in significant health decide and advice on a preventive or interventional gain and, in the long term, reduces smoking-related health-care costs to countries. Unfortunately, advice approach for individual tobacco users RSBO. 2012 Apr-Jun;9(2):193-8 – 195 Next step will be to assess patient's readiness • Illustrating the other ill-effects of tobacco use to quit tobacco; it is recommended that every and the positives of quitting; tobacco user's readiness to make a quick attempt • Creating awareness on the availability of medicines should be checked at each visit no matter what to aid in tobacco cessation;the presenting complaint is. Readiness may be • Using successful ex-tobacco users to motivate ascertained in two ways: • Emphasizing and /or demonstrating that tobacco 1. Self assessment by patient use is an addiction and not a personal choice or These questionnaires can be left in the waiting life style.
room or administered by nursing or secretarial However, if a tobacco user is not feeling fully staff (table II). While all patients may not be able motivated to quit and instead chooses to reduce to fill this questionnaire accurately but when it the number of cigarettes/bidis/gutkha packets then is used along with the dentist own judgment, it the clinician should utilize this period to reinforce will definitely enhance the assessment of patient's motivation and eventually drive complete tobacco cessation. This can be done by analyzing the reasons readiness to quit tobacco use.
not to quit and addressing them appropriately. As a last resort a clinician may use a strategy called Table II – Patient assessment — intent to quit
"paradoxical intentional" to motivate the tobacco questionnaire [10, 11] user. Under this strategy, the clinician should ask Q1. Would you like to reduce or quit tobacco use the tobacco user to choose between continuing to if you could do so easily? take numerous medications for the primary illness Yes----1 No----0 or quitting tobacco use. This strategy has been found to be effective in day to day practice.
Q2. How seriously would you like to reduce or If there are tobacco users who insist that this quit tobacco use altogether? is a matter of personal choice and they can give up Not at all----0 fairly seriously----2 whenever they decide to, a clinician can demonstrate Not very seriously----1 very seriously----3 to them that tobacco use is an addiction. Request the user to give up tobacco use for just one day Q3. Do you intend to reduce or quit tobacco use and if they find it difficult, they can come back in the next 2 weeks? to the clinician for help. In addition to clinician's definitely no----0 probably yes----2 individual efforts with tobacco users, they can be Probably no----1 definitely yes----3 also motivated by displaying educational posters in the clinic and distributing educational material Q4. What is the possibility that 6 months from in the form of newsletters, booklets, audio-visual now you will not have a problem with tobacco aids and leaflets.
For tobacco users who express willingness to definitely no----0 probably will----2 try and quit, help set a quit date approximately Probably no----1 definitely will----3 two weeks away. A day personally significant to the tobacco user makes it more relevant e.g. birthday, anniversary etc. The tobacco user should be 2. Assessment by the clinician/dentist encouraged to announce his/her decision to family This can be carried out by the clinician on a members, friends and colleagues so as to mobilize simple assessment of the patient's body language, their support as well as induce accountability. It is eye contact etc. this can be done on a simple three- strongly recommended that the tobacco user give point scale initially- not ready / unsure/ ready to quit up completely in one go on the quit date.
[14]. For those tobacco users who are not ready to quit, an attempt should be made to motivate them Pharmaco-therapeutic interventions by giving them clear, strong, personalized advice. Building motivation is an important element in Dental clinicians need to offer the option moving tobacco users from one stage to the next. of pharmacotherapy to all patients initiating a Like treatment, strategies to build motivation need quit attempt. FDA approved medicines includes: to be individualized. Motivation can be built by Varenicline, Bupropion and Nicotine Replacement using a combination of one or more of the following Therapy (NRT). These medications have been found techniques: to be safe and effective for the tobacco dependent, • Linking the present illness to tobacco use, when except in the presence of contraindications or with possible; specific populations for whom there is insufficient 196 – Tobacco cessation: what role can dental professionals play? evidence of effectiveness (e.g. pregnant woman and other forms of tobacco and to reduce the severity adolescents). These first line medications have an of nicotine withdrawal. NRT dosage is calibrated established empirical record of effectiveness, and on the basis level of tobacco dependence. The clinicians should consider these agents first in level of tobacco dependency can be checked by choosing a medication.
asking patient to fill a simple six question closed- ended questionnaire [5]. Forms of NRT currently Bupropion was approved for smoking cessation by the US FDA in 199�. Its possible mechanisms a) Nicotine gum (2 mg or 4 mg/OTC) of action include blockade of neural re-uptake The gum should be chewed slightly until a of dopamine and norepinephrine, and blockade peppery/mint flavor is tasted then ‘parked' in the of nicotinic acetylcholinergic receptors. It is vestibule with the cycle repeated in approximately contraindicated in patients with a seizure disorder, 30 minutes. If the gum is chewed too rapidly, the a current or prior diagnosis of bulimia or anorexia patient may feel ill due to the rapid release of nicotine nervosa, use of monoamine oxide (MAO) inhibitor into the system. In addition acidic beverages may within the previous 14 days, or in patients taking interfere with the absorption of nicotine. Patients another medication that contains Bupropion. with dentures or temporomandibular joint problems Recommended dosage for Bupropion is150 mg have reported difficulties chewing the gum and may twice daily.
benefit from the NRT lozenge.
2. Varenicline [10] b) Nicotine Transdermal Patch (� mg, 14mg, 21 It is clinically proven to be most effective mg / OTC) smoking cessation treatment and patients should The transdermal patch is applied directly to be encouraged to use it. Varenicline is a non- the skin allowing nicotine to be absorbed through nicotine medication that was approved for smoking the skin. Up to 50�� of patients experience mild cessation by US FDA in 2006. It is partial agonist skin irritation, which often clears up in a few days. at α4β2 receptors designed to provide relief from Insomnia has also been reported in connection craving and withdrawal (negative reinforcement), with the transdermal patch.
as well as diminish rewa rd from smoking (positive reinforcement). Varenicline has produced c) Nicotine inhaler (prescription only) significantly higher quit rates than Bupropion and Nicotine from the nicotine inhaler is not actually NRT in multiple randomised controlled trials. It is inhaled. The patient takes a puff from the inhaler, well tolerated, with nausea being the most commonly holds the aerosols in the mouth and pharynx area, seen adverse event. To avoid nausea, it should be and then exhales. Mouth and throat irritation, taken with a glass of water after food. Caution is coughing, and rhinitis are common though these advised during its use in patients with a history reactions are often temporary.
of neuropsychosis disorder, though a recent cohort study in UK reported it to be safe and efficacious in d) Nicotine nasal spray (prescription only) such patients. Recommended dosage and duration Nicotine nasal spray poses local irritations with 94�� of users reporting moderate to severe nasal of varenicline are shown in table III.
irritation initially and 81�� reporting irritation after three weeks of use. In addition about 15-20�� Table III – Recommended dosage and duration of
of patients report using the nicotine nasal spray Varenicline therapy longer than recommended because it is potentially • Minimum duration of therapy : 3 months • 1st week - 0.5mg once daily for 3 days and e) Nicotine lozenge (2 mg or 4 mg/OTC) twice daily for next 4 days The nicotine lozenge is a new and effective • 2nd week (quit date) – 1mg twice daily nicotine replacement delivery system that seems to • 3rd-12th week (continuing treatment) – 1mg have addressed many of the drawbacks reported with other NRTs. When placed in the vestibule, the lozenge is able to deliver the whole dose of nicotine. 3. Nicotine replacement therapies (NRTs) [3] Researchers found the lozenge delivered 25�� to 2��� Nicotine replacement therapy medications more nicotine than the same dose of nicotine gum deliver nicotine with the intent to replace, at least due to the retention of nicotine in the gum base. partially, the nicotine obtained from cigarettes or With the increase of available nicotine, participants RSBO. 2012 Apr-Jun;9(2):193-8 – 197 found they experienced less cravings. Similar to In case the patient relapses, the clinician must nicotine gum, acidic beverages may interfere with identify cause of relapse (clinician and social), be the absorption of nicotine, therefore, patients should accepting and empathetic towards the patient and be advised to avoid coffee, juices, and soft drinks refer the patient to suitable specialist for co-morbidity 15 minutes before they use the lozenge.
evaluation and treatment, if need is felt.
Once you are sure patient has quit tobacco Supportive therapy, follow-up and relapse habit successfully, congratulate and encourage the patient on his/her efforts, discuss coping strategies for withdrawal symptoms, urges and triggers, review Dentist must consider supportive therapy for use of tobacco cessation medication, if relevant use on a case – by – case basis after first line and develop a specific extended follow-up plan that medications (either alone or in combination)have includes several visits or numerous phone contacts. been used without success or are contraindicated As a part of extended follow up, clinicians need to and he/she should consider referrals to specialist monitor the patient for a minimum of three months. like chest physician or psychiatrist in your area Ideally, follow-up for a year should be done [13].
for advice and intense counselling.
Tobacco users, who have recently quit, face a Tobacco ce high risk of relapse. Although most relapse occurs Dentist can work with government and non- early in quitting process, some relapse occurs government organizations working for tobacco months or even years after the quit date. The best cessation in your area, he/she could: strategy for producing high long term abstinence • Contribute to the formulation of national plans rates appears to be the use of the most effective of action for tobacco control; cessation medication during the quit attempt and • Work with other health professional organizations providing practical advice and motivation in each to develop a common position on tobacco control visit. The first prescription is advised for at least and consider establishing a coalition; 15 days, making it a point to emphasize the total • Use the news media and work with politicians to duration therapy, follow up with the patient should make them feel that it is in their interest to accept be. First month: weekly contact, 2nd and 3rd months: invitations to meetings and other events that focus monthly and for rest of first year: quarterly. At each on tobacco control issues; visit, dentist has to check for the typical issues • Campaign for smoke-free/tobacco-free health care that arise in tobacco cessation therapy and address facilities to make nonsmoking the norm; them before they result in relapse. Examples of a • Influence the content of health professional few issues and how to address them are as follows education and motivate students by setting up a (table IV).
tobacco control body; • Carry out surveys and prepare regular reports on Table IV – Techniques helpful in relapse prevention [10]
tobacco related issues highlighting tobacco control • Lobby for public and private reimbursement for Consider extending the cessation counseling. use of an approved pharmacotherapy or adding/ combining pharmacological The current literature suggests that dental Provide advice, prescribe interventions conducted in the dental office and Negative mood or appropriate medications, school community setting is more effective than usual or refer the individual to a care for promoting tobacco use cessation. The public health benefits of tobacco cessation interventions Anxiety, irritation, Reassure the patient that within the dental setting are potentially significant feeling depressed these feelings are common and there is an advantage of cessation interventions Reassure the patient that using dental professionals [2]. Tobacco usage is going some weight gain after to emerge as a single most known cause of mortality quitting is common and and morbidity in the world, therefore, it is imperative appears to be self-limiting. that various health agencies and professionals must Advise on proper diet work together to help their patients and public quit this habit at the earliest.
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