From the hit to the quit
Dental professionals are perfectly placed to offer smoking cessation advice to their patients, but few feel comfortable doing so, according to Dr Barry Dace and Dr Rachel Doody
Recent evidence suggests that dental professionals frequently discuss the effects of smoking with their patients. We know the harmful effects, and we are keen to raise awareness to help our patients.
However, how many of us ever get much further than the ‘ask and advise’ steps? What stops us from taking the discussion further, to give helpful practical information that patients can translate into action? In most instances, it’s the fear of not knowing enough about the subject that prevents us from taking the discussion further.
The aim of this short article is to deliver some key information to dental professionals so that they can familiarise themselves with current knowledge in this field – in the hope that they will feel more comfortable talking about cessation strategies.
Current smoking trends
At present 23.6 per cent of the adult Irish population smoke (Office of Tobacco Control figures, 2010). Although this has fallen from over 28 per cent before the workplace ban in 2004, smoking rates are decreasing only very slowly.
Two things have been shown to significantly decrease smoking rates at a population level: higher taxes on tobacco products, and workplace smoking bans. Both of these strategies result in higher quit rates, and decrease the chances of ever starting to smoke. Despite implementing both strategies in Ireland, our residual level of persistent smokers is high. However, a recent study of Irish smokers reveals that 79 per cent want to quit.
The medical cost
Smoking is the leading cause of preventable deaths in Ireland. Lung and other cancers, stroke, acute cardiac events, COPD, and a long list of illnesses are directly related to tobacco smoking. Indeed, last year, smoking directly contributed to the deaths of more than 6,000 Irish people. Compare that with the 2010 figures for Irish road traffic fatalities, where 212 people lost their lives.
No other natural or man-made phenomenon causes this much suffering or premature death. Indeed, no other product, when used as directed, would ever be tolerated to cause such suffering and disease – and that says a lot about the problem we face with tobacco. It’s not a ‘bad habit’ or an ‘individual choice’ for most smokers; it’s one of the strongest chemical addictions we’ve ever known.
Tobacco addiction and cessation strategies
Since smoking is such an addiction, current concepts in cessation strategy treat it as a chemical dependence. Although tobacco smoke contains over 60 known carcinogens, nicotine (the chemical responsible for the addiction) is not thought to be cancer causing.
Smoking a cigarette is the fastest way to deliver the drug to the brain, it’s even faster than the intravenous route, and that’s what makes it so addictive. Indeed, the cigarettes available today are even stronger than those we had õ0 or 20 years ago, as nicotine yields continue to rise. And, while the tobacco industry has shifted its focus on to so-called ‘light cigarettes’ (a name that has recently been banned in the US), it’s important to remember that these cigarettes contain the very same tobacco as their ‘normal’ counterparts. It is only a few laser perforation holes in the paper wrap that make them qualify as ‘light’.
Dental disease and tobacco use
We are all aware of the role smoking and chewing tobacco has on the risk of developing oral cancer. Indeed, the recent initiative by the Cork and Dublin Dental Hospitals was a resounding success in early diagnosis of the condition. The effects of smoking on the dentition are much more widespread and insidious.
For example, periodontal disease is so common in smokers over 50 years of age, that we can more or less assume it is present unless proven otherwise (the odds ratio for periodontitis in a smoker over 50 years of age compared to a younger non smoker is 25.6.* Smokers are also more likely to mask the signs of periodontal disease, as they show less bleeding on probing (despite more disease), and fibrotic hyperkeratoic tissues. They also have more recession, and respond less favourably to both surgical and non surgical periodontal therapy.
The role of the dental team
Dental healthcare providers are in a very privileged position to talk to, and help, tobacco users who are considering quitting. We see our patients frequently, and we have a rapport with them that allows discussion at an informal level. Often, patients are oblivious to the fact their smoking is damaging their teeth and gums, and many don’t realise that tooth loss is much more likely for them than non-smokers.
Smokers tend to ignore the risks of the serious tobacco-associated illnesses. It’s not that they’re unaware of these risks, its just that the consequences are so distant they don’t seem applicable to the individual. For most smokers, telling them more about the risk of heart disease or cancer is unlikely to result in a change of behaviour, as they’re already familiar with this information.
However, when a smoker is shown they have a problem that’s currently there, and that it has potentially very significant consequences (like tooth loss from periodontitis), there is often what’s called a ‘teachable moment’. It is these instances where we may be able to connect with a smoker to trigger a cessation attempt.
It’s important to mention that ‘teachable moments’ are not the only way to trigger a cessation attempt. The majority of smokers want to quit, and they just need some help, information, and guidance in the right direction. This is where we can take it a step further than the ‘ask and advise’ avenue.
‘Counselling’ versus ‘teaching’
Dental professionals are often very good teachers, as we give so much sound information each day. Our tendency is to ‘arm’ the patient with all the reasons why they should quit, and why it’s so bad for them to continue to smoke (usually all in a negative direction).
Evidence suggests that smokers respond poorly to this type of guidance. Cessation attempts are much more successfully triggered when discussions are directed by the ‘counsellor’ (in this case the dental professional), but driven by the smoker. We just need to direct them in discussion so they identify reasons to try quitting. People embrace what they’ve helped bring about, but they resist that which is forced upon them. Once they’ve made a decision, offer them some information about pharmacological aids for cessation, and perhaps direct them to their doctor or a smoking cessation counsellor.
An additional tool is the National Smokers’ Quitline – a free service that has been set up by the Irish Cancer Society and the HSE (the number is 1850 201 203). Once a patient has committed to a cessation attempt, it is important to help them fix a ‘Target Quit Date’, as a fixed date is often the best way to trigger a definitive effort with commitment.
There are currently three FDA approved medical treatments to assist with smoking cessation attempts. While other methods are available and in common use, these three have been conclusively shown in randomised clinical trials to enhance the changes of a successful cessation attempt, the others have not. They are:
1. Nicotine replacement therapy (NRT)
A variety of NRT modalities are available, mostly without prescription. These include long-acting NRT’s like transdermal patches, and short-acting NRT’s such as lozenges, microtabs, gum, inhaler, and nasal spray.
Combined use of a long-acting and a short-acting delivery system can result in even better success rates, as this method provides a background level of nicotine, with intermittent spikes for when cravings are strong.
Many failures with NRT’s relate to under-dosing or too rapid withdrawal, so it’s important that patients have both enough dose and duration. It’s important to mention that no form of nicotine replacement can mimic the rapid transfer to the brain that is produced from a cigarette.
2. Wellbutrin (Zyban)
Wellbutrin has long been used as an anti-depressant, but has the additional effect of reducing the nicotine withdrawal experienced during cessation attempts. It is thought to increase dopamine levels in the brain’s reward centre, mimicking nicotine, although the mechanism is probably more complex than this.
Side effects include insomnia and dry mouth, but one of the interesting benefits is that Wellbutrin appears to help limit the weight gain that many smokers note during a cessation attempt. A slightly increased seizure risk has been reported for Wellbutrin, so routinely its use is avoided in those with a history of seizures, those who have had a brain lesion or surgery, or those who have had previous head trauma.
It can also be used in combination with NRT and results on this multi-therapy approach are encouraging.
3. Varenicline (Champix)
Varenicline is the latest addition to the market, and has shown impressive results in clinical trials. It is a partial agonist for the nicotinic ACh receptor, meaning that it works by partially activating nicotine receptors in the brain to decrease craving and withdrawal. It also blocks the receptor from binding with nicotine, so that smoking while taking the medication has little reward.
Both Wellbutrin and Varenicline now have specific warnings on their packaging about depressed mood and suicidal ideation or behaviour. It is important to note that these adverse effects are extremely rare (but important), and those patients using these medications should be in close contact with their doctor or tobacco treatment counsellor to ensure that they are unaffected.
It should be noted that depressed mood and suicidal ideation can also occasionally be associated with smoking cessation itself, in those not taking these medications.
Cessation rates and relapse
Cessation rates are actually quite low in general, demonstrating the strength of chemical dependency. With ‘will-power’ alone, the one-year quit rate is about one to three per cent. With the use of an FDA-approved medication combined with counselling, the one-year quit rates can be 20-25 per cent.
So, it’s important to remember that more people fail a quit attempt than succeed. However, the good news is that smokers who do make multiple attempts are more likely to be successful at a future quit attempt. It’s vital that the dental team lend an empathetic ear to those who have failed a quit attempt, and give reassurance to the patient not to be too disheartened. If they get themselves ready for another attempt at an identified time, they have another good chance at success.
Tweaking medications, or identifying triggers that led to failure can often help with subsequent quit attempts. Indeed, smokers often have so many triggers in a day that their routine must be significantly altered to try to avoid those mental signals to reach for a cigarette. If these triggers can be identified ahead of schedule, they can be avoided or ‘planned for’ when they do occur.
Dental healthcare providers are perfectly positioned to provide smoking cessation information and guidance to patients who use tobacco products. Familiarisation with the available cessation medications and accepted strategies helps to empower the dental professional to go further than the ‘ask’ and ‘advise’ steps, and into the ‘assist’ stage.
About the authors
Dr Barry Dace and Dr Rachel Doody are both in full time practice limited to periodontics and implant dentistry in Booterstown, Co. Dublin. They are also certified Tobacco Treatment Specialists (Mayo Clinic, Rochester,MN, USA). For further information about their periodontal practice in Dublin, view their website www.number16.ie
*Hyman J.J., Reid B.C. Epidemiologic risk factors for periodontal attachment loss among adults in the United States. J Clin Periodontol. 2003: 30(3): 230-237