4. Tobacco Cessation Counseling Flashcards
Additional Health Consequences
Reduced \_\_\_\_ response • Premature \_\_\_\_ and wrinkling • Increased risk of \_\_\_\_ and macular degeneration • Increase in \_\_\_\_, decrease in \_\_\_\_ Increase \_\_\_\_ secretion in stomach • Impotence and \_\_\_\_ • Disruption of menstruation and menopause • Increase in risk in \_\_\_\_
immune aging cataracts LDL HDL acid infertility SIDS
Smoking and Periodontal Disease • Smoking promotes periodontal disease – Depresses immune function, especially \_\_\_\_ – Accelerates rate of \_\_\_\_ loss
• Smoking affects treatment of periodontal disease:
– Delaying ____
– Suppressing immune response
– Correlated with implant failure
PMN’s
alveolar bone
wound healing
Oral Effects of
Second Hand Smoke
• Children exposed to smoking in home have about ____ the rate of caries in primary teeth than children in non-smoking homes
• ____ also promotes the growth of microbial biofilm and bacteria and in smokers
• Caries is a ____ disease: smoking parents who kiss children pass on cariogenic bacteria
• Non-____ effects aswell
double
nicotine
communicable
oral
Other Oral Effects of Smoking • Bad \_\_\_\_ • \_\_\_\_ Teeth • Altered sense of \_\_\_\_ and \_\_\_\_ • “Smoker’smouth” – As a dentist, you will recognize smokers immediately...even if they deny it
breath
discolored
taste
smell
Oral Health Effects of Smokeless Tobacco
- Oral cancer, ____ cancer & Leukoplakia • Caries
- Gingival recession & Periodontitis
- Damage to oral bone structure
pharyngeal
Other Effects of Smokeless Tobacco • Addiction • Higher amounts of \_\_\_\_ than cigarettes • Increase in \_\_\_\_/ heart rate • Tooth \_\_\_\_ • Impaired \_\_\_\_
nicotine
BP
abrasion
taste
Tobacco Prevalence Rates (CDC,2015)
Healthy People 2020 Target: 12% adults 16% teens
• Current Rates for Cigarette Smoking
16.7% men, 13.6% women, 8.2% teens, 8.4% seniors
• Current Rates for Spit Tobacco (Target 0.3%)
3.4% all adults; 6.7% men, 0.3% women
Highest in ____, WVA, ____ and Mississippi
Lowest in ____, Hawaii, ____ & California
• Current Prevalence Rates for Cigars (Target 0.2%) 8.2% men, 2% women, 7.5% Black adults; 14% teens
wyoming
montana
DE
massachusetts
US Smoking Prevalence • \_\_\_\_ (21.9%) • Non-Hispanic whites (16.6%) and non-Hispanic blacks (16.7%) • Hispanics (10.1%) and Asians (7%) • Those below poverty level (\_\_\_\_%) • Less than HS education (\_\_\_\_%) • Live in the Midwest (18.7%)
____ High Smoking Rate at 19.9%
American Indians/Alaska Native
26.1
24.2
Philadelphia
Advocate Community Interventions
• No-____ zones, ie Penn campus wide ban, restaurants
• High ____, Phila now 3rd highest in nation for cigarettes, still low for ____ tobacco
• Increased enforcement of age ____ sales
• Ban on tobacco company ____ and support of sport events
smoking taxes spit 21 promotions
2016 Philadelphia Cigarette Tax raised cost to $4.60 per pack, ____ highest in nation
third
Types of Tobacco
• ____
• Smoking
• ____
smokeless
e-cig
Types of Tobacco • Smokeless – \_\_\_\_ tobacco – Chewing tobacco – \_\_\_\_ tobacco
dipping
snuff
Popularity of Chewing Tobacco
• Traditional Sports Affiliation
• Increasing Use with ____ Girls & Women
• Recommendation as Harm Reduction
• Novel Use as Cigarette Replacement in ____ or ____
• SNUS
teen
workplace
airplanes
E-Cigarettes
• Personal vaporizer (PV)
• PEG, PG, Nicotine
• Harm reduction strategy
• Little ____ on safety
• 2016 FDA strict ____ apply to all tobacco products including tobacco bans, ads, & age limits
• Early adoption 2006-2012, ____ consumption in 2015 due to safety concerns & cost
research
regulations
decreased
Smokeless Tobacco:
A Unique Opportunity
• Use is often missed by other ____
• Dental visit is ideal venue to address this problem:
– Routinely ask about use & perform screening
– Discuss ____
– Encourage substitution & cessation
health professions
negatives
Your Role (Cont.)
• Dental professionals are not expected to be ____
• Do what you are comfortable with
• Discussing cessation elevates importance
– Reinforcing a common message
- motivate, ____ and ____
psychologists
educate
refer
Rationale for Tobacco Cessation
• Current Behavior Change Issues
– Average of ____ attempts to quit for good
– ____ at least one attempt ever; 44% in 2010
• ____ behavior more difficult
• Physical as well as ____ addiction
• ____
– People like being told “good job!”
– A little enthusiasm and support can go a long way
– You may be the only person in their life that genuinely cares if they quit smoking
5 70% subtracting psychosocial encouragement
The Five A’s
- ____
- ____
- ____
- ____
- ____
ask advise assess assist arrange
Assess
- Yes: refer to ____ programs
- No: discuss ____
cessation
barriers
The Stages of Change
Behavior change usually occurs in ____ stages
- Not considering ____
- Thinking about ____
- Quitting
- ____
- Relapse
discreet
change
quitting
maintenance
• Not Thinking about Quitting
– Educate, but don’t ____
• Thinking About Quitting
– Motivate, Educate____
• Quitting Now – Encourage & \_\_\_\_ • Maintenance – Support \_\_\_\_, Emphasize Benefits • Relapse – Motivate, Educate, Refer
push
refer
refer
absitnence
EDUCATE
• ____ oral cancer screening
• ____ effects of smoking/tobacco use on oral
health and general health
• ____ smoking cessation products
• ____ behavioral treatment
• Again: You ARE NOT a psychologist or cessation expert. You are a (valuable) resource for information and education.
conduct
review
discuss/recommend
discuss/recommend
Conducting an Oral Cancer Screening
• Standardized ____ & ____ Oral Examination – Tell them what you are doing and why you are
doing it
• Educating Patients Regarding Examination
• Community Oral Cancer Screening Programs – Philadelphia Oral Cancer Walk & 5K
– Free oral cancer screenings! – Great way to get involved
extra
intra
Treating Each Aspect • Physical Addiction – \_\_\_\_ Products • Habit/Behavioral – \_\_\_\_ • Psychological Dependence – Distinguish \_\_\_\_ vs. Reality
cessation
coping
myth
Physical Addiction • Addictive substance: \_\_\_\_ • Reinforcer – Releases \_\_\_\_ in brain – Produces pleasure – Gets to brain in one to two minutes
• Withdrawal Syndrome
– Levels begin to drop ____
– Negative feelings occur
nicotine
immediately
Typical Smoking Pattern • Usually in withdrawal upon \_\_\_\_ • First cigarette leads to \_\_\_\_ peak • Serum levels begin to drop immediately upon completion of cigarette • Withdrawal occurs • Next cigarette is smoked to relieve withdrawal • Pattern is repeated throughout the a day
waking
quick
Nicotine Absorption
Readly absorbed from:
- respiratory tract: ____
- nasally: ____
- orally: ____
- skin: ____
Minimal stomach absorption due to ____
1-2 min
5-10 min
10-16 min
6-9 hours
acidity
Nicotine Absorption
• Nicotine replacement therapy works well in eliminating the pleasurable effect because ____ the products take much longer to produce peak concentrations.
• The “hit” or buzz one gets from smoking cannot be achieved from using these products.
• Therefore, it is generally quite difficult to become ____ addicted to any smoking cessation medication.
• This is why e-cigarettes or vaping will not ____ nicotine dependence. Their rapid absorption provides the same “hit” as cigarettes, creating the same withdrawal-usage pattern throughout the day.
all
physically
reduce
Other Effects of Nicotine • Effects depend of dose • Stimulant/tranquillizer • Increases \_\_\_\_ • Increases \_\_\_\_ and motor activity • Some evidence to suggest it facilitates \_\_\_\_ and decreases aggression • Slight shift in \_\_\_\_
respirations
GI tone
memory
metabolism
Nicotine Delivery from Smokeless Tobacco
- Does not deliver the ____ of nicotine as smoking does
- Generally speaking, smokeless tobacco contains much ____ levels of nicotine
- Therefore, smokeless tobaccos are just as ____ as cigarettes
“hit”higher
addicting
Withdrawal
- ____
- anxiousness
- ____
- restlessness
- ____
- cravings
- ____ disturbances
- increased appetite
irritability
impatience
depression
sleep
Pharmacotherapy: Nicotine Replacement Therapy (NRT)
Benefits
– Prevent ____ withdrawal symptoms to allow cessation of behavioral habit
– Eliminates the ____ effect of nicotine when administered through smoking
– Gives the quitter the time to comfortably break the habit and psychological dependency
– Delay or Decrease ____
physical
reinforcing
weight gain
Pharmacotherapy: Nicotine Replacement Therapy (NRT)
• Nicotine Toxicity
– ____
– Dizziness
– ____/vomiting/diarrhea
– Very ____ even with concomitant use of NRT and smoking
perspiration
nausea
rare
FDA Approved “First Line” Medication Recommendations
____
Nicotine Patch
Nicotine Gum Nicotine Lozenge
____
Nicotine Inhaler
Nicotine Nasal Spray Bupropion SR 150mg Varenicline 1mg
over-the-counter
prescription
Pharmacotherapy: Limitations
Not “magic pills”, and not a “cure” • Work best when combined with \_\_\_\_ counseling: – In office if you are inclined or – Refer to • Local programs • Medication sponsored program • PA Free Quit Line: 1-877-724-1090
behavioral
Recommending vs. prescribing
• Patch, Gum and Lozenge are over-the- counter
• FDA has certified these products as safe
– Side effects are ____
• Clinical Practice Guidelines show that:
– These products are efficacious
– They double or triple ____
• ____ products is good health care
minimal
success
recommending
Patch: Heavy Smokers
• ____ 24/16 Hours
– 10/day or more
– 21mg x 6wks, 14mg x 2wks, 7mg x 2wks
• ____ 24/16 Hours
– 20/day or more
– 21mg x 3/4wks, 14mg x 3/4wks, 7mg x 3/4wks
nicoderm CQ
habitrol
Patch: Heavy Smokers
• ____ 16 Hours
– 10/day or more
– 15mg x 6wks, 10mg x 2wks, 5mg x 2wks
• ____
– 15 day or more
– 22mg x 6wks
Nicotrol
Private Label
Moderate Smokers
• ____ (Less than 10/day)
– 14mg x 6wks, 7mg x 2wks
• ____ (Less than 20/day)
– 14mg x 3/4wks, 7mg x 3/4wks
• ____ (Less than 15 day)
– 11mg x 6wks
• ____ not recommended for light smokers (no studies done)
Nicoderm
Habitrol
Private Label
Nicotrol
Light Smokers • \_\_\_\_ cigarettes a day or less – \_\_\_\_ is generally not recommended – If quitter insists use only the lowest patch strength for a few weeks – Suggest \_\_\_\_, lozenge or \_\_\_\_
5
NRT
gum
inhaler
Patch Patient Counseling
• Apply ____
• Apply a new patch every day to a different,
dry, clean, hairless place
• Rotate sites over a ____ day period
• Do not leave on for more than ____ hours
• Do not use if using ____ (____ hour bolus left in skin when removed)
promptly seven 24 tobacco 4
Patch Side Effects
• ____ Dreams
• Localized Skin Reactions (rash, pruritis, burning)
– Up to 50% of patients have mild form
– Incidence higher with ____ hour products
– Less than ____ discontinue therapy
vivid
24
5%
Nicotine Gum • \_\_\_\_ (Original, Mint, Orange) • Generic • Both come in – 2mg (< 25 cigarettes a day) – 4mg ( >25 cigarettes a day) • Option of choice for heavy \_\_\_\_ tobacco users
nicorette
smokeless
Dosing Gum • Schedule the same for 2mg and 4mg • Weeks 1-6 – 1 piece every one to \_\_\_\_ hours • Weeks 7-9 – 1 piece every \_\_\_\_ hours • Weeks 10-12 – 1 piece every \_\_\_\_ hours
two
2-4
4-8
Gum: Patient Counseling
• Must use on a ____, consistent basis throughout the day (at least 9 pieces)
• Use for a full ____ months with a fixed tapering schedule
• Do not use more than ____ pieces in one day
• Avoid ____ or drinking with gum in mouth
• Additional pieces can be used ____ to deal with specific urges
regular three 24 eating PRN
Proper Gum Technique • Do Not \_\_\_\_!! • Proper technique – Activate slowly until “\_\_\_\_” emerges – Then park between cheek and gum – When taste disappears, move to another spot and repeat – One piece is usually good for \_\_\_\_ minutes
chew
peppery taste
30
Gum Precautions
Incorrect use may lead to:
- mouth ____
- ____, hiccups, etc.
- ____ ache
soreness
dyspepsia
jaw
Lozenge
• “Commit”
• ____ administration
• ____ Acting
• Mint Flavor
• 2mg—first cigarette > 30 min. from waking
• 4mg—first cigarette < 30 min. from waking
• Weeks 1-6: – One piece every one to two hours • Weeks 7-9: – One piece every two to four hours • Weeks 10-12: – One piece every four to eight hours
sublingual
quick
Oral Inhaler
• ____
• Two part mouth piece enclosing nicotine
cartridge
• Cartridge = ____mg nicotine
• Mimics the ____ aspect of smoking
• Use 6-16 cartridges/day puffing as needed for up to ____ months
prescription
10
oral
six
Nasal Spray
• ____
• One metered spray contains ____mg nicotine
• One to two sprays in each nostril per ____, initially—increase as needed
• No more than 5 doses/hr. or 40 does/day
• Use for eight weeks then taper for 4-6 wks.
prescription
0.5
hour
Precautions for NRT Use • \_\_\_\_ within two weeks • Unstable \_\_\_\_ • Dysrhythmia • \_\_\_\_ NRT Contraindicated in \_\_\_\_
MI
angina
hypertension
pregnancy
Efficacy of NRT
• Using NRT produces doubles or triples the long term quit rates over placebo
• Caution: Not a magic bullet
– Not a ____ for smoking
– Part of a comprehensive treatment program
– Most effective when combined with a ____ modification program
cure
behavior
Oral Effects of NRT
• Gum
– Not recommended for individuals with extensive dental work, dentures, or ____ disorders
• Lozenge
– May cause minor mouth ____ if left in one spot too long
• Oral Inhaler
– Nicotine vapor mist may irritate ____
• Patch/Bupropion/Varenicline – No ____ effects
– May be ideal for patients with oral concerns
TMJ
sores
mouth
oral
Safety Concerns
• These are nicotine ____ products
• Using the patch, gum or lozenge does not
introduce anything ____ to the smoker
• Smokers simply get nicotine in a way that
allows them to comfortably reduce usage
• AMA, American College of Cardiology and many other medical societies strongly encourage use
replacement
new
Buproprion SR 150mg (Zyban) • Repackaging of \_\_\_\_ • May increase \_\_\_\_ • Begin 1-2 weeks prior to \_\_\_\_ • Start 150 mg daily, target dose 150mg twice daily • 7-10 weeks of therapy: no tapering
wellbutrin
dopamine
quitting
Buproprion SR 150mg
• Drug interactions:
– Tricyclic antidepressants (lowers ____
threshold)
– MAOI (____ crisis)
• Absolute contraindication: ____ disorder or ____ trauma, ____
• Relative contraindications: Anxiety Disorder, PTSD, Bulimia and Anorexia
seizure hypertensive seizure head pregnancy
Buproprion SR 150mg
• Side effects: ____, insomnia, agitation
– If occurs with initial use of SR Q/day then try
75mg ____ release
– Can be minimized by:
• Reducing SR dosage to ____ daily
• Give entire dose in ____
• Move second dose to as ____ in day as possible
– SR Q/day vs. BID give almost identical ____ mth quits
dry mouth immediate once morning early 6
Varenicline 0.5 - 1mg
• Begin with .5mg taken 1 week before cessation, increase to 1mg on quit date
• Monitor for changes in ____, evaluate for depression and suicide ideation (2008 Warning)
• Side effects: ____, Nausea, ____, Abnormal, vivid strange dreams
• Contraindication: ____ or Psychiatric illness
• Caution with Kidney Disease & Dialysis Patients
____ for Combination Therapy with NRT
mood dry mouth insomnia pregnancy not approved
Combination Therapies
• Clinical trials show that using ____ and ____ increases quit rates over using either alone
– Probably best for ____ smokers: > 2packs/day
• Can use patch or Buproprion as ____ therapy
• Gum, lozenge or inhalers can then be used PRN for specific trigger situations
• CANNOT Use ____ in combination with NRT
patch buproprion heavy "base" varenicline
Any Exceptions? Medical Contraindication \_\_\_\_ Women Adolescents \_\_\_\_ Users Light Smokers(
pregnant
smokeless tobacco
10
Other Products • No clinical evidence of efficacy: – Other \_\_\_\_ – Nicotine Lollypops – Nicotine \_\_\_\_ – Nicotine Water – \_\_\_\_ Remedies
Other Treatment Modalities • \_\_\_\_ • Acupuncture • Ear Clips • “Fake” cigarettes • \_\_\_\_ • Nicotine Fading • \_\_\_\_ Techniques
antidepressants
lip balm
herbal
hypnosis
tapering
aversive
REFER
• Local MD specializing in cessation
• Hospital/Community based groups
• Pharmacists specializing in smoking cessation
• American Lung Association/American Cancer Society
• Private therapists
Other Referral Sources • Product support programs • PA Free Quit Line 1-877-724-1090 • Five proactive phone calls • 24-hour support • Online Support Programs
YA
Elements of a comprehensive cessation program
• ____ has been specifically trained as a smoking cessation specialist
• Program is multi-session with follow up
• Smoking cessation medication use is
encouraged and monitored
• Emphasizes coping skills and problem solving
• Provides intra- and extra- treatment social
support
• 6-month and one year quit rates are over ____%
counselor
35
Special Consideration
• Maintenance Phase: staying quit • Support and Encourage
– “Keep up the good work!” – “I am proud of you!”
– Rewards
• Encourage compliance – Medication regime – Behavioral changes
• Strategize about potential barriers
YA
