Smoking Cessation Flashcards
smoking prevalence in adults
UK population
- 14.1%
Scotland
- 19% , roughly split sexes
Influence of deprivation
- 27% SIMD 1 v 9% SIMD 5
smoking prevalence in young people
Smoking rates for 13- and 15-year olds in Scotland currently very low.
Only 2% of 13-year olds and 7% of 15 year olds were regular smokers (< 1 cig/week)
- Different regular smoker definition in children
97% of 13-year olds and 88% of 15 year olds were non smokers
BUT 17% of children under 16 in Scotland report exposure to smoke in the home
tobacco control Scotland
Scotland very active
- Legislative and fiscal measures
Access to and supply of tobacco
- Age of purchase: 16 to 18
- Plain packaging of tobacco
- Sale of tobacco not visible
- Vending machines
Scotland aims to be tobacco free by 2034
- Chance if current trajectory continues
access to and supply of tobacco in Scotland controls
- Age of purchase: 16 to 18
- Plain packaging of tobacco
- Sale of tobacco not visible
- Vending machines not anymore
dental role in smoking cessation
Tobacco has a profound effect on the mouth.
- Links with oral cancer, perio, implants
3 levels of advice on quitting smoking
Very brief advice (VBA)
- 1 min - opportunistic
Brief advice
- 3-10 min – engage at a slightly higher level
- can include 5As
Detailed advice,
- up to 30 min
- with multiple sessions - -usually not time in dentistry
3As PHE
- ASK:
establish and record smoking status - ADVISE on personal benefits of quitting in light of findings in the mouth
- ACT:
offer help and signpost to local stop smoking service
Smokefree and smiling helping dental patients to quit tobacco
5As brief
ASK your patient
ADVISE your patient
ASSESS your patient
ASSIST your patient
ARRANGE FOLLOW-UP for your patient
3As Scotland Dental (VBA)
Ask your patient about smoking
Advise your patient about smoking
Act by offering individualised help and referral to stop smoking services if appropriate.
what to ASK
ASK about smoking status ( current, ex-, non)
- Once a year, updated in notes
- No of Cigs smoked per day
- No of years a smoker
- Age when started smoking
- What products used ( cigs, cigars, rollups, smokeless)
Measurement of Lifetime exposure/ PACK YEARS
- 1 pack (20) a day = 1 pack year
- 10 cigarettes a day for 10 years = 5 pack years
Quitting history can be quite cyclical – find out where they are
what to ask about Quitting history
- Have you tried before?
- How many attempts?
- What helped you?
- Are you interested now?
- Would you be interested in getting further help and support?
- If interested, proceed with advice and referral
can be quite cyclical – find out where they are
how to work out pack years/measurement of lifetime exposure
need to know
- No of Cigs smoked per day
- No of years a smoker
1 pack (20) a day = 1 pack year 10 cigarettes a day for 10 years = 5 pack years
how to ACT (refer)
Depends on what is available locally re specialist services
- Quit your Way is the national branding
Pharmacy have greater reach, accessibility
Specialist services have greater success
- More experience
CONSIDER - What patient wants - Help/advice given, - Referral Note outcome in patient’s record (important)
Refer Electronically - NHS patients in GDH, for clinicians Trakcare New request ( same as radiology) Other Smoking cessation services
No data yet about no of referrals/successful quits etc
oral side effects of tobacco (4 key)
Smoking causes many oral diseases including oral cancer, potentially malignant lesions
- smokers 2-4 times the risk of non-smokers
Smoking is a modifiable risk factor for periodontal disease
- relative risk for smokers 2-6 times that of non-smokers
Smoking increases dental treatment risks and problems
- Implants/extractions
Smokers have significantly greater medical risks, compromised health and more days of illness.
epidemiology and oral cancer
In the UK, in 2015-2017, there were 12,238 new cases of head and neck cancer
In Scotland, in 2016, there were 1,240 new cases
More men than women, though the ratio is decreasing
Links with deprivation
risk depends on age, genetics and exposure to risk factors
oral cancer aetiology
Tobacco and alcohol are main determinants
- if both are present, risks are synergistic.
a diet high in ACE vitamins thought to be protective.
sunlight
pre-existing mucosal abnormalities
HPV, younger age groups
potentially malignant lesions
Leukoplakia ‘defined as a white patch that cannot be rubbed off’
- Leukoplakia can occur 6x more frequently in smokers
Strong relationship between smoking and development of LK in floor of mouth
- Tobacco pools in bottom of mouth – thus more exposed
Malignant transformation rate varies (0.6-30%)
- Stop smoking may result in disappearance.
leukoplakia
‘defined as a white patch that cannot be rubbed off’
- Leukoplakia can occur 6x more frequently in smokers
leukoplakia and smoking
Strong relationship between smoking and development of LK in floor of mouth
- Tobacco pools in bottom of mouth – thus more exposed
erythroplakia
Patient has long history of chronic white and red lesions of soft palate
more likely for malignant transformation than white patches
- less common but more likely to be malignant
smoking and periodontal disease
Smoking associated with increased rates of alveolar bone loss, attachment loss and pocket formation
40% of chronic periodontitis is attributable to smoking
Smoking demonstrates a dose-response with PDD, as shown by pack-years (1pack/day for a year = 1 pack year)
Has a masking effect on gingival symptoms of inflammation (bleed less)
Prevalence /severity of PDD in former smokers is less than current smokers
Treatment for PDD is more likely to succeed in non-smokers
tobacco use and dental implants success
Failure rate of implants in smokers is at least 2x that in non-smokers
Implants more likely to fail in maxilla – not evenly distributed between maxilla and mandible
There is evidence that quitting, prior to implantation can improve success
smoking effect on gingival symptoms
masking effect (e.g. on bleeding)
treatment for perio disease and smokers
treatment for PDD is more likely to succeed in non-smokers
smoking and prevalence of PDD
Smoking associated with increased rates of alveolar bone loss, attachment loss and pocket formation
40% of chronic periodontitis is attributable to smoking
Smoking demonstrates a dose-response with PDD, as shown by pack-years (1pack/day for a year = 1 pack year)
affect of smoking cessation on PDD
Prevalence /severity of PDD in former smokers is less than current smokers
other tobacco related oral lesions (5)
Staining of teeth, dental restorations and dentures, halitosis
Nicotinic stomatitis (smokers palate)
Smokers melanosis (pigmentation)
Black hairy tongue – stain papilla on tongue
Apthae tend to be less common in smokers
- When they quit more likely to get ROU need support to stay off smoking due to discomfort
Extractions take longer to heal
impact on legislations being put in place and prevalence of smoking
prevalence of smoking reduced in relation to the legislations introduced to help reduce
why do people smoke? (7)
Enjoyment ++++
Keep weight down/appetite depressant ++
Help concentrate +++
Relieve boredom ++++
Socialise +++
Cope with stress ++++
And to avoid discomfort, and manage withdrawal symptoms +++++
withdrawal symptoms of smoking
Nicotine cravings
Sweating
nausea /abdominal cramps
headaches
coughing
sore throat
insomnia
difficulty concentrating
anxiety
irritability
depression
weight gain
tingling in hands/feet
level of withdrawal symptoms of smoking
how long and how many you smoked will affect severity
nicotine dependence
…..is a chronic relapsing disease defined as a compulsive craving to use the drug despite harmful consequences
exhibits tolerance
- frequent smoker will need to smoke more to get the same level of hit as new smoker
nicotine
C6H12N2
Addictive element in both tobacco and ecigs
90% of non-smokers and 75% of smokers in Great Britain believe that nicotine is harmful to health
- a fundamental misconception that we have not change
- it is the many other toxicants in cigarettes that cause disease and death
harmful as it is the addictive element but doesn’t actually cause harm
smokeless tobacco
Number of products up to 30, not homogenous products, very different
Health risks will vary, can have 100 times the TSNA (tobacco specific nitrosamines) than cigarettes
- Higher the TSNA the more lethal
In the UK, smokeless forms such as snus (Sweden) and Skoal Bandits (US) banned
- Toombak is most lethal form of smokeless tobacco, from ethopia
snus and skoal bandits
illegal to sell in UK
snus
Snus (Swedish) is a moist powder tobacco
- Placed under upper lip
- can cause recession around upper centrals
- less lethal than tobacco
skoal bandits
american
Dipping tobacco, moist (look like teabags)
Place in buccal sulcus by 6s or above incisors
shisha
Hookah operates by water filtration and direct heat
- Number of cafes in Glasgow, particularly west end
Scented tobacco is crumbled into the bowl
Compared to a single cigarette, 45 min of water pipe use approx doubles CO and triples nicotine exposure (equivalent to 10 cigs)
Smoking hookahs poses many health risks - TB airborne transmission - Hepatitis A. - Helicobacter pylori - Pulmonary aspergillosis (pipe sharing) NOT a safe alternative type
shisha/hookahs health risks
- TB airborne transmission
- Hepatitis A.
- Helicobacter pylori
- Pulmonary aspergillosis (pipe sharing)
NOT a safe alternative type
pharmacotherapy options fir smoking cessation (4)
Nicotine replacement therapy
- Patches, gum, inhalers, nasal spray, lozenges, microtabs, oral strips
Varenicline (Champix)
Bupropion (Zyban)
- 5-10 years old
Role of e cigarettes
examples of nicotine replacement therapy
Patches, Gum, Tabs, Lozenges, Nasal sprays, Inhalators, Oral films
effectiveness of nicotine replacement therapy
Increases likelihood of successful quit attempt
All forms of NRT increase success of quitting, by 50-70%
- No difference between types of NRT
Up to patient preference
No benefit after 8 weeks
- Short term therapy – don’t want to become addicted to NRT
Side effects
- Skin irritation ( patch)
- Oral irritation gum/tabs
No evidence that NRT increases heart attacks.
Varenicline (Champix) Vs Bupropion (Zyban)
Varenicline 2-3 x increase chances of quitting compared to willpower alone
Quit rates for Champix better than Zyban
Varenicline (Champix) stats
Varenicline 2-3 x increase chances of quitting compared to willpower alone
- 25% increased chance of serious adverse effect
- Lower dose, lower risk of adverse effects
- Most reported side effect is nausea, mostly mild, wears off
If on champix need to be monitored
E-cigarettes use
Not for non smokers
Ex-current smoker, users
Banned for under 18s
Aid to quitting ( some evidence)
Less toxic alternative to cigarette smoking (evidence)
BUT
Recent spate of deaths in US (2019), and respiratory symptoms
- NO similar outbreak in the UK, E liquids carefully controlled. (linked to 1 brand)
ECIGS SAFER THAN CIGARETTES BUT SAFETY IN LONGER TERM NOT KNOWN
what is vaping
Vaping is the act of inhaling and exhaling the water vapour produced by an electronic device
E-liquid in gaseous form
Looks like thick smoke but dissipates more quickly
Smells better
what is in the liquid in ECigs? (4)
Propylene glycol (PG)
- Thinner, more flavour, throat hit
- In asthma inhalers
Vegetable glycerine (VG)
- Thicker, big clouds, smooth
- Cough medicine
Natural/ artificial flavourings
Nicotine level, mg/ml / 0.0%
- 0%, 1.5/0.15%, 3, 6, 12, 18 mg/ml
Also quote the % of PG and VG.
- Culture wyld75% VG 25% PG
- Vaporised Coconut PG 65% VG 35%
vegetable glycerine (VG) in vape liquid
- Thicker, big clouds, smooth
- Cough medicine
propylene glycol (PG) in vape liquid
- Thinner, more flavour, throat hit
- In asthma inhalers
heavy smoker nicotine level in vape liquid
12-18mg/ml
mg/ml / 0.0%
light smoker nicotine level in vape liquid
no higher than 6mg/ml
nicotine level in vape liquid
mg/ml / 0.0%
0%, 1.5/0.15%, 3, 6, 12, 18 mg/ml
second hand smoke
(Environmental Tobacco Smoke, ETS)
Term for smoke that non smokers are exposed to
Children’s exposure, cars, play areas - concern
mainstream smoke
most
smokers inhales then exhales
sidestream smoke
wafts off the end of a lit cigarette
85% of smoke in room is sidestream
contains more carcinogens
third hand smoke
is carcinogen laden residue that builds up on surfaces
Walls slightly brown in smokers home
aim of dental team in smoking cessation
raise awareness and refer.
Referral can be:
- proactive, where the care giver sends the referral to the specialist services, who then contact the patient,
- reactive, where the dental team member puts the onus on the person to contact, giving forms
what to find out from pt re smoking
Type of tobacco used – chewing, cigarettes, cigars etc
For cigarettes -
- No of Cigs smoked per day
- No of years a smoker
- When started smoking
Can calculate PACK YEARS
- 1 pack (20) a day = 1 pack year
- 10 cigarettes a day for 10 years = 5 pack years
Heaviness of smoking Index (HSI) – check on internet
- How many cigs/day?
- How quickly light up?
Quitting History
- Have you tried before? How many attempts?
- What helped you? Are you interested now?
- What’s motivating you now?
Help/advice given, referral, outcome
Write in notes
