"You've come a long way, baby!" was one of those catchy commercial jingles that made an impression on many of us back when cigarettes were still being advertised on television. It had been known for many years that tobacco smoking was not healthy for you, but it was in January 1964 that the first Surgeon General's report about tobacco was published. That information led to warning labels on the packages about carbon monoxide, lung cancer, heart disease, danger to her baby for a pregnant woman, and the removal of tobacco advertising from broadcast media. We have come a long way in understanding the serious health implications of using tobacco, but is it even possible that people were allowed to smoke in dentists' offices?
One of my first memories of a visit to a dental office was not as a patient, but as a daughter of a dentist. I remember being about five-years-old or so and going in to see where my dad went every day. It was during one of these trips when I wanted to help my dad prepare for his patients that I was asked to straighten up the waiting room. That meant putting the magazines in nice rows and emptying the trash cans. It also meant cleaning out the ashtrays that were invariably full of cigarette butts and ashes. I knew then that it was a smelly habit, but the very concept of the poisons and cancer dangers were lost on a little girl. The ashtrays were all very eccentric shapes that were popular at that time and, except for several burn marks, were sculpted of hard plastic that was really cool modern art. I wasn't allowed to smoke, of course, but the behavior seemed to attract a lot of attention. Luckily for me, I never started. I tried it and it made me so sick that I never got to the enjoyment stage. I was also hanging out with a lot of athletes, and we didn't want to lose a step in our running because of shortness of breath.
With all the known side effects of smoking, it amazes me that some three thousand people start smoking every day in America. Forty years after that Surgeon General's report, we are still seeing teenagers getting tobacco (illegally in most states) and getting hooked. Nearly 47 million people use tobacco in the United States, and approximately 430,000 deaths are attributed to cigarette smoking each year. There's a great deal of evidence for the addictive lure of tobacco. Nicotine is a powerful chemical that affects the brain and the cardiovascular system. The tars and other components of tobacco have even more effects on the lungs and bronchial system, and, of course, we see the changes in the oral cavity. [Data from CDC] Just advising your patients not to smoke may not be good enough anymore. In this article, I will outline a program that you can implement in your dental practice to assist your patients. Also included are some resources for you to provide to your patients, as well as free items that can be ordered for distribution in your office.
Why should dentists be involved with tobacco cessation? Dr. C. Everett Koop, U.S. Surgeon General from 1981 to 1989, stated, "Cigarette smoking is the chief, single-most- avoidable cause of death in our society and the most important public health issue of our time." He also believes that dentists and dental hygienists have more time in each patient contact than most physicians do.
To that end, tobacco-cessation counseling is ...
- Ethical — Stopping the use of tobacco will allow patients to be more healthy.
- Moral — We know that the use of tobacco is dangerous, so it is appropriate to share this information.
- Evidence-based — Studies show that brief, personalized comments have helped patients to quit.
- Practical — Dental patients spend more time with the dentist than they may with their physician.
- Cost-effective — The time spent in tobacco-cessation counseling improves the patient's oral and overall health, as well as the long-term success of dental procedures. [from ADA Guide to Dental Therapeutics]
In the oral cavity, tobacco smoking leaves stains and odors on the teeth and tongue. Periodontal disease is worsened, and postsurgical healing is delayed. With spit tobacco, the location of the tobacco "chaw" is likely to show recession of the gingiva, erosion and decay of the teeth, and leukoplakia and squamous cell carcinoma of the mucosa. Pipe smokers often have severe occlusal wear patterns where the pipe stem is held.
All of these results of tobacco use should be pointed out to patients. Hand patients a mirror or use an intraoral camera to project the evidence. Intraoral cameras make before-and-after comparisons easy. Many dentists will not place new cosmetic restorations or implants until their patients understand the compromised prognoses of these procedures.
The 5 A's intervention
This system for intervention has been designed for the busy office environment. It is flexible and easily implemented.
ASK each and every patient about tobacco use. Document this information in the dental record at each visit, and include quantity and material. An indication of "current, former, or never" is a simple way to note this, as well as a description — e.g., one pack per day for 10 years; three cigars per week for three years. This quantity can help show progress.
ADVISE every tobacco user to quit. Simple comments from each member of the dental care team will show the patient that everyone is giving the same message. It is important that the message is not too long at this point, perhaps 60 seconds or less, and given in a non-nagging manner. For example, "I think that it is important for you to quit using tobacco now, and I will be happy to help you."
ASSESS the patient's willingness to accept assistance. If the patient is not willing at this appointment, you may need to provide motivational information or wait until another visit. Don't lose the patient's attention to the primary message of the dental visit, such as oral hygiene instructions or postsurgical care.
ASSIST those patients who are willing to stop using tobacco. Help set a quit date, usually within two weeks, incorporating the patient's meaningful upcoming dates if available — e.g., wedding anniversary or a child's birthday. Get a firm commitment to try to quit on that date. It is important to stress abstinence from tobacco, and self-help materials can be given at this point. Don't use scare tactics.
ASSIST your patient and help him or her prepare. Inform the family and friends (with the patient's permission), and have the patient remove tobacco- related temptation cues. If the patient always smokes when the phone rings, change the sound of the phone to a bell or buzzer. Other strategies include avoiding high-risk situations for a while, engaging in distracting activities, and anticipating challenges and how to cope with them. For many patients, it is helpful to choose a stress-reduction activity. For some, prescription or over-the-counter nicotine-replacement drugs may need to be added. Dentists can legally prescribe nicotine-replacement medications and bupropion, a non-nicotine tablet, when appropriate, but review the prescribing information carefully beforehand.
ARRANGE for follow-up contact by the dental team. A phone call just prior to the patient's quit date and another call one to two weeks after the quit date will reinforce the effort. The caller should offer coping skills, congratulate lifestyle changes, and, if necessary, help the patient who has a relapse set a new quit date. For some, a local support group may add to the success rate of the cessation program.
- ADA Guide to Dental Therapeutics, 2nd edition. American Dental Association Publishing Company, 2000, Chicago, Ill. Chapter 31, "Cessation of Tobacco Use," Robert E. Mecklenburg, DDS, MPH, and Martha Somerman, DDS, PhD, pages 569-581.
- Smoking cessation. Agency for Healthcare Research and Quality clinical practice guideline No. 18. U.S. Department of Health and Human Services.
Wendy S. Hupp, DMD
Dr. Hupp is assistant professor and director of oral medicine at Nova Southeastern University College of Dental Medicine. She has taught about the risks of tobacco use and tobacco cessation for 10 years in the U.S. Navy Dental Corps and around the country. Contact her at [email protected].
Tobacco cessation resources
Web sites —
Many Web sites are available to help patients in tobacco cessation:
- The American Lung Association (www.lungusa.org) also provides a search by zip code for local support groups.
- The National Cancer Institute (1-800-4CANCER or www.nci.nih.gov) has a free, illustrated pamphlet for dental health-care providers titled, "Tobacco Effects in the Mouth." This pamphlet has pictures of how to do a cancer screening exam as well as clinical changes due to tobacco use that can be shown to your patients.
- The American Cancer Society (www.cancer.org) and Centers for Disease Control Office on Smoking and Health (www.cdc.gov/ tobacco) are helpful resources for cessation strategies and free support plans.
Pharmaceutical products —
Several pharmaceutical products also provide resources, from booklets to money-back coupons and Web sites.
- GlaxoSmithKline has a nicotine patch (www.nicodermCQ. com), chewing gum (www.nicorette.com), and a smoking-cessation program (www.committedquitters.com).
- The new Commit Lozenge, also from GlaxoSmithKline, is discussed at www.commitlozenge.com and supported by quit.com, an interactive Web site.
- Pfizer, Inc. makes Nicotrol patches and provides guidelines at www.pfizer.com.