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Up in smoke: Tobacco issues

June 16, 2011
Do you consider it your responsibility to help your patients quit smoking?  If so, then you are in good company says FOCUS Editorial Director Maria Perno Goldie, RDH, MS, who notes that the American Dental Hygienists’ Association answers affirmatively to the question. This issue of FOCUS highlights several resources that can help hygienists assist patients with tobacco cessation.
By Maria Perno Goldie, RDH, MS
This year, more than 5 million people will die from a tobacco-related heart attack, stroke, cancer, lung ailment, or other disease. That does not include the more than 600,000 people who will die from exposure to second hand smoke.(1) Countries throughout the world are instituting tobacco control measures, such as the WHO Framework Convention on Tobacco Control, to help reduce the harm caused by smoking. World No Tobacco Day was May 31. Ashtrays with fresh flowers are a common symbol of World No Tobacco Day. Is an International Tobacco Control Project: Evaluating the impact of the WHO treaty across the globe, the answer?Do you consider it your responsibility to help your patients quit smoking? If so, then you are in good company. The American Dental Hygienists’ Association (ADHA) thinks so as well. Also, a recent study that surveyed 231 periodontists found that 92% believe that tobacco-cessation interventions are a responsibility of the dental profession.(2) While the topics surrounding these issues are many, this issue will highlight how to reach younger smokers with a quit message, second hand smoke and risk for periodontitis, a message from the Smoking Cessation Leadership Center, and the hookah and its effects on oral health.In addition to systemic health issues, tobacco use and dependence causes oral health problems and has a great impact on the development and progression of periodontal disease. There is a clear causal relationship between smoking and periodontal disease and the negative effects of smoking on wound healing.(3) Smokers present tougher bacterial challenge to periodontal treatment than non-smokers. Periodontal disease is difficult to successfully treat in any dental patient. One patient type that can be especially challenging is smokers. Smokers are up to 6X more likely to experience periodontal destruction compared to non-smokers.(4) A new study has found that smoking may pose other problems.(5) In patients with moderate-to-severe chronic periodontitis, researchers in this study found that smokers consistently demonstrated lower levels of health-protective bacteria, and significantly higher levels of disease-related bacteria subgingivally. These included higher levels of the red complex Treponema and Tannerella species, which have been linked to more severe and refractory periodontitis.(6,7)This may help to explain why smokers are less responsive to scaling and root planing (SRP) alone, exhibiting smaller pocket depth reductions and fewer clinical gains resulting in deeper periodontal pockets.(4,8,9,10,11,12) In addition to other types of treatment, minocycline microspheres improve healing in patients who smoke. A study demonstrated that at 9 months, patients experienced 32% greater reduction in pocket depths with Arestin+ SRP vs. SRP alone.(9) Another study demonstrated that Arestin+ SRP was nearly 4X more likely to reduce pockets to <5 mm than SRP alone.(13) ** Tobacco-dependence treatment and tobacco cessation programs are vital components of clinical practice, and tobacco cessation programs should be incorporated into practice protocols. The use of tobacco cessation interventions by dental hygienists, general dentists, and oral maxillofacial surgeons has been reported in the literature. There is an ADA code for tobacco counseling in dental practice, D1320, and this can be used when cessation programs are implemented.The primary barriers to providing tobacco-cessation interventions were low patient acceptance of treatment, lack of time, and lack of training. The following were other barriers cited: lack of reimbursement; believing that there was little chance of success in providing tobacco-cessation intervention; believing that patient acceptance of treatment is low; possibility of offending and losing patients; and lack of personal interest by the provider.The basic steps of a tobacco-dependence treatment protocol can be implemented in three minutes or less. If the dental hygienist is familiar with community or state resources for tobacco-dependence treatment, like 1-800-QUIT NOW quit hot line, patients can be given information on these resources and referred for further assessment and assistance in quitting.
Ask, advise, refer is a shortened form of the 5 A's (ask, advise, assess, assist, and arrange) -- a series of steps to be used in a healthcare setting to treat tobacco use and dependence -- and for promoting tobacco cessation. For more information, go to ADHA’s When it comes to lack of reimbursement, while many insurance plans do not provide coverage for cessation counseling, this seems to be changing.In a newly updated Cochrane Review, Cahill and Perera summarize the effectiveness of incentives for smoking cessation.(14,15) Their disappointing conclusion is that, while there is some evidence that incentives work in the short term, the effects generally dissipate, and there is still insufficient evidence to recommend their adoption into routine practice. Much therefore remains to be discovered, but what are the particular questions that this review highlights?Behavior change has been divided into “simple” or single actions at a point in time, and “complex” behavior change are those requiring effort over a sustained period.(16) Adherence to medication is an example of a simple behavior change. A systematic review in the British Medical Journal (BMJ), which assessed financial incentives to motivate adherence to medical instructions, identified 11 randomized controlled trials.(17) The incentives ranged from USD 5 to about USD 1,000. Of the 11 studies included in the review, 10 demonstrated a positive effect. The studies incentivized several types of interventions, such as immunization, engaging with antihypertensive treatment, attending postpartum appointments, completing cocaine dependency treatment, and dental care for children.Complex behavior change requires both sustained effort and typically the adoption of multiple strategies to achieve change. Tobacco and smoking cessation, and weight loss to reduce obesity, require complex behavior change. A systematic review of trials of incentives for weight loss found that larger incentives seemed more effective but that the effectiveness of interventions seemed to decline when the incentive was withdrawn, paralleling the data in the Cahill and Perera review.(18) Should we conclude that incentives are effective for simple but not complex behavior change? This conclusion does not take into effect the strong evidence for the efficacy of incentives for the management of drug misuse.(19) There is also evidence for improved abstinence from problem drug use, clearly a complex behavioral change. Although ceasing to use illicit drugs does require complex change, some actions are simple. Deciding to engage in a treatment program and partaking in programs for supervised dispensing of methadone are simple behaviors. These are part of the set of behaviors that have been effectively rewarded in previous trials of incentives in drug misuse. The shining exception to the rather negative findings in the Cochrane Review of incentives for smoking cessation is the trial by Volpp and colleagues.(20) In the Volpp study, participants obtained rewards for attending a smoking cessation clinic and for validated abstinence. As a result, nearly three times as many in the intervention group attended as in the control group. The intervention also increased the rate at which participants achieved abstinence at short-term follow-up. Though a somewhat lower proportion of people who achieved early abstinence returned to smoking in the intervention group than the control group, it seems the main effect was inducing two simple behavior changes. One prompted individuals to decide to quit smoking, and the other prompted individuals to use evidence-based treatment.Smoking in pregnancy is a difficult public health problem. A Cochrane Review of smoking cessation in pregnancy found that many of the interventions that are known to be effective in adult smokers are not known to be effective in pregnant women.(21) Financial incentives seemed the most effective intervention, increasing abstinence over three-fold. However, the outcomes of these trials were abstinence for the previous seven days, so the data are preliminary. According to the authors, many women who smoke in pregnancy are among the most disadvantaged in society. If incentives have a place in smoking cessation, it is perhaps this group who might be seen as the most deserving. Both this review and the Cahill and Perera review show us the potential value of incentives. They appear to work sometimes for some smokers. Understanding how they work, whether the benefits are sustained, and that their effects are not due to gaming the system, is a public health priority.Tobacco use is the single most preventable cause of disease, disability, and death in the United States. Each year, an estimated 443,000 people die prematurely from smoking or exposure to second hand smoke, and another 8.6 million live with a serious illness caused by smoking. The CDC issued a brief entitled “Tobacco Use: Targeting the Nation’s Leading Killer, At A Glance 2011”.(22) The tobacco use epidemic can be stopped. The Institute of Medicine (IOM) report, “Ending the Tobacco Problem: A Blueprint for the Nation”, presents a plan to “reduce smoking so substantially that it is no longer a public health problem for our nation.(23) Foremost among the IOM recommendations is that each state should fund a comprehensive tobacco control program at the level recommended by CDC in Best Practices for Comprehensive Tobacco Control Programs–2007.(24) This publication is a guide to help states plan and establish effective tobacco control programs to prevent and reduce tobacco use.Evidence-based, statewide tobacco control programs that are comprehensive, sustained, and accountable have been shown to reduce smoking rates, tobacco-related deaths, and diseases caused by smoking. A comprehensive program is a coordinated effort to establish smoke-free policies, reduce the social acceptability of tobacco use, promote cessation, help tobacco users quit, and prevent initiation of tobacco use. This approach combines educational, clinical, regulatory, economic, and social strategies. Research has documented the effectiveness of laws and policies to protect the public from second hand smoke exposure, promote cessation, and prevent initiation by young people.(25)
CDC also promotes MPOWER, a package of six proven strategies identified by the World Health Organization (WHO) that can help reduce tobacco use and tobacco-related illness and death.(26) Monitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help to quit tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising, promotion, and sponsorship; and Raise taxes on tobacco. CDC, in partnership with the National Cancer Institute, the North American Quitline Consortium, and state tobacco control programs, has developed the National Network of Tobacco Cessation Quitlines. By calling 1-800-QUIT NOW, callers from across the nation have free and easy access to tobacco cessation services in their state.(27) So what are you waiting for? With all these resources, there is no excuse not to assist your patients with tobacco cessation. If not you, who? If not now, when?References
1. Press release, 5/25/2011, Canadian Institutes of Health Research (CIHR).2. Patel AM, Blanchard SB, Christen AG, Bandy RW, and Romito LM. A Survey of United States Periodontists' Knowledge, Attitudes, and Behaviors Related to Tobacco-Cessation Interventions. Journal of Periodontology, March 2011, Vol. 82:3, pp. 367-376.3. Papantonopoulos GH. Smoking influences decision making in periodontal therapy: a retrospective clinical study. J Periodontol 1999;70:1166-1173. 4. American Academy of Periodontology. Position paper: Tobacco use and the periodontal patient. J Periodontol 1999;70:1420. 5. Shchipkova AY, Nagaraja HN, Kumar PS. Subgingival microbial profiles in smokers with periodontitis. J Dent Res 89:2010:1247-1253.6. Colombo APV, Boches SK, Cotton SL, et al. Comparisons of subgingival microbial profiles of refractory periodontitis, severe periodontitis, and periodontal health using the human oral microbe identification microarray. J Periodontol 2009;80:1421-1432.7. Dumitrescu AL, et al. Etiology and pathogenesis of periodontal disease. 2010: Springer. 8. Ah MKB, Johnson GK, Kaldahl WB, Patil KD, Kalkwarf KL. The effect of smoking on the response to periodontal therapy. J Clin Periodontol 1994;21:91-97.9. Paquette D, Oringer R, Lessem J, et al. Locally delivered minocycline microspheres for the treatment of periodontitis in smokers. J Clin Periodontol 2003;30:787-794.10. Preber H, Bergström J. The effect of non-surgical treatment on periodontal pockets in smokers and non-smokers. J Clin Periodontol 1985;13:319-323.11. Preber H, Linder L, Bergström J. Periodontal healing and periopathogenic microflora in smokers and non-smokers. J Clin Periodontol 1995; 22: 946-952. 12. Haffajee AD, Cugini MA, Dibart S, Smith C, Kent RL Jr, Socransky SS. The effect of SRP on the clinical and microbiological parameters of periodontal diseases. J Clin Periodontol 1997;24:324-334.13. Data on file, OraPharma, Inc. For more information visit: ** ARESTIN is indicated as an adjunct to scaling and root planing (SRP) procedures for reduction of pocket depth in patients with adult periodontitis. ARESTIN may be used as part of a periodontal maintenance program, which includes good oral hygiene and SRP. Manufactured for OraPharma, Inc.14. Cahill K, Perera R. Competitions and incentives for smoking cessation. Cochrane Database of Systematic Reviews 2011, Issue 4. Art. No.: CD004307. DOI: 10.1002/14651858.CD004307.pub4.15. Aveyard P, Bauld L. Incentives for promoting smoking cessation: what we still do not know. The Cochrane Library 2011 (13 Apr). (accessed June 13, 2011).16. Kane RL, Johnson PE, Town RJ, Butler M. A structured review of the effect of economic incentives on consumers' preventive behavior. American Journal of Preventive Medicine 2004;27:327–52.17. Giuffrida A, Torgerson DJ. Should we pay the patient? Review of financial incentives to enhance patient compliance. BMJ 1997;315:703–7.18. Paul-Ebhohimhen V, Avenell A. Systematic review of the use of financial incentives in treatments for obesity and overweight. Obesity Reviews 2007;9:355–67.19. National Collaborating Centre for Mental Health. Drug misuse: psychosocial interventions. National clinical practice guideline number 51. London: The British Psychological Society and the Royal College of Psychiatrists, 2008.20. Volpp KG, Troxel AB, Pauly MV, Glick HA, Puig A, Asch DA et al. A randomized, controlled trial of financial incentives for smoking cessation. New England Journal of Medicine 2009;360:699–709.21. Lumley J, Chamberlain C, Dowswell T, Oliver S, Oakley L, Watson L. Interventions for promoting smoking cessation during pregnancy. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD001055. DOI: 10.1002/14651858.CD001055.pub3. 22. National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health. 24. Best Practices for Comprehensive Tobacco Control Programs–2007. 25. 26. 27. Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion. Reading
IOM: Second hand Smoke Exposure and Cardiovascular Effects: Making Sense of the Evidence.,

Maria Perno Goldie, RDH, MS

To read previous RDH eVillage FOCUS introductions by Editorial Director Maria Perno Goldie, go to introductions.