Treating Tobacco Dependency

This is the second of two articles on smoking cessation. The first appeared in the November/December 2003 issue, which can be accessed in the archives of this website.

Tobacco use is a major health risk worldwide. Dental health care providers can be at the forefront of assessing and treating tobacco dependence.^1,2 The adverse oral health effects due to tobacco use are visually detectable and obvious to people when pointed out in their own mouths.³

Five published randomized controlled trials demonstrated that an oral cancer screening with feedback about oral problems related to oral snuff and chewing tobacco use, coupled with cessation advice, self-help materials, and brief cessation counseling by a dental hygienist promote long-term tobacco cessation.^4-8 Findings from seven other studies showed that physicians’ brief advice (3 minutes or less) to quit smoking significantly promoted long-term smoking abstinence rates by about 10%.⁹ Additionally, a meta-analysis of 29 studies determined that tobacco users who received a brief tobacco cessation intervention from a nonphysician clinician (eg, dentist, dental hygienist) or a physician were twice as likely to quit their tobacco use compared to tobacco users who did not receive an intervention from a clinician.⁹

NICOTINE ADDICTION

Like all drug addictions, nicotine addiction is characterized by compulsive use, use despite harmful effects, pleasant effects, difficulty in quitting or controlling use, recurrent cravings, tolerance, physical dependence, and relapse following abstinence.¹⁰ Helping tobacco-using clients abstain requires an understanding of the physical, psychological, sensory, behavioral, and social aspects of nicotine addiction in order to assist them in coping during the quitting process.^10-12

Reinforcing effects. The rewards that nicotine provides are known as its reinforcing effects. The action of nicotine on the brain causes the release of chemicals such as dopamine, norepinephrine, acetylcholine, vasopressin, serotonin, and beta-endorphins. The action of these chemicals in the brain causes the user to experience pleasure, arousal, memory improvement, appetite suppression, and reduction of anxiety and tension.¹³ The sense of well-being and comfort produced by the release of these chemicals is a reinforcing effect. These reinforcing effects reward tobacco users and increase their desire to continue using tobacco. They also make it difficult to stop their tobacco use and these effects should be addressed when individuals are trying to quit.¹³ For example, because nicotine is an appetite suppressant, people often increase their food intake when they reduce their nicotine exposures.¹⁴ Drinking a lot of water, getting exercise, and eating a balanced, low-fat diet can help avoid this weight gain.¹⁴

Tolerance. With chronic exposure to nicotine, brain cells adapt to compensate for the actions of nicotine and then the brain returns to normal functioning. This process produces tolerance to the drug so that a given level of nicotine eventually has less effect on the brain and a larger dose is needed to produce the rewarding effects that lower doses formerly produced.¹³ Thus, the longer people use tobacco, the more product they need to achieve the desired physiologic effect or psychological response.

Physical dependence. Even though the brain adapts to function normally in the presence of nicotine, it also becomes physically dependent on nicotine for that normal functioning.¹³ When nicotine is not available, the brain function becomes disturbed, resulting in nicotine withdrawal.^13,15 Symptoms include craving, irritability, anxiety, inability to concentrate, depression, nausea, headache, and insomnia.^10,13 Although these symptoms usually last only 2 to 3 weeks^15,16 and are the brain’s way of healing itself, they can make abstinence very difficult. Not all individuals experience withdrawal symptoms. For those who do, however, pharmacologic adjuncts such as nicotine replacement therapy or Bupropion SR (Zyban) may be indicated to help them cope with the quitting process.⁹

Psychological, behavioral, and sensory aspects of nicotine addiction also sustain tobacco use. These factors provide a comfort level and add to the complexity and difficulty of tobacco cessation.^11-12

Psychological aspects. Psychological aspects are frequently a direct effect of nicotine withdrawal. Tobacco use is often used to elevate negative moods and, thereby, cope with stress and depression. In addition, tobacco use can serve as passive entertainment to decrease boredom.¹²

Behavioral aspects. Behavioral aspects of nicotine addiction derive from learned anticipatory responses. These develop from experiencing various forms of gratification from tobacco use in the presence of certain environmental cues.^12,16,17 For example, when a user encounters a situational reminder of tobacco use (eg, after a meal or when drinking alcohol) these stimuli are associated with the pleasure or other reinforcing effects of tobacco use, which then generate the urge to use tobacco. Such recurrent anticipatory responses can last 6 months or longer after physical dependence is overcome and are many times responsible for relapses that occur beyond the first 2 weeks of cessation.¹³

Sensory aspects. Puffing on a cigarette or using a dip of a specific size and texture provide oral gratification. Because of the sense of well-being provided, the use of nontobacco oral substitutes (eg, chewing gum, sunflower seeds) is important to the quitting process.¹⁶

Sociocultural aspects. Peer pressure; the influence of family members and significant others who use tobacco; and a social network that supports, accepts, and allows the habit are all sociocultural factors that can impede cessation. Users frequent environments where tobacco use is acceptable and often associate with other users. Users trying to quit frequently need to avoid situations where they will be tempted to use until they are secure that they can cope with these situations.^12,16

In assisting clients in their efforts to stop tobacco use, physical, psychological, behavioral, and sensory aspects of nicotine addiction must be confronted and alternative coping strategies identified. Being supportive and assisting the client with problem solving is critical to promoting tobacco cessation.^12,16

CLINICAL PRACTICE GUIDELINES

The Public Health Service (PHS) has provided Clinical Practice Guidelines for Treating Tobacco Use and Dependence, which highlight the Five A’s Approach used by health care professionals.⁹ This approach includes: asking all clients if they use tobacco; advising those who do to quit; assessing the client’s readiness to quit in the next month; assisting clients with quitting; and arranging follow-up to find out where they are in the quitting process and to provide encouragement and support with problem solving.

An essential feature of the Five A’s Approach is that the clinician’s actions to assist the client are based on assessing the client’s willingness to quit tobacco use in the next month.

The process of assisting clients with quitting can occur either by providing a brief intervention at chairside, which may include referral to a tobacco use quitline or some other community-based program, or by offering more intensive tobacco cessation treatment in the dental setting.

BRIEF CLINICAL INTERVENTIONS

It is essential to provide at least a brief intervention to all tobacco users at each clinical visit. To do so usually requires 3 minutes or less. For individuals who are not ready to quit, the clinician may provide the following brief motivational intervention:⁹

1. Ask the client why quitting may be personally relevant.
2. Ask the client to identify potential negative consequences of use and highlight those that are most relevant to the client.
3. Ask the client to identify potential benefits of stopping use and highlight those that are most relevant to the client.
4. Ask the client to identify impediments to quitting and note elements of treatment that can help.
5. Provide educational information on the benefits of quitting.

It is important to be patient and nonjudgmental when dealing with people who are not ready to stop their tobacco use. Once they decide that the benefits of quitting outweigh the benefits of using tobacco, they will make a decision to try to stop.

For those who are ready to quit, the clinician provides the following brief intervention:⁹

1. Reinforce motivation to quit by asking questions about reasons for quitting and reinforcing the personal benefits of cessation rather than making general statements about the negative consequences of tobacco use.
2. Reassure those who mention past failures that most tobacco users try many times before they are ultimately successful.
3. Tell them that each time they try to quit, they learn something new about the quitting process that makes them better prepared to stop. As long as they are trying to quit, they are not failing.
4. Encourage them to tell family and friends about their intention to quit and to request their understanding and support.
5. Provide written self-help information.
6. Refer them to either the in-office intensive counseling program (described below), a telephone quitline, or some other community-based individual or group counseling program.
7. Make at least one follow-up appointment either in-office or by telephone.

Assistance for individuals who have recently quit includes the following:⁹

1. Reinforce the individual’s decision to quit.
2. Review the benefits of quitting.
3. Assist in resolving any problems that arise from quitting.

INTENSIVE IN-OFFICE TREATMENT PROGRAM

Although tobacco use quitlines are an excellent referral source for clients who are ready to quit, many dental hygienists may want to personally provide a more intensive tobacco cessation treatment for them in the dental setting. This process usually requires multiple appointments. Following are the key elements to such a program:¹⁸

• Assessment
• Setting a quit date
• Establishing a plan for quitting
• Coping skills training
• Encouraging the enlistment of support from others
• Using pharmacologic agents
• Follow-up

Assessment. For clients willing to quit in the next month, the dental hygienist assesses their level of nicotine dependence, their experience with previous quit attempts, their history of mood disorders, and their pattern of tobacco use (ie, the number of dips, chews, or cigarettes used per day and associated cravings and mood states). The data collected from this assessment are used to individually tailor a quit plan.

To assess nicotine dependence, dental hygienists can use the Fagerstrom Test for Nicotine Dependence for Adults,¹⁹ the modified Fagerstrom Tolerance Questionnaire for Adolescents,²⁰ and the Smokeless Tobacco Dependence Scale.²¹ Alternatively, they can informally ask clients if they use tobacco on a daily basis. If they do, then ask these follow-up questions:

1. How soon after waking do you have your first cigarette (or other form of tobacco like dip or chewing tobacco)?
2. Do you use most of the day?
3. Do you crave tobacco when you have not used for 2 hours?

Individuals who respond “yes” to any of these questions—especially to using tobacco within 30 minutes of waking—are nicotine dependent.¹⁷

 

Patterns of use. To assess patterns of use, ask individuals to recall each cigarette, chew, or dip they have in a typical day. Focusing on a typical day, help them fill out the form shown in Figure 1. Record the time of day tobacco was used and the situation when that use occurred. Then ask them to do the following:¹⁵

• Rate their desire or craving for each recorded tobacco use on a scale of 1 to 10, where a score of 1 represents the lowest craving and a score of 10 represents the strongest craving. The tobacco uses with low craving scores are the easiest to eliminate and can be given up first in the weaning process.
• Describe their mood when using each recorded tobacco use by indicating a number between 1 and 10 where 1=relaxed; 2=bored; 3=angry; 4=happy; 5=stressed; 6=excited; 7=tired; 8=sad; 9=hungry; and 10=irritable.¹⁶

Understanding the level of craving and people’s moods when tobacco is used helps identify coping strategies to prevent relapse once they quit.

Previous quit attempts. Ask if they have tried to quit before and, if so, what were the problems encountered. If nicotine replacement was used, find out what happened.^11,15

History of mood disorders. Ask if they have ever been treated for depression or anxiety. Because nicotine is a mood elevator, some individuals may use tobacco to self-medicate for depression or anxiety. If this is the case, stopping tobacco use abruptly may trigger their mood disorder. Ask those with a history of mood disorders, how they currently manage their negative moods. After determining their coping strategies, ask for permission to contact their physician to determine the best way to manage the mood disorder during and after the tobacco cessation process.

Reasons for use. To enhance motivation to quit, ask clients about why they want to stop their tobacco use and suggest that they write them down. Remembering the reasons for quitting enhances motivation and provides incentive to get through tough times during the quitting process. Strong motivation is essential for tobacco users who are trying to quit, and success is unlikely without it.^11,15

Setting a quit date. An important strategy is to set a quit date 2 to 4 weeks from the time they decide to quit. The period between the time clients decide to quit and their quit date provides an opportunity for them to get ready to quit. There is no ideal time to quit, but some times are better than others. Low-stress times are best, such as a day when there are no work deadlines due. If the person is struggling to select a date, offer suggestions, such as birthdays, anniversaries, moving dates, or new car purchases.^15,16

Choosing a method. After the quit date is set, individuals need to establish a method to help them get ready to quit and to cope with the quitting process. The two basic methods of quitting tobacco use are cold turkey and gradual nicotine reduction.

Cold turkey is the abrupt approach where tobacco use is ceased on the quit date.¹⁵ Gradual nicotine reduction^12,16 means to slowly and systematically reduce the amount of nicotine so they will have fewer withdrawal symptoms. Nicotine reduction can be done by switching to a lower nicotine content brand or by gradually tapering down use of the original brand. If they switch to a lower nicotine brand of tobacco, they must be careful not to increase the size of their dip of snuff or to inhale a cigarette more deeply in an effort to maintain the same level of nicotine.^12,16

Tapering down use is a method of systematically reducing the number of tobacco uses by a set amount, such as one or two uses every few days, and tapering with nontobacco oral substitutes. When users get to the point where they are using half of their original amount of tobacco, they can try to quit cold turkey. For those who choose to taper down their tobacco use, their “typical day” diary developed during the assessment phase must be the reference point. They should start cutting back on those dips/cigarettes with the lowest craving scores. Specific coping strategies and the rewards they plan for themselves on their quit day and for the first week should be recorded in the client record.^15,16

COPING SKILLS TRAINING

High-risk situations are those where users are very tempted to use tobacco. Coping skills training^15,16 assists them in identifying strategies they can implement (action responses) and statements they can say to themselves (thinking responses) in high-risk situations to avoid tobacco use.

The following are suggested action responses:¹⁶

1. Avoidance. In the first 2 weeks of being tobacco free, individuals need to avoid situations where their potential for using tobacco will be high. During these high-risk situations, craving and temptation may be strong and motivation may fade.
2. Distraction. A craving disappears in 3 to 5 minutes whether the person uses tobacco or not, so teaching clients to focus their attention on doing something else can help them cope with cravings. For example, when a craving arises, they could have a glass of water, do a crossword puzzle, doodle, call a friend, brush their teeth, or take a walk.
3. Plan ahead. People need to identify three tough situations where they know they will be tempted to use tobacco and then identify what they will do instead.
4. Use of oral substitutes. Dental hygienists can help clients make a list of nontobacco oral substitutes that they can use when they have a strong craving. These substitutes should be stocked up on in advance and kept where they normally keep their tobacco.¹⁵
5. Relaxation techniques. Anxiety, muscle tension, and stress can be reduced through relaxation and deep breathing. Other forms of relaxation, like listening to soothing music or having a massage, can also be suggested.¹⁶
6. Night before quitting. Instruct individuals to throw out all tobacco and stock up on nontobacco substitutes the night before they quit.¹⁵
7. On quit date. Encourage clients to change their daily routine on the quit date to break away from tobacco triggers and to decrease temptation to use tobacco, (eg, get right up from the table after meals). They need to make plans to keep busy. For example, aerobic exercise helps in relaxation and boosts energy and stamina. Also, making an appointment to have their teeth cleaned is a good action strategy because the fresh feeling can be a source of enjoyment.¹⁶

Thinking responses¹⁶ are thoughts about quitting tobacco use. They include:

1. Positive thinking. People trying to quit need to be as supportive to themselves as they would be to their best friend. For example, it is important for them to tell themselves “I will succeed.” When a negative thought or self-doubt (“I can’t do this”) arises, instruct them to substitute a positive thought such as “I know it’s difficult, but I can do this, and I will.” Encourage them to think in terms of getting rid of an addiction rather than giving up tobacco.
2. Delay. If they delay satisfying their craving, it will go away in 3 to 5 minutes. Therefore, encouraging them to tell themselves, “I won’t have one now, I’ll decide again in an hour,” is important. If they find something else to get their minds off the craving, by the time an hour passes they may have forgotten all about their desire for tobacco.¹⁶
3. Rewards. Helping clients plan a reward system for attempting to stop their tobacco use is important because rewards help them avoid the feeling of deprivation while quitting tobacco. Clients should choose rewards for themselves every day for the first week they are tobacco-free and should always reward themselves on anniversaries. For example, initial rewards could include buying a new CD or going to a movie with a friend. With the money they save from not buying tobacco, they can plan to buy something special for themselves. They can also give themselves other rewards such as sleeping late on the weekend or getting a massage from a friend. Specific coping strategies clients decide to use and the rewards they plan for themselves on their quit day and for the first week should be recorded in the client record.¹⁶
4. Support from others. Clients need to seek encouragement from family and friends about trying to quit tobacco use so they can receive praise for progress made and encouragement when they slip.^11,15,16
5. Pharmacologic adjuncts. There are five first-line pharmacotherapies with evidence that they increase long-term tobacco abstinence when used in conjunction with behavioral counseling. They are Bupropion SR, the nicotine inhaler, nicotine nasal spray, nicotine gum, and the nicotine patch. The first three are obtained by prescription only and the last two can be bought over-the-counter. Clients need to be cautioned that no pharmacologic adjunct is a magic bullet. Such adjuncts are helpful in diminishing withdrawal symptoms, which then allows them to concentrate on action and thinking coping strategies to resist the temptation to use.

CONCLUSION

Dental professionals can play an important role in primary prevention of adverse health effects by promoting cessation of tobacco use. Effective treatments are available and it is essential that tobacco-using dental patients who are willing to quit be offered effective treatment, and those unwilling to quit be provided a brief intervention to motivate them to quit.⁸ The US Department of Health and Human Services’ Healthy People 2010 states that by the year 2010 “at least 75% of the population of primary care and oral health care providers will routinely advise cessation and provide assistance and follow-up to all of their tobacco using patients.”²²

Studies show that people, even those who plan to continue using tobacco, prefer that health care professionals advise them to quit.²³ Although 17 million adults attempted cessation in 1993, only 7% were still abstinent 1 year later.²⁴ These statistics are disheartening, but should not discourage clinicians into thinking they are ineffective in treating tobacco dependence. Recognizing the long-term nature of the disorder allows health care providers to expect relapse and to view it as a reflection of the chronic nature of nicotine dependence and not as a personal failure or a failure of the person trying to quit.⁹ The stakes are too high to give up.

Margaret M. Walsh, RDH, MS, EdD, is a professor in the Department of Preventive and Restorative Dental Sciences at the University of California San Francisco (UCSF) School of Dentistry.

Acknowledgement
Sincere appreciation is extended to the Smoking Cessation Leadership Center at UCSF for supporting the establishment of the American Dental Hygienists’ Association Task Force on Tobacco Cessation.

REFERENCES

1. Gordon JS, Severson HH. Tobacco cessation through dental office settings. J Dent Educ. 2001;65:354-363.
2. Tomar SL. Dentistry’s role in tobacco control. J Am Dent Assoc. 2001;132:30S-35S.
3. 3.Mecklenburg RE, Greenspan D, Kleinman DV, et al. Tobacco Effects in the Mouth. Washington, DC: US Department of Health and Human Services; 1992. US Department of Health and Human Services publication NIH 92-3330.
4. Stevens VJ, Severson H, Lichtenstein E, Little SJ, Leben J. Making the most of a teachable moment: smokeless tobacco cessation intervention in the dental office. Am J Public Hlth. 1995;85(2):231-235.
5. Severson HH, Andrews JA, Lichtenstein E, Gordon JS, Barckley MF. Using the hygiene visit to deliver a tobacco cessation program: results of a randomized clinical trial. J Am Dent Assoc. 1998;129:993-999.
6. Greene JC, Walsh MM, Masouredis C. A program to help major league baseball players quit using spit tobacco. J Am Dent Assoc. 1994;125:559-568.
7. Walsh MM, Hilton JF, Masouredis CM, Gee L, Chesney MA, Ernster VL. Smokeless tobacco cessation intervention for college athletes: results after 1 year. Am J Public Health. 1999;89:228-234.
8.  Walsh MM, Hilton JF, Ellison JA, Gee L, Chesney MA, Tomar SL, Ernster VL. Spit (smokeless) tobacco cessation intervention for high school athletes: results after 1 year. Addict Behav. 2003;28(6):1095-1113.
9. Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, Md: US Department of Health and Human Services; 2000.
10. Huges JR, Hatsukami D. Signs and symptoms of tobacco withdrawal. Arch Gen Psychiatry. 1986;43:289-294.
11. Hatsukami DK, Gust SW, Keenan RM. Physiological and subjective changes from smokeless tobacco withdrawal. Clin Pharmacol Ther. 1987;41:03-107.
12. Freshstart Quit Smoking Program Facilitator’s Guide. Atlanta: American Cancer Society Inc; 1982.
13. Lynch BS, Bonnie RJ. Growing Up Tobacco Free. Washington DC: National Academy Press; 1994.
14. Hall SM, Ginsberg D, Jones RT. Smoking cessation and weight gain. J Consult Clin Psychol. 1986;54(3):342-346.
15. Orleans CT, Connolly GN, Workman S. Beat the Smokeless Habit. Bethesda, Md: National Cancer Institute; 1993.
16. Jensen J, Hatsukami D. Tough Enough to Quit Using Snuff. Twin Cities, Minn: University of Minnesota, 1997.
17. Hatsukami DK, Anton D, Callies A, Keenan R. Situational factors and patterns associated with smokeless tobacco use. J Behav Med. 1991;14(4):383-396.
18. Walsh M, Hatsukami D, Greene J, Letendre M. Tobacco Cessation Training Manual for Athletic Trainers. San Francisco: University of California, San Francisco; 1999.
19. Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerstrom Test for Nicotine Dependence: a revision of the Fagerstrom Tolerance Questionnaire. Br J Addict. 1991;86:1119-1127.
20. Prokhorov AV, Koehly LM, Pallonen UE, Hudmon KS. Adolescent nicotine dependence measuring by the modified Fagerstrom Tolerance Questionnaire at two time points. J Child Adolesc Subst Abuse. 1998;7(4):35-47.
21. Severson HH, Hatsukami D. Smokeless tobacco cessation. Prim Care. 1999;26(3):529-551.
22. Healthy People 2010 Information Access Project. Office of Disease Prevention and Health Promotion, US Department of Health and Human Services. Available at: www.healthypeople.gov. Accessed March 20, 2003.
23. Campbell HS, Sletten M., Petty T. Patient perceptions of tobacco cessation services in dental offices. J Am Dent Assoc. 1999;130:219-226.
24. Schroeder SA. Conflicting dispatches from the tobacco wars. N Engl J Med. 2002;347:1106-1109.

From Dimensions of Dental Hygiene. January 2004;2(1):22-27.