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  OHNTPC   :   21.10.2018

 
Tobacco use Prevention and Cessation (TUPAC)
Level of Care Model

Given that Tobacco use prevention and cessation (TUPAC) in the dental treatment setting occurs in brief interventions over repeated visits, dental practitioners should consider adopting the following level of care model.

 

Basic Care: brief interventions of a few minutes in order to identify tobacco users, assess readiness to quit, request permission to re-address tobacco use at a subsequent visit, and if preferred, refer for further TUPAC counselling.

Intermediate Care: interventions of 5 to 10 or more minutes consisting of (brief) motivational interviewing sessions to build on readiness to quit, enlist resources to support change, and to include cessation medications. If preferred, refer for further TUPAC counselling.

Advanced Care: multiple intensive interventions of 20 or more minutes for complex care patients to develop a detailed quit plan including the use of suitable pharmacotherapy, past failure exploration, and recommendation adjustments as needed.

The level of care model was originally published by Davis et al. 2010 and summarized in the 2nd OHNTPC European Workshop Consensus Report by Ramseier et al. 2010.

 

Basic Care: tobacco use brief interventions

Ask

Ask all patients aged 16 years and over (younger if appropriate):

“Do you use tobacco?”

It is well recognized that the medical history form plays a critical role in developing an oral health care plan that is cognisant of the general health status. The inclusion of the patients’ tobacco use history is shown to be a vital component of the medical history form on a myriad of levels that are integral to the promotion of tobacco use prevention and cessation. For example, if the patient identifies as a never-smoker, it enables the oral health professional to reinforce the benefits of this lifestyle choice.

Particularly in the case of young adults, the opportunity to congratulate their decision to remain tobacco free offers a positive counter to the efforts of peer pressure, advertising or other adverse influence. Should the patient identify as a former smoker, the opportunity arises again to provide positive reinforcement to the decision to change.

 

Assess

With all tobacco users assess readiness to quit:

“Are you interested in stopping?”

When asked about their readiness to quit smoking, tobacco users often reply that they want to quit smoking "sometime" but that the time is not yet right. There are certain things they need to do first, which are seen as more important than giving up smoking. Even if the patient feels that they are ready to quit smoking, there still may be some uncertainty about the next steps. They may experience a lack self-efficacy to achieve this goal and feel under prepared to make a quit attempt. Behind this attitude is often the fear of failure, potential change to social habits, or worry about gaining unwanted weight.

 

(Brief) Motivational Interviewing, (B)MI

Numerous behavioral studies have demonstrated predictable success in supporting patients to change using Motivational Interviewing (MI). MI is a patient-centred method to enhance the patient’s intrinsic motivation to change by exploring and resolving ambivalence (Miller and Rollnick 2002). A "short form" of MI known as "Brief Motivational Interviewing" (BMI) appears to be suitable for use during short interventions for tobacco use prevention and cessation in dental practices. The aim of BMI is to achieve the following objectives within a relative short amount of time:

  1. to ask the patient about his or her motivation to change,

  2. to ask the patient’s self-efficacy to change, and

  3. to get the patient’s commitment to discuss the change in behavior at the next visit.

Understanding the current levels of recognized motivation and self-efficacy as indicators of the readiness to change can greatly assist the process of supporting the patient through a quit attempt (Rollnick et al. 1997).

For example, asking the patient to use a number scale to rate how motivated he or she is to quit smoking will give a direction for the oral health professional to follow. Using the same number scale to rate how confident they are in achieving this goal will further direct the conversation towards identifying the type of support the patient may need.

 

Intermediate Care: behavior support for tobacco use cessation

Assist

Providing assistance for the patient who wants to quit using tobacco often requires a combination of behavioral modification techniques and pharmacological support. Making arrangements for on-going support either via the dental office or other health agencies provides the patient with a valuable sense of reassurance as they undertake a quit attempt.

“How would you like to stop?”

When available, refer to TUPAC specialist service, whether in-house (including suitably trained dental personnel) or external (i.e. www.quitline.com)

If no TUPAC specialist service is available or patient declines referral consider to offer behavioral support and pharmacotherapy as outlined in the following step-by-step protocol.

 

Assist: Step-by-step protocol

People who want to kick the smoking habit do not always participate in carefully controlled nicotine withdrawal programs, e.g. in linear fashion and from start to finish. Nevertheless, simple instructions – like those offered in the "Assist" (to help) and "Arrange" (to organize follow-up visits) – can be valuable tools for dental professionals supporting their patients to quit smoking.

Some smokers may even be euphoric about quitting smoking that would therefore tend to quit in a premature – e.g. unprepared – manner. Even if this approach works for some smokers, others require varying amounts of support. This support can be given in an individual way manner by adapting the following four steps:

 

Step 1: Ask the patient to fill in the tobacco use journal

Every smoker has his or her individual smoking habits. To pinpoint the behavioral changes required in each particular case, it is recommended to fill in a tobacco use journal for several days. The patient will be instructed to fill in every column in the jornal.

  • Instructions for the period up to the patient's next appointment: Fill in each cigarette and the time it is smoked; again, be sure to fill in all four columns of the journal labelled as “Time”, “Place or activity”, “Companion”, “Importance”, and “Alternative”.

 

Step 2: Evaluate the tobacco use journal

Reading through the journal entries at the follow-up appointment may reveal patterns of smoking and assessments of importance which may not have been aware to the patient. This information will serve as the basis for re-assigning new habits for the patient in order to give up smoking (ideally without withdrawal symptoms) and to replace the old habit with new patterns of behavior. During this period, the patient will be advised to reduce tobacco use to a bearable minimum.

The four columns of the journal contain information on four important elements of the cessation protocol:

  • "Time": Patients who smoke regularly throughout the day are primarily advised to alleviate the physical symptoms of withdrawal with sustained-release nicotine patches. On the other hand, patients who only smoke at certain times throughout the day are generally advised to use nicotine gum, sublingual tablets or lozenges. The smoking behavior that has been evaluated can be entered later in the form labelled "Recommendations for Use of Nicotine Replacement Therapy" (see below).

  • "Place or Activity" and "Companion": Instructions for the period up to the patient's next appointment: Attempt to change situations. Example: Spend your work break with different colleagues and at a different location than usual.

  • "Importance": Instructions for the period up to the patient's next appointment: Try to reduce the number of "less important" cigarettes.

  • "Alternative": Instructions for the period up to the patient's next appointment: The patient should try to find his or her own personal alternatives – so-called replacements – which could help them to resist. In this context, they should take care to alternatively distract their mind (mental), their hands (physical) and their mouths (oral). Examples: Play a game that requires mental concentration or manual dexterity. Do not select alternatives that simulate smoking. Example: chewing on a stick of liquorice.

 

Step 3: Behavioral changes and nicotine dependence

The process of successfully replacing smoking habits with other activities can be difficult and time-consuming. Each patient should identify replacements (see above) that contain a personal reward. It might be wise to schedule and arrange additional consultation time as this point so that enough emphasis can be devoted to this important step.

  • Note the replacements identified.

  • Determine the degree of nicotine dependence: This can be assessed easily by asking the following questions (Fagerström 1978):

  1. "Have you already attempted to give up smoking?"

  2. "How many cigarettes do you smoke a day?"

  3. "How many minutes after waking-up in the morning do you smoke your first cigarette?"

On the basis of the answers to these questions, the patients can be divided into four groups: very high dependence, high depende, medium dependent and low dependence. The answer showing the greatest dependency indicates the overall dependency.

  • Set the quit date.

 

Step 4: Set the Quit Date

On the quit date, ideally, the patient will be released from the dental practice as a former smoker. It may be worthwhile to give each individual patient a written recommendation for the use of nicotine replacement therapy for the following three months.

  • Confirm or redefine the replacements that have been identified.

  • Give the patient a written recommendation on nicotine replacement therapy on the basis of both his or her smoking behavior and degree of nicotine dependence.

 

Arrange

Experience reveals that smokers have to make several attempts to quit smoking before staying a former smoker. Of the patients who initially succeed in kicking the habit, 50% - 60% will suffer a relapse within the next year. Even though there are at present no evidence-based methods for preventing relapses, the dental practice team can continue to offer support during their patients' repeated attempts to quit smoking. Alternatively, the patients can be referred at this time to tobacco use cessation specialists, their family doctors, pharmacists or psychotherapists.

 

Intermediate Care: pharmacotherapy for tobacco use cessation


Nicotine replacement therapy (NRT)

The symptoms of nicotine withdrawal can substantially hamper a person's success to quit smoking. The most common symptoms of nicotine withdrawal are reported to be headache, gastrointestinal complaints, sleeping disorders, depression and increased appetite. Withdrawal usually occurs shortly after the person has smoked his or her last cigarette and occasionally lasts for several days or a few weeks. Withdrawal symptoms can be significantly reduced by pharmacotherapy e.g. with the replacement of nicotine. It can help former smokers to resist their withdrawal symptoms and to carry out the replacements instead as planned. Nicotine replacement therapy (NRT) is shown to increase success rates by roughly 100%. Additionally, research on NRT consistently revealed that comparable success rates were achieved with the use of nicotine gum, nicotine sublingual tablets or lozenges, or nicotine patches.

If there are no medical contraindications for the patient, NRT products can be used without restrictions. Nevertheless, some reservations remain for pregnant women and patients with cardiovascular conditions. Literature suggests, however, that the benefits of NRT for smoking cessation may outweigh the detrimental effects from the continued use of tobacco.

Significant success rates from the use of NRT will be achieved when the appropriate product is selected adjusted to

  1. the degree of nicotine dependency and

  2. the individual smoking behavior (see Table above). In general, patients with "high" or "very high" nicotine dependence are advised to take combinations of NRT. Furthermore, NRT should be used for the entire duration of the therapy (3 months), while the nicotine dose will be reduced every month as suggested by the manufacturer.

 

Bupropion SR

Sustained-release Bupropion (Bupropion SR) is a non-nicotine-containing drug used for tobacco use cessation therapy (Zyban®, Wellbutrin®, GlaxoSmithKline, USA). With Bupropion, the neuronal uptake of catecholamines will be selectively inhibited in the central nervous system. Consequently, catecholamine levels will increase in certain areas of the brain resulting in the reduction of nicotine withdrawal symptoms.

The manufacturer recommends that Bupropion SR is prescribed for the duration of seven weeks. In order to reach therapeutic levels, Bupropion SR will have to be taken for two weeks. Tobacco use should be ceased only after therapeutic levels have been established. During the first week, it is recommended that 150mg of Bupropion SR is taken per day. After one week, 150mg will be taken twice daily for the duration of six weeks.

The efficacy of Bupropion SR either alone or in in combination with other nicotine replacement therapy options was evaluated with non-depressed cigarette smokers in placebo-controlled double-blind trials (Holm & Spencer 2000). The abstinence rates for the use of Bupropion SR alone was 23.1% following 12 months after the quit date (Hurt et al. 1997), and 35.5% following 12 months when Bupropion SR was used in combination with nicotine replacement therapy (Jorenby et al. 1999).

The most common side effects of Bupropion have been described as insomnia, headaches, and dry mouth. Prior to prescription, it has to be noted that the simultaneous use of psychotropic drugs or cortisone should be avoided. Further contraindications exist in patients with a history of bulimia, anorexia nervosa, and in those who experience epilepsy. Pregnant women are to be advised not to take Bupropion SR, since its safety during pregnancy has not been studied in clinical trials.

 

Varenicline

Varenicline has been specifically developed for smoking cessation therapy (Chantix®, Champix®, Pfizer Inc., USA). Varenicline connects as a partial agonist with a high affinity to the α4β2-nicotinic acetylcholine receptors in the central nervous system. Subsequently, the binding of nicotine will be blocked resulting in the elimination of its addictive effect. Additionally, the binding of Varenicline sufficiently reduces the symptoms of craving and withdrawal (Coe et al. 2005, Keating & Siddiqui 2006).

Varenicline prescription is recommended for a duration of three months and may be extended if necessary by a subsequent three months. In order to reach therapeutic blood plasma levels, 1mg of Varenicline will be taken per day for the duration of one week. Only thereafter, tobacco use should be ceased. After one week, 1mg will be taken twice daily for the duration of 11 weeks.

Five clinical studies involving a total of aproximally 4300 patients, mostly heavy, long-term smokers have shown significantly greater success rate following one year after quit date with Varenicline (14.4 - 23%) (Gonzales et al. 2006, Jorenby et al., 2006, Nides et al., 2006) and placebo (3.9 - 10.3.%) (Oncken et al., 2006). When taking Varenicline for the duration of six months, one-year success rates of 43.6% have been reached (Tonstad et al., 2006).

The most common side effects of Varenicline include dizziness, insomnia, indigestion and vomiting. Patients with renal insufficiency and pregnancy are not recommended for treatment with Varenicline.

 

References

Davis, J. M., Ramseier, C. A., Mattheos, N., Schoonheim-Klein, M., Compton, S., Al-Hazmi, N., Polychronopoulou, A., Suvan, J., Antohe, M. E., Forna, D. & Radley, N. (2010) Education of tobacco use prevention and cessation for dental professionals--a paradigm shift. Int Dent J 60, 60-72.

Ramseier, C. A., Warnakulasuriya, S., Needleman, I. G., Gallagher, J. E., Lahtinen, A. et al. (2010) Consensus report: 2nd European workshop on tobacco use prevention and cessation for oral health professionals. Int Dent J 60, 3-6.

Ramseier, C. A. & Fundak, A. (2009) Tobacco use cessation provided by dental hygienists. Int J Dent Hyg 7, 39-48.

Rollnick, S., Butler, C. C. & Stott, N. (1997) Helping smokers make decisions: the enhancement of brief intervention for general medical practice. Patient Educ Couns 31, 191-203.

Miller, W. R. & Rollnick, S. (2002). Motivational Interviewing: Guilford Press, New York.

Fagerstrom, K. O. (1978) Measuring degree of physical dependence to tobacco smoking with reference to individualization of treatment. Addict Behav 3, 235-241.

 

Clinical Practice Guidelines "Tobacco use and Dependence"

Please consider as well the clinical practice guideline "Treating Tobacco use and Dependence" by Fiore et al. 2008 as a reference.

 

Reference

Fiore MC, Jaén CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, 2008.

 

Tobacco Use Cessation Care Pathway for the Dental Practice

At the first European Workshop of Tobacco use Prevention and Cessation for Oral Health Professionals in 2005, the following care pathway has been defined.

You may want to download and print the '05 workshop care pathway, courtesy provided from the Quitessence Publishing Group:

Download:

TUC_care_pathway.pdf

 

References

Ramseier, C. A., Mattheos, N., Needleman, I., Watt, R. & Wickholm, S. (2006) Consensus report: First European Workshop on Tobacco Use Prevention and Cessation for Oral Health Professionals. Oral Health Prev Dent 4, 7-18.

Needleman, I., Warnakulasuriya, S., Sutherland, G., Bornstein, M. M., Casals, E., Dietrich, T. & Suvan, J. (2006) Evaluation of tobacco use cessation (TUC) counselling in the dental office. Oral Health Prev Dent 4, 27-47.

 
 

© 2001 - 2018 by the Swiss Task Force "Tobacco - Intervention in dental practices" | date - 21.10.2018


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