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Counseling

The dentist can motivate\ counsel their patient in the following ways:

Motivational intervention

The following five steps for motivational intervention (5R™s) can be taken by the dentist if the patient is not ready to quit tobacco. This can be due to misinformation, concern about the effects of quitting or demoralization because of previous unsuccessful quitting attempts. This presents the dentist an opportunity to educate, reassure and motivate.

• Relevance: Indicate to patients why quitting is personally important to them. This has the greatest impact if a patient has family (e.g. having children in the home), health concerns, age, gender and other important patient characteristics (e.g. prior quitting experience, personal barriers to cessation).
• Risks: Identify negative consequences of tobacco use. Emphasize that using low-tar/low- nicotine cigarettes or other forms of tobacco (e.g. smokeless tobacco, cigars and pipes) will not eliminate the risks. These can be:
  • Acute risks: Shortness of breath, exacerbation of asthma, harm to pregnancy, impotence, infertility and increased serum carbon monoxide.
  • Long-term risks: Heart attacks and strokes, lung and other cancers (larynx, oral cavity, pharynx, oesophagus, pancreas, bladder, cervix), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), long-term disability and need for extended care.
  • Environmental risks: Increased risk of lung cancer and heart disease in spouses; higher rates of smoking in children of tobacco users; increased risk for low birth weight, SIDS, asthma, middle ear disease and respiratory infections in children of smokers.
• Rewards: Highlight benefits such as better health, improved sense of taste and smell, money saved, good example for children, more physically fit, improving oral health and less yellowing of teeth, reduced wrinkling and aging of skin.
• Roadblocks: Ask the patient to identify barriers to quitting, such as withdrawal symptoms, fear of failure, weight gain, lack of support and depression. Note elements of cessation treatment, such as problem solving or pharmacotherapy.
• Repetition: Repeat the motivational intervention each time the patient comes to the clinic. Let the patient know that most people make repeated attempts to quit before they are finally successful. The dentist should never cease to motivate the patient, telling him that slipping or relapse is normal.

Road map of 5As

Once you have motivated a patient to quit, then the 5A™s are a road map for dentist to follow as a guide for helping smokers quit. The 5A's are ask, assess, advise, assist and arrange.

• Ask: Is the most fundamental of all the 5As. It involves asking a patient about their smoking pattern as a matter of concern. Questions asked in the first stage determine a patient™s smoking history, possible side- effects and factors that contribute to their continued smoking. This gives an insight to an individual™s addiction and possible strategies for breaking the cycle.
• Assess: Assessment of a patient™s dependence would provide insight into their addiction or dependence and help tailor advice, planning and referral process in latter stages. First of all the dentist has to know if the patient is willing to quit. The stages of change model, identifies an individual™s mental transition. If patient (pre- contemplation) is seeing no immediate need to quit there would be resistance to counselling. If unsure, then the patient needs information or counselling to assist with their decision. If the patient is ready (prepared), may still be smoking but willing to stop then a plan to help them quit needs to be formulated. Those patients who have stopped (action) will need reinforcement of their decision, as the risk of relapse is a problem in the early stages of the process. Those who have stopped for more than six months (maintenance) will require ongoing support to ensure they do not relapse.
  The Fagerstrom Test for Nicotine Dependence (FTND) is needed to be done to assess nicotine dependence in patients. This relates to how and when they smoke and assigns a score to each response. The higher the tallied score the higher the dependence on nicotine. The nicotine withdrawal allows insight and possible strategies to assist the patient with any stress, anger, depression, insomnia, anxiety or weight gain concerns associated with giving up smoking.
• Advise: Can be given to all present and past patients who smoke. Advice should be tailored to the individual patient and should include the effects of smoking on themselves and their loved ones as well as the potential benefits of quitting.
• Assist: Formulates a quit plan for the patient using the information gained so far. Assist can be as a form of motivational interviewing whereby the counsellor/nurse discusses the patient's ambivalence to an issue and allows the patient to come to an appropriate decision for themselves. It incorporates such techniques as weighing up the pros and cons of smoking, open- ended questions relating to specific advice that has already been given.

To help assist the 4D’s must be followed, a smoking cessation method for coping with cravings. A combination of counseling and pharmacotherapy. The method is meant to distract the potential smoker from succumbing to the urge to smoke. The 4D™s are:

• Delay the urge to smoke as much as possible.
• Deep breaths.
• Drink water.
• Do something else.

Assistance can be given as pharmacological options by the dentist in form of Nicotine Replacement Therapy (NRT) . NRT comes in various forms such as patch, gum, inhaler and lozenge. Another medication is the antidepressant Bupropion that has been widely advocated as first line of treatment.

• Arrange: This encourages further ongoing interaction with the patient in relation to their smoking. This may entail referral to a relevant smoking cessation advice if the patient is serious about quitting.

Pharmacotherapy (Nicotine Replacement Therapy)

Prescription Options

Prescription NRT options include nasal sprays and nicotine inhalers as well as the prescription antidepressant Bupropion, which has been shown to be effective in helping people to quit smoking. Many people feel most comfortable working with their doctor while attempting to quit smoking. The advantage of using a prescribed method is that your doctor or dentist can help to monitor your efforts. Because the doctor is familiar with medical history and the different treatment options, he or she is best equipped to decide which method is right for you.

• Nicotine Nasal Spray
  Another prescription NRT option are nicotine nasal sprays. These sprays come in containers similar to over-the-counter decongestant sprays and deliver nicotine to the bloodstream faster than any of the other NRT options. For this reason, nicotine nasal spray is able to relieve cravings quickly and is often helpful for people who have a high degree of dependence on nicotine. Two sprays, one in each nostril, is considered one dose of nicotine nasal spray. The maximum recommended dose is 40 individual doses per day.

Dosage: 10 ml bottles (10mg/ml)

1-2 doses/hr (up to 5) for 4-8 weeks

4-6 weeks gradual or abrupt reduction

Bottle = 100 doses; lasts about a week

Contraindications: Chronic respiratory problems.

Side Effects: Coughing, sneezing, runny nose and watery eyes.

• Nicotine Inhaler
  Nicotine inhalers are plastic devices that look very similar to cigarettes. Inhalers mimic the action of smoking by providing a substitute for the cigarette. Users obtain nicotine from a cartridge located inside the inhaler when they puff on the device. When you begin using these NRTs, the initial dose is four inhalers a day. The maintenance dose is four inhalers a day with gradual tapering of use. Nicotine inhalers should not be used for more than 12 weeks. If you think the nicotine inhaler may work for you, keep in mind that inhalers are the most expensive form of NRT.

Because inhalers mimic the action of smoking, they may or may not be a good idea. On one hand, inhalers can be useful for people who have difficulty giving up the behavioral actions of smoking. On the other hand, inhalers do not allow the user to eliminate this behavior. One of the most difficult things to overcome on the way to smoking cessation is the behavioural cues associated with smoking. Since a person will ideally try to eliminate the cues associated with smoking as they go through the cessation process, nicotine inhalers may not be a good option.

Here nicotine is absorbed through the mouth and not the lungs.The inhaler kit contains 42 cartridges.

Dosage: 6-16 cartridges every day
Gradual reduction after 12 weeks
Puff 1 cartridge for 5 minutes x 4

Contraindications: Allergy to menthol.

Side Effects: Throat irritation, cough and headaches.

• Drugs anti-craving medications
  Non-nicotine preparations are used to curb the craving for nicotine that smokers often feel. Taking these drugs in tandem with nicotine replacement therapy is known to be more successful in tobacco cessation. The most efficacious ones are discussed below.
  • Bupropion Hydrochloride Sustained Release tablets

Bupropion (an anti-depressant agent) has been used along with NRT as first- line therapy for treating tobacco dependence. However, Bupropion’s efficacy is not because of its anti- depressant properties. The exact mechanism by which Bupropion works is not known. It is presumed that the medicine affects noradrenaline and dopamine, the two chemicals in the brain that may be the key components of the nicotine addiction pathway.

Taking the drug alone produces higher cessation rates than placebo and taking it along with nicotine replacement is even more successful.

Dosage (for adults): 300 mg/day (given as 150 mg twice daily). Begin with a single dose of 150 mg a day in the morning. If the initial dose is adequately tolerated, increase the dosage to 150 mg twice daily and this can be done as early as day 4 of dosing.

There should be an interval of at least 8 hours between successive doses.

Doses above 300 mg/day should not be used.

Set quit date for 1-2 weeks after beginning Bupropion treatment

• Continue 150 mg b.i.d. for 7-12 weeks after quit date.
• For maintenance therapy, consider 150 mg b.i.d. for up to 6 months.
• If insomnia is marked, the PM dose should be taken in afternoon.
• Alcohol if used at all should be in moderation.

Course of Treatment: 7-12 weeks

Maintenance: Up to 6 months

It is important that the patient continues to receive counselling and support throughout the treatment with Bupropion, and for a period of time thereafter.

Whether to continue treatment for longer periods for smoking cessation with Bupropion HCl must be individually determined for patients. If no significant progress toward abstinence is seen by the 7th week of therapy, it is unlikely that the patient will quit during the attempt and treatment should probably be discontinued. Dose tapering of Bupropion is not required when discontinuing treatment.

Contraindications: Seizure disorder, concurrent psychiatric medications and eating disorders like anorexia nervosa, bulimia and pregnancy.

Drug Interactions: Antidepressants like Fluoxetine are associated with panic and psychosis; Carbamezapine (Tegretol) increases metabolism.

Side Effects: Dopaminergic effects may be activated with feelings of agitation and restlessness. These however decrease in 1-2 weeks after medication begins. Other effects are insomnia, gastrointestinal upset, appetite suppression and weight loss, headache and lowering of seizure threshold. Seizure incidence is 1 in 4000 but the incidence is rare with sustained release preparations below 400 mg/day.

• Varenicline

Varenicline is a selective α4β2 nicotinic acetylcholine receptor partial agonist. It helps in reducing withdrawal symptoms and blocking dopaminergic stimulation.

Dosage: Varenicline should be started one week before the quit date and should be taken after eating food.

Treatment is continued for up to 12 weeks.

Day 1 to Day 3: 0.5 mg, 1 tablet each day

Day 4 to Day 7: 0.5 mg, twice a day

(1 in the morning and 1 in the evening)

Day 8 to the end of treatment: 1 mg twice a day

(1 in the morning and 1 in the evening)

Contraindications: Use with caution in patients with impaired renal function. Not recommended for use in patients under 18. Use in pregnant women only if the potential benefit justifies the potential risk to the foetus. This drug has no significant pharmacokinetic drug interactions.

Side Effects: Nausea, sleep disturbances, constipation, gas, vomiting, some reports of depression, agitation and suicidal thoughts.

Follow up: Meet the patient within one week of the quit date. The next visit must be scheduled within the first month. Other visits may be scheduled as per individual cases. During the follow up, assess pharmacotherapy use and its problems.

If the patient has slipped (consuming tobacco minimally) or relapsed (consuming tobacco according to initial habit pattern), identify the triggers. Reaffirm his commitment towards total abstinence and use the event as a learning experience.

Maintenance: May last for 6 months to a lifetime.