The smoking public are generally antagonistic against cessation advice. They are weary of the constant message to quit smoking, but never really being told why they should and as a result, largely switch off. What they require is a better understanding of the need to quit, support and practical advice on how to stop smoking.
The basic level of understanding by the public about smoking is that smoke goes into their lungs and is puffed out, which makes them feel ‘less stressed’. They do not appreciate the harmful chemicals enter the blood stream, interact with the blood and circulate around the body and entering every cell, with nicotine actually measurable in toe nails.
As far as the mouth is concerned smokers understand it will stain the teeth and cause bad breath, but damaging the gums, reducing the underlying bone, loosening their teeth, and affecting the cells which fight off infection is hard for them to comprehend. But information like this has been shown to increase awareness among receptive smokers and help them interact with literature and other information given to them.
Another way to interact is to provide biofeedback – information relating directly to a person’s medical condition. This could take the form of sequential photographs showing the increase in staining or changes such as leukoplakias. Another approach shown to be successful is salivary cotinine measurements (1). Cotinine is the major metabolite of nicotine and it can be measured by chair-side, point-of-care tests, such as SmokeScreen® (2). The speed and visual impact of the test’s colour change allows the oral health professional to assess the extent of a person’s smoking habit, rather than relying on self-reported cigarette consumption. The test’s colour change can be shown to the patient and this has a powerful impact on many smokers, helping them to appreciate more about their smoking and realising nicotine is in their blood stream. This can be directly related to their oral health. This helps to personalise the information and it can be used to tailor the advice given to an individual.
Yet achieving change in smoking behaviour largely depends on a smokers ‘readiness to quit’. The ‘Stages of Change’ model (3) divides the process of quitting smoking into five stages (See box 1), through which each smoker must pass to achieve abstinence. Recent research has shown that patient’s attitudes and desire to quit is important and nearly half current smokers who wanted to quit requested cessation advice to be provided by the dental team alongside periodontal treatment (4).
One simple step that can be taken to focus a patient’s thought towards an attempt at stopping is to set a ‘quit date’. This allows them to prepare psychologically, recruit support from family and friends, dispose of smoking materials and time to read around the subject. This also gives an excuse for the members of the dental team to ask later how the quit attempt went. If they didn’t adhere to it then another date should be set. If it went well, then encouragement should be given and perhaps retesting to reinforce the message.
Variations of this approach have been reported (5) and condensed to the 5As: Ask, Advise, Assess, Assist and Arrange (See box 2). Estimates put this type of intervention at about 10 minutes and it should be revisited at each of the patient’s visits.
The amount of counselling given to the smoker will obviously depend on the amount of time available, but it has shown the longer it is the better the outcome. But just a brief, three minutes of counselling has been shown to have a significant impact by encouraging more quit attempts (6).
But an important question is should the smoker be advised to quit outright or cut-down? Clearly abstinence from tobacco is the ultimate goal, but many smokers feel incapable of quitting immediately. Fading is the term given to cutting down, and this has been shown to be useful in some individuals on future cessation attempts (7), but much depends upon the individual smoker and their belief in their ability to quit. However, cutting down often results in ‘compensation’, the process by which the fewer cigarettes are smoked more effectively to maintain the usual circulating nicotine level. Again, cotinine testing can establish if this is the case.
Smoking cessation intervention should come from the whole dental team. The practitioner should be the first to address the issue of smoking and its effects on oral health and give brief general advice and then pass on the responsibility of testing and counselling to the hygienist, therapist or oral health promoter who have undergone specialist training to plan the cessation programme (8). This will involve practical advice on how to avoid the stimulus to smoke, how to cut out specific cigarettes in the day and avoid being with others who smoke, particularly partners. Advice on the use of nicotine replacement therapy and other pharmaceutical aids, such as Zyban (Bupropion) and Varenicline (Champix) is also helpful. However, it should be borne in mind that many smokers quit without these aids and an initial quit attempt could be made without.
The dental team should also be aware of the national and local facilities for smoking cessation, such as the national telephone helpline (0800 0224332) or the local stop smoking service. Referrals to these services help many people to quit, but they do not suit all.
Finally, the expectation of success by the dental team with regards smoking cessation should recognise that the addictive nature of nicotine is very powerful and the circumstances and attitudes of many do not lend themselves to stopping; but there are individuals who want to stop and seek advice and support to do so. Quit attempts are essential, but it has to be remembered that it takes on average six quit attempts before an individual is successful – it may take less, but in others it might never happen. The point is it is worth trying.