Smoking cessation advice

Dental professionals can play an important role in helping smokers stop, reports Naomi Davis.

Smoking is the largest single preventable cause of death and disability in the UK¹ and costs the NHS £1.7 billion each year.² Dental professionals can have an important role to play in supporting smokers who want to quit.¹

'Smoking cessation advice is an important but often overlooked aspect to preventative dental care'.

Smoking cessation advice is an important but often overlooked aspect to preventative dental care. Oral cancers, periodontal diseases, smokers' palate, smokers' melanosis and poor wound healing are some of the most serious effects of smoking on the mouth.^1,2 Dentists and their teams can become engaged in an interesting, relevant and important area of prevention through offering smoking cessation advice.²

Stopping smoking

'The four As' (see Box 1) is a recognised approach to identifying smokers who want to stop and how to help them reach their goal. Bullying or even gently coercing people who are not prepared to stop is unlikely to provide much more than frustration on all sides. Tailor your approach to the people who want and appreciate your help.

Ask

All patients should have their smoking habits recorded at the start of each course of treatment, and if they are a smoker there are a series of useful questions that can be asked (see Box 2). The answers give an indication of a patient's level of dependence on nicotine; patients who smoke 15-20 cigarettes a day and who have their first cigarette within 30 minutes of waking up each morning show a high nicotine dependence.

Advise

Users of all kinds of tobacco should be informed of the benefits of stopping. Most people seem to know about the dangers of smoking regarding lung cancer and heart disease. However, Nicola Smith, an oral health educator in the CDS in East Hants with responsibilities for smoking cessation advice, explains 'Public awareness of the effects of smoking on oral health in not high'. Advice should be clear and personally relevant and a range of reasons for stopping may be a more effective approach than frightening images of diseased organs. For example teenagers may be more influenced by the side effects of bad breath and stained teeth; students may be more interested in the financial savings of stopping; or pregnant women may be more influenced by the increased risk of spontaneous abortion and low birth weight.

Arrange

Stop Smoking Services have been set up across the country to help smokers who want to stop. A patient can contact the local service directly or be referred by a dentist. Local primary care trusts or health promotion services have details of their local NHS Stop Smoking Service. When explaining the service try and answer any questions that the patient might have, and consider points such as access difficulties; would the patient need assistance to access the service? Consider how you can encourage the patient to attend, and be sure to follow up their progress at their next dental appointment. Box 3 is an example of a Smoking Cessation Service.

Assist

If a patient is interested in stopping smoking but does not wish to attend the Stop Smoking Services they can still be offered help. There are six points at which a healthcare professional can help a patient quit smoking:

• 1 Negotiate a quit date with the patient which allows them time to prepare.

• 2 If the patient has tried quitting before, discuss their experiences and talk about what helped in previous attempts and what they think stopped their success.

• 3 Including the results of discussions in point 2 above, identify any possible pitfalls ahead and plan how these potential hurdles may be overcome.

• 4 Encourage the enlisting of family and friends in the support of the patient.

• 5 Discuss the possible use of nicotine replacement therapy (NRT) and Bupropion (Zyban). One of the main difficulties of quitting smoking is the addictive nature of nicotine, which is where NRT may be useful. There are a number of different products available and the choice is dependent on the individual. These products are available on prescription, which helps towards the costs.

• 6 There are telephone support lines that provide support and encouragement for people trying to quit smoking, make sure the patient has details of these.

Monitoring progress is part of achieving success, so arranging a date to check on progress within the first 1-2 weeks after the quit date is a good idea. If it is possible to do this in conjunction with a follow-up dental treatment appointment or hygienist appointment it makes the process more convenient and the patient is more likely to be able to attend. At this early point, the patient needs support and encouragement, and particularly congratulations if the patient has managed to not smoke since their quit date. Smokers often take more than one attempt to quit, the average is 3-4 attempts, so if a patient has smoked since their quit date, continue to encourage and support, taking into account the possible reasons for their smoking over this period. This can help to predict problems in future quit attempts.

Staying stopped

Help the patient to identify where their pitfalls and danger points might be. Identify diversions which they may be able to use when the desire to smoke arises. It is likely that they will experience cravings, and being prepared will help them to stay strong in their resolve to quit smoking. Patients may also experience other side effects such as an increase in coughing, bowel upsets, dizziness and disturbed sleep. All should only last for the first 2-3 weeks and being warned in advance and reassured should help them through this period.

You can make a difference

Evidence has shown^x2 that cessation advice works. Brief advice from a health professional lasting up to 3 minutes will help an additional 2% of smokers to quit each year. This goes up to 6% if the support is more intensive, lasts up to 10 minutes and the patient uses NRT. If all GDPs routinely offered smoking cessation advice based on the 4As, 2%-6% can represent between 63,000 and 190,000 people when translated to a populations estimate.

The Department of Health provides leaflets, posters and stickers to health professionals in England. There is a dental practice ceiling poster (5080C) and other promotional material along with more information and advice from www.givingupsmoking.co.uk

Table 1 The dental team can contribute to smoking

BOX 1: The 4 As

ASK

All patients should have their smoking status checked

ADVISE

All smokers should be advised on the value of quitting

ARRANGE

Referral should be arranged to local smoking cessation services

ASSIST

For those smokers who would want to stop but do not want to attend the smoking cessation services, appropriate support should be offered

BOX 2: Questions to ask patients regarding their smoking habits

Are you a smoker?

How many cigarettes do you smoke each day?

How soon after waking up in the morning do you have your first cigarette?

Have you ever tried to stop smoking?

Are you interested in stopping now?

BOX 3: An example of a Smoking Cessation Service

The East Hants SCS has a programme that lasts for seven weeks which people can refer themselves to or health professionals can refer their patients. At the first session, the patient is assessed for motivation, commitment and state of health; there is also a discussion regarding NRT after which the patient is given a prescription recommendation letter to take to their GP. This way medication can be provided on prescription. A quit date is also negotiated at this first session, which is normally in two weeks' time. Patients then attend weekly sessions for the duration of the course and can continue to attend monthly if they feel they need the support.