4. Tobacco Cessation Counseling Flashcards by J L

Additional Health Consequences

 Reduced \_\_\_\_ response
• Premature \_\_\_\_ and wrinkling
• Increased risk of \_\_\_\_ and macular degeneration
• Increase in \_\_\_\_, decrease in \_\_\_\_
 Increase \_\_\_\_ secretion in stomach
• Impotence and \_\_\_\_
• Disruption of menstruation and menopause
• Increase in risk in \_\_\_\_

immune
aging
cataracts
LDL
HDL
acid
infertility
SIDS

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Smoking and Periodontal Disease
• Smoking promotes periodontal disease
– Depresses immune function, especially
\_\_\_\_ 
– Accelerates rate of \_\_\_\_ loss

• Smoking affects treatment of periodontal disease:
– Delaying ____
– Suppressing immune response
– Correlated with implant failure

PMN’s
alveolar bone
wound healing

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Oral Effects of
Second Hand Smoke
• Children exposed to smoking in home have about ____ the rate of caries in primary teeth than children in non-smoking homes
• ____ also promotes the growth of microbial biofilm and bacteria and in smokers
• Caries is a ____ disease: smoking parents who kiss children pass on cariogenic bacteria
• Non-____ effects aswell

double
nicotine
communicable
oral

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Other Oral Effects of Smoking
• Bad \_\_\_\_
• \_\_\_\_ Teeth
• Altered sense of \_\_\_\_ and \_\_\_\_
• “Smoker’smouth”
– As a dentist, you will recognize smokers immediately...even if they deny it

breath
discolored
taste
smell

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Oral Health Effects of Smokeless Tobacco

Oral cancer, ____ cancer & Leukoplakia • Caries
Gingival recession & Periodontitis
Damage to oral bone structure

pharyngeal

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Other Effects of Smokeless Tobacco
• Addiction
• Higher amounts of \_\_\_\_ than cigarettes
• Increase in \_\_\_\_/ heart rate
• Tooth \_\_\_\_
• Impaired \_\_\_\_

nicotine
BP
abrasion
taste

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Tobacco Prevalence Rates (CDC,2015)

Healthy People 2020 Target: 12% adults 16% teens
• Current Rates for Cigarette Smoking
16.7% men, 13.6% women, 8.2% teens, 8.4% seniors

• Current Rates for Spit Tobacco (Target 0.3%)
3.4% all adults; 6.7% men, 0.3% women
Highest in ____, WVA, ____ and Mississippi
Lowest in ____, Hawaii, ____ & California

• Current Prevalence Rates for Cigars (Target 0.2%) 8.2% men, 2% women, 7.5% Black adults; 14% teens

wyoming
montana
DE
massachusetts

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US Smoking Prevalence
• \_\_\_\_ (21.9%)
• Non-Hispanic whites (16.6%) and non-Hispanic
blacks (16.7%)
• Hispanics (10.1%) and Asians (7%)
• Those below poverty level (\_\_\_\_%)
• Less than HS education (\_\_\_\_%)
• Live in the Midwest (18.7%)

____ High Smoking Rate at 19.9%

American Indians/Alaska Native
26.1
24.2
Philadelphia

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Advocate Community Interventions
• No-____ zones, ie Penn campus wide ban, restaurants
• High ____, Phila now 3rd highest in nation for cigarettes, still low for ____ tobacco
• Increased enforcement of age ____ sales
• Ban on tobacco company ____ and support of sport events

smoking
taxes
spit
21
promotions

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2016 Philadelphia Cigarette Tax raised cost to $4.60 per pack, ____ highest in nation

third

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Types of Tobacco
• ____
• Smoking
• ____

smokeless

e-cig

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Types of Tobacco
• Smokeless
– \_\_\_\_ tobacco
 – Chewing tobacco 
– \_\_\_\_ tobacco

dipping

snuff

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Popularity of Chewing Tobacco
• Traditional Sports Affiliation
• Increasing Use with ____ Girls & Women
• Recommendation as Harm Reduction
• Novel Use as Cigarette Replacement in ____ or ____
• SNUS

teen
workplace
airplanes

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E-Cigarettes
• Personal vaporizer (PV)
• PEG, PG, Nicotine
• Harm reduction strategy
• Little ____ on safety
• 2016 FDA strict ____ apply to all tobacco products including tobacco bans, ads, & age limits
• Early adoption 2006-2012, ____ consumption in 2015 due to safety concerns & cost

research
regulations
decreased

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Smokeless Tobacco:
A Unique Opportunity
• Use is often missed by other ____
• Dental visit is ideal venue to address this problem:
– Routinely ask about use & perform screening
– Discuss ____
– Encourage substitution & cessation

health professions

negatives

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Your Role (Cont.)
• Dental professionals are not expected to be ____
• Do what you are comfortable with
• Discussing cessation elevates importance
– Reinforcing a common message

motivate, ____ and ____

psychologists
educate
refer

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Rationale for Tobacco Cessation
• Current Behavior Change Issues
– Average of ____ attempts to quit for good
– ____ at least one attempt ever; 44% in 2010

• ____ behavior more difficult
• Physical as well as ____ addiction
• ____
– People like being told “good job!”
– A little enthusiasm and support can go a long way
– You may be the only person in their life that genuinely cares if they quit smoking

5
70%
subtracting
psychosocial
encouragement

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The Five A’s

____
____
____
____
____

ask
advise
assess
assist
arrange

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Assess

Yes: refer to ____ programs
No: discuss ____

cessation

barriers

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The Stages of Change

Behavior change usually occurs in ____ stages

Not considering ____
Thinking about ____
Quitting
____
Relapse

discreet
change
quitting
maintenance

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• Not Thinking about Quitting
– Educate, but don’t ____
• Thinking About Quitting
– Motivate, Educate____

• Quitting Now
– Encourage &amp; \_\_\_\_
• Maintenance
– Support \_\_\_\_,
Emphasize Benefits
• Relapse
– Motivate, Educate, Refer

push
refer
refer
absitnence

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EDUCATE
• ____ oral cancer screening
• ____ effects of smoking/tobacco use on oral
health and general health
• ____ smoking cessation products
• ____ behavioral treatment
• Again: You ARE NOT a psychologist or cessation expert. You are a (valuable) resource for information and education.

conduct
review
discuss/recommend
discuss/recommend

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Conducting an Oral Cancer Screening
• Standardized ____ & ____ Oral Examination – Tell them what you are doing and why you are
doing it
• Educating Patients Regarding Examination
• Community Oral Cancer Screening Programs – Philadelphia Oral Cancer Walk & 5K
– Free oral cancer screenings! – Great way to get involved

extra

intra

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Treating Each Aspect
• Physical Addiction 
– \_\_\_\_ Products
• Habit/Behavioral 
– \_\_\_\_
• Psychological Dependence 
– Distinguish \_\_\_\_ vs. Reality

cessation
coping
myth

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``` Physical Addiction • Addictive substance: ____ • Reinforcer – Releases ____ in brain – Produces pleasure – Gets to brain in one to two minutes ``` • Withdrawal Syndrome – Levels begin to drop ____ – Negative feelings occur

nicotine | immediately

``` Typical Smoking Pattern • Usually in withdrawal upon ____ • First cigarette leads to ____ peak • Serum levels begin to drop immediately upon completion of cigarette • Withdrawal occurs • Next cigarette is smoked to relieve withdrawal • Pattern is repeated throughout the a day ```

waking | quick

Nicotine Absorption Readly absorbed from: - respiratory tract: ____ - nasally: ____ - orally: ____ - skin: ____ Minimal stomach absorption due to ____

1-2 min 5-10 min 10-16 min 6-9 hours acidity

Nicotine Absorption • Nicotine replacement therapy works well in eliminating the pleasurable effect because ____ the products take much longer to produce peak concentrations. • The “hit” or buzz one gets from smoking cannot be achieved from using these products. • Therefore, it is generally quite difficult to become ____ addicted to any smoking cessation medication. • This is why e-cigarettes or vaping will not ____ nicotine dependence. Their rapid absorption provides the same “hit” as cigarettes, creating the same withdrawal-usage pattern throughout the day.

all physically reduce

``` Other Effects of Nicotine • Effects depend of dose • Stimulant/tranquillizer • Increases ____ • Increases ____ and motor activity • Some evidence to suggest it facilitates ____ and decreases aggression • Slight shift in ____ ```

respirations GI tone memory metabolism

Nicotine Delivery from Smokeless Tobacco * Does not deliver the ____ of nicotine as smoking does * Generally speaking, smokeless tobacco contains much ____ levels of nicotine * Therefore, smokeless tobaccos are just as ____ as cigarettes

"hit"higher | addicting

Withdrawal - ____ - anxiousness - ____ - restlessness - ____ - cravings - ____ disturbances - increased appetite

irritability impatience depression sleep

Pharmacotherapy: Nicotine Replacement Therapy (NRT) Benefits – Prevent ____ withdrawal symptoms to allow cessation of behavioral habit – Eliminates the ____ effect of nicotine when administered through smoking – Gives the quitter the time to comfortably break the habit and psychological dependency – Delay or Decrease ____

physical reinforcing weight gain

Pharmacotherapy: Nicotine Replacement Therapy (NRT) • Nicotine Toxicity – ____ – Dizziness – ____/vomiting/diarrhea – Very ____ even with concomitant use of NRT and smoking

perspiration nausea rare

FDA Approved "First Line" Medication Recommendations ____ Nicotine Patch Nicotine Gum Nicotine Lozenge ____ Nicotine Inhaler Nicotine Nasal Spray Bupropion SR 150mg Varenicline 1mg

over-the-counter | prescription

Pharmacotherapy: Limitations ``` Not “magic pills”, and not a “cure” • Work best when combined with ____ counseling: – In office if you are inclined or – Refer to • Local programs • Medication sponsored program • PA Free Quit Line: 1-877-724-1090 ```

behavioral

Recommending vs. prescribing • Patch, Gum and Lozenge are over-the- counter • FDA has certified these products as safe – Side effects are ____ • Clinical Practice Guidelines show that: – These products are efficacious – They double or triple ____ • ____ products is good health care

minimal success recommending

Patch: Heavy Smokers • ____ 24/16 Hours – 10/day or more – 21mg x 6wks, 14mg x 2wks, 7mg x 2wks • ____ 24/16 Hours – 20/day or more – 21mg x 3/4wks, 14mg x 3/4wks, 7mg x 3/4wks

nicoderm CQ | habitrol

Patch: Heavy Smokers • ____ 16 Hours – 10/day or more – 15mg x 6wks, 10mg x 2wks, 5mg x 2wks • ____ – 15 day or more – 22mg x 6wks

Nicotrol | Private Label

Moderate Smokers • ____ (Less than 10/day) – 14mg x 6wks, 7mg x 2wks • ____ (Less than 20/day) – 14mg x 3/4wks, 7mg x 3/4wks • ____ (Less than 15 day) – 11mg x 6wks • ____ not recommended for light smokers (no studies done)

Nicoderm Habitrol Private Label Nicotrol

``` Light Smokers • ____ cigarettes a day or less – ____ is generally not recommended – If quitter insists use only the lowest patch strength for a few weeks – Suggest ____, lozenge or ____ ```

5 NRT gum inhaler

Patch Patient Counseling • Apply ____ • Apply a new patch every day to a different, dry, clean, hairless place • Rotate sites over a ____ day period • Do not leave on for more than ____ hours • Do not use if using ____ (____ hour bolus left in skin when removed)

``` promptly seven 24 tobacco 4 ```

Patch Side Effects • ____ Dreams • Localized Skin Reactions (rash, pruritis, burning) – Up to 50% of patients have mild form – Incidence higher with ____ hour products – Less than ____ discontinue therapy

vivid 24 5%

``` Nicotine Gum • ____ (Original, Mint, Orange) • Generic • Both come in – 2mg (< 25 cigarettes a day) – 4mg ( >25 cigarettes a day) • Option of choice for heavy ____ tobacco users ```

nicorette | smokeless

``` Dosing Gum • Schedule the same for 2mg and 4mg • Weeks 1-6 – 1 piece every one to ____ hours • Weeks 7-9 – 1 piece every ____ hours • Weeks 10-12 – 1 piece every ____ hours ```

two 2-4 4-8

Gum: Patient Counseling • Must use on a ____, consistent basis throughout the day (at least 9 pieces) • Use for a full ____ months with a fixed tapering schedule • Do not use more than ____ pieces in one day • Avoid ____ or drinking with gum in mouth • Additional pieces can be used ____ to deal with specific urges

``` regular three 24 eating PRN ```

``` Proper Gum Technique • Do Not ____!! • Proper technique – Activate slowly until “____” emerges – Then park between cheek and gum – When taste disappears, move to another spot and repeat – One piece is usually good for ____ minutes ```

chew peppery taste 30

Gum Precautions Incorrect use may lead to: - mouth ____ - ____, hiccups, etc. - ____ ache

soreness dyspepsia jaw

Lozenge • “Commit” • ____ administration • ____ Acting • Mint Flavor • 2mg—first cigarette > 30 min. from waking • 4mg—first cigarette < 30 min. from waking ``` • Weeks 1-6: – One piece every one to two hours • Weeks 7-9: – One piece every two to four hours • Weeks 10-12: – One piece every four to eight hours ```

sublingual | quick

Oral Inhaler • ____ • Two part mouth piece enclosing nicotine cartridge • Cartridge = ____mg nicotine • Mimics the ____ aspect of smoking • Use 6-16 cartridges/day puffing as needed for up to ____ months

prescription 10 oral six

Nasal Spray • ____ • One metered spray contains ____mg nicotine • One to two sprays in each nostril per ____, initially—increase as needed • No more than 5 doses/hr. or 40 does/day • Use for eight weeks then taper for 4-6 wks.

prescription 0.5 hour

``` Precautions for NRT Use • ____ within two weeks • Unstable ____ • Dysrhythmia • ____ NRT Contraindicated in ____ ```

MI angina hypertension pregnancy

Efficacy of NRT • Using NRT produces doubles or triples the long term quit rates over placebo • Caution: Not a magic bullet – Not a ____ for smoking – Part of a comprehensive treatment program – Most effective when combined with a ____ modification program

cure | behavior

Oral Effects of NRT • Gum – Not recommended for individuals with extensive dental work, dentures, or ____ disorders • Lozenge – May cause minor mouth ____ if left in one spot too long • Oral Inhaler – Nicotine vapor mist may irritate ____ • Patch/Bupropion/Varenicline – No ____ effects – May be ideal for patients with oral concerns

TMJ sores mouth oral

Safety Concerns • These are nicotine ____ products • Using the patch, gum or lozenge does not introduce anything ____ to the smoker • Smokers simply get nicotine in a way that allows them to comfortably reduce usage • AMA, American College of Cardiology and many other medical societies strongly encourage use

replacement | new

``` Buproprion SR 150mg (Zyban) • Repackaging of ____ • May increase ____ • Begin 1-2 weeks prior to ____ • Start 150 mg daily, target dose 150mg twice daily • 7-10 weeks of therapy: no tapering ```

wellbutrin dopamine quitting

Buproprion SR 150mg • Drug interactions: – Tricyclic antidepressants (lowers ____ threshold) – MAOI (____ crisis) • Absolute contraindication: ____ disorder or ____ trauma, ____ • Relative contraindications: Anxiety Disorder, PTSD, Bulimia and Anorexia

``` seizure hypertensive seizure head pregnancy ```

Buproprion SR 150mg • Side effects: ____, insomnia, agitation – If occurs with initial use of SR Q/day then try 75mg ____ release – Can be minimized by: • Reducing SR dosage to ____ daily • Give entire dose in ____ • Move second dose to as ____ in day as possible – SR Q/day vs. BID give almost identical ____ mth quits

``` dry mouth immediate once morning early 6 ```

Varenicline 0.5 - 1mg • Begin with .5mg taken 1 week before cessation, increase to 1mg on quit date • Monitor for changes in ____, evaluate for depression and suicide ideation (2008 Warning) • Side effects: ____, Nausea, ____, Abnormal, vivid strange dreams • Contraindication: ____ or Psychiatric illness • Caution with Kidney Disease & Dialysis Patients ____ for Combination Therapy with NRT

``` mood dry mouth insomnia pregnancy not approved ```

Combination Therapies • Clinical trials show that using ____ and ____ increases quit rates over using either alone – Probably best for ____ smokers: > 2packs/day • Can use patch or Buproprion as ____ therapy • Gum, lozenge or inhalers can then be used PRN for specific trigger situations • CANNOT Use ____ in combination with NRT

``` patch buproprion heavy "base" varenicline ```

``` Any Exceptions? Medical Contraindication ____ Women Adolescents ____ Users Light Smokers( ```

pregnant smokeless tobacco 10

``` Other Products • No clinical evidence of efficacy: – Other ____ – Nicotine Lollypops – Nicotine ____ – Nicotine Water – ____ Remedies ``` ``` Other Treatment Modalities • ____ • Acupuncture • Ear Clips • “Fake” cigarettes • ____ • Nicotine Fading • ____ Techniques ```

antidepressants lip balm herbal hypnosis tapering aversive

REFER • Local MD specializing in cessation • Hospital/Community based groups • Pharmacists specializing in smoking cessation • American Lung Association/American Cancer Society • Private therapists ``` Other Referral Sources • Product support programs • PA Free Quit Line 1-877-724-1090 • Five proactive phone calls • 24-hour support • Online Support Programs ```

Elements of a comprehensive cessation program • ____ has been specifically trained as a smoking cessation specialist • Program is multi-session with follow up • Smoking cessation medication use is encouraged and monitored • Emphasizes coping skills and problem solving • Provides intra- and extra- treatment social support • 6-month and one year quit rates are over ____%

counselor | 35

Special Consideration • Maintenance Phase: staying quit • Support and Encourage – “Keep up the good work!” – “I am proud of you!” – Rewards • Encourage compliance – Medication regime – Behavioral changes • Strategize about potential barriers

4. Tobacco Cessation Counseling Flashcards

(64 cards)