Download Tobacco Cessation for the Dental TeamLarry N Williams, DDS

Tobacco Cessation for the Dental TeamLarry N Williams, DDS, ABGD, FACD,
FADI, FICDNODC / LDA Annual Conference 2015
1
Objectives
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Discuss dental team role
Review both systemic and oral health complications associated with tobacco use
Discuss educational resources
Explore patient and provider resources
TUC Background
 Tobacco Cessation must be a continuum
 “One size” or method of cessation does not fit all those wishing to become tobacco free
 Access to evidence-based cessation must be unfettered
Clinical Practice Guideline Guiding Principles
 “We have to make cessation support as accessible as buying cigarettes for those
patients who want to quit.”
 Recent surveys showed 62% of tobacco users want to quit in the next 6 months
 Cessation support must have a range of intensity
 One “size” of tobacco cessation will not cover all patients who wish to quit
The Dental Team approach
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Patient
Dentist
Dental Hygienist
Dental Assistant
Other providers
The decision tree of treating tobacco addiction & cessation
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As a Dentist, do I address tobacco or not?
 If I address tobacco, will I treat or refer?
 If I decide not to address tobacco, what can happen?
Do I need special training to help someone quit?
How can I get my staff involved?
Key POINT!
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Repeat after me:
“Do you use tobacco?”
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What did we not say… Do you smoke?
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Must include all forms of tobacco.
Tobacco Cessation for the Dental TeamLarry N Williams, DDS, ABGD, FACD,
FADI, FICDNODC / LDA Annual Conference 2015
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What do I say?
“As your oral healthcare provider, I need to inform you that quitting your tobacco use is
the most important decision you can make for your health.”
“As your Dentist, I need to tell you that quitting tobacco will help to greatly improve your
oral health.”
One-on-One
Staff-Patient Interaction
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How to start
 Ask, Advise, Assess, Assist, Arrange
 Tie to health issue or need
Be prepared for “push-back”
 Have they tried before?
 What worked/didn’t work?
 What would help them decide to quit?
 What is keeping them from quitting?
One-on-One
Patient-Centered Focus
 Patient points:
 Weight gain concerns
 Meds didn’t work
 My spouse and/or significant other uses tobacco
 It is my only break
 Your counterpoints
 You don’t have to gain weight
 New evidence-based ways to use meds
 Help is available for everyone- quit together
 Find other break options
Resources for Tobacco Facts
 Smoked Tobacco
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http://www.cdc.gov/tobacco/basic_information/index.htm
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http://www.cancer.gov/cancertopics/tobacco/smoking
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http://betobaccofree.hhs.gov/about-tobacco/index.html
 Smokeless Tobacco
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http://www.cancer.gov/cancertopics/factsheet/Tobacco/smokeless
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http://www.tobaccofreekids.org/facts_issues/fact_sheets/
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http://oralhealthamerica.org/wp-content/uploads/Quitting-Spit-Tobacco.pdf
Bottom Line(s)- Up Front
 Over 60% current tobacco users want to quit in 6 months
 One can of dip/week = 15 cigarettes smoked/day!
Tobacco Cessation for the Dental TeamLarry N Williams, DDS, ABGD, FACD,
FADI, FICDNODC / LDA Annual Conference 2015
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A cigar the size of your index finger = 7 cigarettes
Tobacco cessation medications must fit patient’s needs and the patient must fit the
medication
 Cessation must fit the patient’s desires and address ad lib use of NRT and habit
substitution
 The patient’s medical history must be taken into account when choosing meds
National Institute of Drug Abuse (NIDA) Facts
More NIDA Facts
More NIDA Facts
A Key “Tobacco Fact”
 Here is a really significant issue for our young people:
 Based on national average of tobacco costs, a one pack/can per day habit for a
person on a minimum wage job is equal to ONE month’s minimum-wage pay
for a year
 Tobacco has a major impact on the quality of life for our young people and
their families
 They are the ones who can least afford it!
Tobacco Facts
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More than 4,800 chemical compounds in tobacco
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60 compounds are known carcinogens, tumor initiators,
and tumor promoters
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The 60 chemicals include: hydrocarbons (tar), cyanide, phenols, benzene,
nitrosamine(s)
Tobacco Facts
 Tobacco plant concentrates two naturally occurring radioisotopes: radium and
polonium
 Nicotine is as addictive as opiates
 Nicotine has not been shown to be a carcinogen or co-carcinogen in humans
Tobacco Facts
 Smokeless tobacco is made from the scraps and refuse from the floor of the tobacco
factory
 Includes dead animals and insects
 Animal waste
 Trash
 Very little tobacco
 Nicotine added due to high level of non-tobacco product
Smokeless Tobacco
 One can of smokeless tobacco has the same nicotine as over 5 packs of cigarettes
(Skoal, Copenhagen & Kodiak have the highest rates of freebase nicotine on the
market).
 The cancer causing chemicals in tobacco are 100x stronger than in cigarettes.
Tobacco Facts
Tobacco Cessation for the Dental TeamLarry N Williams, DDS, ABGD, FACD,
FADI, FICDNODC / LDA Annual Conference 2015
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Smokeless tobacco produces additional carcinogens when combined with saliva
91% of oral cancer patients had used smokeless tobacco
Cigars
 Smoking a cigar the size of your index finger is the same as smoking 7 cigarettes
 5 % of users are female
 Very expensive habit
 27 % of kids 14 to 19 had tried a cigar in 1996
 Smoking has increased from 18.5 % in 1991 to 22.2 % in 1996 for 12 graders
Health Concerns
 New “Less Harmful” Tobacco Products
 There are NO SAFE(R) FORMS OF TOBACCO!
 No proven health benefit!
 Electronic cigarettes do not “deliver”
Newer Forms- not safe either!
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Snus
Orbs, Strips, Sticks
Lozenges
Hookah
Electronic Nicotine Delivery Devices
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This product is not an FDA approved drug delivery device
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It is NOT an evidence-based tool for tobacco cessation
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It has not been tested for efficacy or safety
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FDA tests have shown carcinogens to be present in the liquid that is volatilized
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FDA tests have also shown other impurities such as propylene glycol (car antifreeze)
in the chemical matrix
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It has been legally ruled as a tobacco product
Hookah (Waterpipe/Shisha)
 Same health risks of cigarette smoking
 40 to 45 minutes of use can approach same level of inhaled tobacco equal to 100 cigarettes
 250 times more nicotine and 120 times more cotinine
 Multiple users can pose a public health risk
Other Nicotine Products
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NicLite - nicotine “juice”
Nicogel - nicotine hand gel
The Systemic and Oral Health Impact of Tobacco
Oral Health and Tobacco
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Increased risk of:
Tobacco Cessation for the Dental TeamLarry N Williams, DDS, ABGD, FACD,
FADI, FICDNODC / LDA Annual Conference 2015
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Tooth stain
Caries
Alveolar osteitis
Bone loss
Tooth loss
Poor healing
Implant failures
Cancer
Oral Health:
Implant failure impact
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Tobacco involves a 15.8% risk of implant failure
Light smoking (LS) or moderate smoking (MS) tobacco use involves a 10.1% relative
risk of implant los
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Consumption of >20 cigarettes per day increases this risk to 30.8%.
Oral Health:
Root coverage concerns
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Cigarette smoking negatively impacts the clinical outcomes of coronally positioned
flaps (CPF)
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Specifically in residual recession and decreased percent root coverage
Risk Factors - Smoking
The majority of tooth loss in adults aged 19-40 is associated with smoking more than 15
cigarettes a day (Holm G, J Periodontol 1994;65:996-1001).
There is a linear dose-response relation between smoking and bone loss - compared with a
nonsmoker, a light smoker (< 10 cigarettes a day) was 2 times (200%) more likely to have
alveolar loss. In a heavy smoker (> 10 cigarettes a day), the odds were 7.3 (Grossi SG et al.
J Periodontol 1995;66:23-9).
Cigar and pipe smoking have also showed a similar negative impact on the pattern of
periodontal disease (Albandar JM et al. J Periodontol 2000;65:545-550; Grossi SG et al.
Holm G, J Periodontol 1994;71:1874-1881;Krall EA et al. J Am Dent Assoc
1999;130:57-64).
Risk Factors - Smoking
Smokers tend to show a poorer tissue response to S/RP, flap surgery, regenerative and
plastic surgery, and implants (AAP - position paper J Periodontol 1999; 70:1419-1427;
Preber H, Bergstrom J. J Clin Periodontol 1990;17:324-328).
Therefore, tobacco use will adversely affect long-term prognosis of periodontally involved
teeth.
Tobacco Cessation for the Dental TeamLarry N Williams, DDS, ABGD, FACD,
FADI, FICDNODC / LDA Annual Conference 2015
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Smoking Effects on Therapy
Non-surgical therapy:
 Less PD reduction and less gain in CAL
Surgical therapy:
 Resective
 Less PD reduction and more attachment loss
 Implant
 Greater failure rate
 Plastic (CTG)
 Less root coverage of Miller Class I or II defects
 Regenerative (GTR/bone grafts)
 Greater risk of failure
Smokeless Tobacco
↑ Gingival recession and ↑
attachment loss
↓ Gingival blood flow
Health Concerns
 4 million children are sick each year due to second hand smoke
 307,000 cases of asthma
 354,000 cases of middle ear infections
 Greater risk of tooth decay
 Even limited exposure to second-hand smoke (SHS) can lead to significant disease
Impairs Patient Recovery
 Recovery room stays are 20% longer for smokers than non-smokers. (Handlin DS,
Baker T. Woolrich J: Effect of smoking on duration in recovery room. Anesthesiology
1990)
 Patients who smoked regularly before surgery had twice the risk of wound infections
as non-smokers. (Jones, RM: Smoking before surgery: The case for stopping. BR Med J
1985)
 Smoking will retard wound healing, whether the wound is surgical or the result of
trauma or burns. (Smoking and wound healing. Am J Med. 1992 Jul
15/93(1A):22S-24A. Review. PMID: 1323208 [PubMed-indexed for MEDLINE]
Injury Recovery
“Cigarette smoke delays the formation of healing tissue and sets the stage for increased
scarring at the edges of a wound…”
“Nothing messes up the timing (of the healing process) like cigarette smoke. Clinical studies
have consistently shown that individuals exposed to cigarette smoke – whether “first-”
Tobacco Cessation for the Dental TeamLarry N Williams, DDS, ABGD, FACD,
FADI, FICDNODC / LDA Annual Conference 2015
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or “second-hand”– heal poorly and are more likely to develop scarring and associated
diseases.”
****Weight Gain****
 Smoking depresses body weight
 Nicotine acts as an appetite suppressant
 On average smokers weigh less than non-smoking counterparts
 Many women fear quitting because of weight gain
 Teens start smoking to avoid weight gain
Pregnancy
 Smoking during pregnancy is the most preventable cause of poor pregnancy outcomes
 Maternal smoking is linked to a greater risk of pre- and peri-natal mortality
 Current studies underway to look at NRT use during pregnancy
 ACOG Issues Recommendations for Providers to Support Perinatal Smoking
Cessation
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http://www.medscape.org/viewarticle/730940
Practical Clinical Advice and Relapse Prevention
Change starts now….
 Ad lib gum use is a must
 Address oral habit
 Fake cigarettes- www.smokersoption.com
 Fake dip- www.mintsnuff.com
 Delimit access and remove any barriers
 Empower those wanting to quit
 Ask the patient what they want in quitting support
Practical Clinical Advice
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Dosing (available upon request)
 Vary per tobacco intake
 Individual preference
Clinical follow-ups
 Pharmacotherapy efficacious
Patient interaction
 Minimal intensity vs. Maximum intensity
Relapse prevention
More practical advice…
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Combination of patch, gum, and bupropion have best track record at limiting weight
Tobacco Cessation for the Dental TeamLarry N Williams, DDS, ABGD, FACD,
FADI, FICDNODC / LDA Annual Conference 2015
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gain
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Best odds ratio for meds includes ad lib gum use
Few eat food with gum in their mouth
Few smoke or dip in their sleep
Titrate meds to effect
Follow-up is important
EXTREMELY IMPORTANT!!!
**Address Relapse Issues**
Preventing Relapse
 Most relapses occur soon after a person quits using tobacco
 People relapse months or even years after the quit date
 All clinicians should work to prevent relapse
 Components of Clinical Practice Relapse Prevention
 For every encounter with a recent quitter
 Use open-ended questions
 Emphasize any success (duration of abstinence, reduction in withdrawal, etc.).
 Discuss any problems encountered or anticipated (e.g., depression, weight gain,
alcohol, other tobacco users in the household)
Relapse Prevention
 Recognize specific relapse problems by identifying a problem that threatens his or her
abstinence.
 Lack of support for cessation
 Schedule follow-up visits or telephone calls
 Help the patient identify sources of support
 Refer the patient for intense counseling or support.
 Negative mood or depression
 Refer patient to a specialist.
 Strong or prolonged withdrawal symptoms
 Consider extending the use of an approved pharmacotherapy or
adding/combining pharmacologic medication to reduce strong
withdrawal symptoms.
Relapse Prevention
 Weight gain
 Increase physical activity; discourage strict dieting.
 Reassure the patient that some weight gain after quitting is common and
appears to be self-limiting.
 Emphasize the importance of a healthy diet.
 Maintain the patient on pharmacotherapy
 Refer the patient to a specialist or program.
 Flagging motivation/feeling deprived
 Reassure the patient these feelings are common.
 Recommend rewarding activities.
Tobacco Cessation for the Dental TeamLarry N Williams, DDS, ABGD, FACD,
FADI, FICDNODC / LDA Annual Conference 2015
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Evaluate for periodic tobacco use.
Emphasize that beginning to smoke (even a puff) will increase urges and
make quitting more difficult
Resources and Training
University of Wisconsin Center for Tobacco Research and Intervention (CTRI)
www.ctri.wisc.edu/HC.Providers/healthcare.htm
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Materials: Print or Order
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Mental Health, Substance Abuse and Nicotine Dependence
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Dentists and Hygienists
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Videos + Webinars
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Physicians
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Pharmacists Training,
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Technical Assistance & Education
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Nurses Case for Tobacco Treatment
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How Other Providers Treat Tobacco
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Billing Codes
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Clinical Practice Guideline
Free Online CE from UW:
http://cme.uwisc.org/index.pl?op=show;isa=Course;iid=532379
Louisiana Resources
http://quitwithusla.org/pages/detail/73/Louisiana-Tobacco-Quitline
Provider Resources
Pharmacotherapy for Tobacco Cessation
Disclaimer
 All topics discussed are based on the professional training and opinions of the speaker
 Any mention of trade names is purely academic in nature and does not reflect any
proprietary intention
 Any off-label use is in keeping with current CPG
Objectives
 Review current “OTC” nicotine delivery systems
 Discuss OTC and Rx pharmacotherapies used with tobacco cessation to include
indication, utilization, and any precautions.
 Discuss training opportunities for providers wishing to learn more about tobacco
cessation pharmacotherapy.
“Dangerous” Nicotine Delivery Systems
“Newer” Dangerous Delivery Systems
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Snus
Orbs, Strips, Sticks
Tobacco Cessation for the Dental TeamLarry N Williams, DDS, ABGD, FACD,
FADI, FICDNODC / LDA Annual Conference 2015
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Lozenges
Hookah
Electronic Nicotine Delivery Products
CPG Pharmacotherapy
 Seven first-line medications (5 nicotine and 2 non-nicotine) reliably increase
long-term smoking abstinence rates:
– Bupropion SR
– Nicotine gum
– Nicotine inhaler
– Nicotine lozenge
– Nicotine nasal spray
– Nicotine patch
– Varenicline
• Clinicians also should consider the use of certain combinations of indications
identified as effective in this Guideline
Pharmacotherapy
Meds plus Counseling
 Counseling and medication are effective when used by themselves for treating tobacco
dependence. The combination of counseling and medication, however, is more
effective than either alone. Thus, clinicians should encourage all individuals making a
quit attempt to use both
counseling and medication.
NRT: Products
Polacrilex gum
 Nicorette (OTC)
 Generic nicotine gum (OTC)
Lozenge
 Commit (OTC)
 Generic nicotine lozenge (OTC)
Transdermal patch
 Nicoderm CQ (OTC)
 Generic nicotine patches (OTC, Rx)
Plasma Nicotine Concentrations
Transdermal Nicotine Patch
Nicoderm CQ (GlaxoSmithKline); generic
 Nicotine is well absorbed across the skin
 Delivery to systemic circulation avoids hepatic first-pass metabolism
 Plasma nicotine levels are lower and fluctuate less than with smoking
Nicotine Gum
Tobacco Cessation for the Dental TeamLarry N Williams, DDS, ABGD, FACD,
FADI, FICDNODC / LDA Annual Conference 2015
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Nicotine Lozenge
 Nicotine formulation
 Delivers ~25% more nicotine than equivalent gum dose
 Sugar-free, mint or cherry flavor (boxed or POP-PAC)
 Contains buffering agents to enhance buccal absorption of nicotine
 Available: 2 mg, 4 mg
Nicotine Nasal Spray
 Aqueous solution of nicotine in a 10-ml spray bottle
 Each metered dose actuation delivers
 50 µl spray
 0.5 mg nicotine
 ~100 doses/bottle
 Rapid absorption across nasal mucosa
Nicotine Inhaler
 Nicotine inhalation system consists of
 Mouthpiece
 Cartridge with porous plug containing 10 mg nicotine
 Delivers 4 mg nicotine vapor, absorbed across buccal mucosa
 May satisfy hand-to-mouth ritual of smoking
Bupropion SR (Zyban)
 150 mg sustained release formulation
 Weak inhibitor of the neuronal re-uptake of norepinephrine and dopamine
 One pill daily for the first 3 days
 On day 4 take one pill in the morning and a second pill 8 hours later (late afternoon)
 Set quit date during the 2nd week of Bupropion use
 Continue Bupropion for 7 to 10 weeks after quitting tobacco
 Can and should often be combined with Nicotine Replacement Therapy
Bupropion Mechanism of Action
 Atypical antidepressant thought to affect levels of various brain neurotransmitters
 Dopamine
 Norepinephrine
 Clinical effects
  craving for cigarettes
  symptoms of nicotine withdrawal
Bupropion Contraindications
 Patients with a seizure disorder
 Patients taking
 Wellbutrin, Wellbutrin SR, Wellbutrin XL
Tobacco Cessation for the Dental TeamLarry N Williams, DDS, ABGD, FACD,
FADI, FICDNODC / LDA Annual Conference 2015
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 MAO inhibitors in preceding 14 days
Patients with a current or prior diagnosis of anorexia or bulimia nervosa
Patients undergoing abrupt discontinuation of alcohol or sedatives (including
benzodiazepines)
Bupropion and Pregnancy
 Category C drug
 Use only if clearly indicated
 Attempt nondrug treatment first
Varenicline (Chantix)
 Partial agonist selective for α4β2 nicotinic acetylcholine receptor subtypes
 Steady-state conditions were reached within 4 days
 Two pill types:
 0.5 mg (white)
 1.0 mg (blue)
 Should not use with NRT due to side effects
Zyban and Chantix
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Both are psychotropic medications
Zyban
 May not be suitable for those with IED exposure or PTSD (i.e. military)
 Can lead to insomnia and anxiety
Chantix
 Possible link to suicidal ideations with PTSD
 New warning
Varenicline and Pregnancy
 Category C drug
 Use only if potential benefit justifies potential risk
 Attempt nondrug treatment first
 Unknown if drug excreted in human breast milk
Varenicline Side-Effects
Common side effects (≥5% and twice the rate observed in placebo-treated patients)
include:
 Nausea
 Sleep disturbances (insomnia, abnormal dreams)
 Constipation
 Flatulence
 Vomiting
Chantix warning
 "Chantix has proven to be effective in smokers motivated to quit…”
 "While Chantix has demonstrated clear evidence of efficacy, it is important to
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Tobacco Cessation for the Dental TeamLarry N Williams, DDS, ABGD, FACD,
FADI, FICDNODC / LDA Annual Conference 2015
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consider safety concerns…”
 “Health care professionals should closely monitor patients for behavior and mood
changes if they are taking this drug."
Chantix warnings
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Patients should tell their health care provider about any history of psychiatric illness
prior to starting Chantix. Chantix may cause worsening of current psychiatric illness
even if it is currently under control. It may also cause an old psychiatric illness to reoccur.
FDA notes that patients with these illnesses were not included in the studies conducted for
the drug's approval.
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Health care professionals, patients, patients' families, and caregivers should be alert
to and monitor for changes in mood and behavior in patients treated with Chantix.
Symptoms may include anxiety, nervousness, tension, depressed mood, unusual behaviors
and thinking about or attempting suicide. In most cases, neuropsychiatric symptoms
developed during Chantix treatment, but in others, symptoms developed following
withdrawal of varenicline therapy.
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Patients should immediately report changes in mood and behavior to their doctor.
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Vivid, unusual, or strange dreams may occur while taking Chantix.
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Patients taking Chantix may experience impairment of the ability to drive or operate
heavy machinery.
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Case Examples and Discussion
Case 1
29 year old car salesman tells you during her dental appointment that she wants to
quit smoking. She currently smokes 1½ packs daily. She tried to quit before by
cutting down. She tells you that she smokes as a way to cope with stress and to relax.
Smoking also enables her to take breaks, socialize, and network with others. She
states that her spouse and friends also smoke. Her husband does not want to quit. She
tells you she wants to try meds.
No health issues noted during the health interview.
Case 2
A 19 year old college student tells you during a dental appointment that he wants help
in quitting his tobacco use. He states that he smokes 1 pack daily, more if drinking.
Last night said he drank 6 or more beers with his college roommates. He presents
today with bloodshot eyes, smells like a brewery, and said was hung over. When asked
about his alcohol consumption, he tells you he usually consumes a 6 pack daily with
peers. He has heard about cessation medications and wants to try Zyban.
No health issues noted during the health interview.
Case 3
Your new dental patient is a 36 year old lawyer with a 20 year history of smoking one
pack per day of cigarettes. She tells you that smoking helps with her weight control
and stress relief. She also states that she stopped twice before when pregnant, then
resumed smoking. Her physician says she needs to quit before her upcoming plastic
surgery. She wants to try the nicotine patch to help her stop smoking.
No health issues noted during the health interview.
Tobacco Cessation for the Dental TeamLarry N Williams, DDS, ABGD, FACD,
FADI, FICDNODC / LDA Annual Conference 2015
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Case 4
During a dental examination, your 55 year old patient tells you that he wants to quit
smoking and dipping. He is currently an office manager and is being considered for
a senior leadership position. He began dipping as a teenager and now only uses
smokeless tobacco when he cannot get away to smoke during the day. He also uses
smokeless on his frequent flights between company locations. He tells you he smokes
about 10 cigarettes per day and dips 2 cans per week.
No health issues noted during the health interview.
Case 5
Your newly assigned 35 year old dental patient tells you that she quit smoking
cigarettes a year ago. She has since been going to Hookah bars once a week with
friends. She is also smoking one or two cigarettes on week ends. She is concerned
about getting addicted again.
No health issues noted during the health interview.
Case 6
A 32 year old patient presents with a 12 year history of using two cans per week of
Copenhagen. His previous dentist encouraged him to quit. He states he likes to spit!
The “Cope” gives him a boost and he does not know what he’d do without it. He uses
it daily, sneaks use during work, uses heavily at lunch and after work. His father,
brothers, and some friends use it.
No health issues noted during the health interview.
Case 7
Your patients are a retired couple in their 60’s, both of whom want to quit. The wife is
obese and has chronic obstructive pulmonary disease (COPD), diabetes mellitus
(DM), and hypertension (HTN). The husband has a diagnosis of coronary artery
disease (CAD) and depression. Both smoke 2 packs cigarettes daily.
Case 8
During a recent dental health review you learn that your 22 year old patient is
pregnant and smokes 10 cigarettes per day. She states that she smoked during her
last pregnancy and the baby was okay. Her mother smoked while pregnant with her
and she turned out all right. She does not see a reason to quit other than to get
people to stop bugging her about smoking…
No other health issues noted during the health interview.
Case 9
A 35 year old computer programmer tells you during his dental health review that he
is in Mental Health treatment (counseling and medications) for depression, anxiety
and marriage problems due to his highly stressful job. He currently smokes 25
cigarettes per day. He heard from friend that you helped him quit smoking.
No other health issues noted during the health interview.
Case 10
Your current 35 year old dental patient returns to see you for a three month
periodontal maintenance appointment. She states that she has resumed smoking two
months ago due to being with friends who were drinking and smoking. She had been
Tobacco Cessation for the Dental TeamLarry N Williams, DDS, ABGD, FACD,
FADI, FICDNODC / LDA Annual Conference 2015
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tobacco free for 1 month after counseling with you. She still wants to quit and wants
to talk about options.
 No health issues noted during the health interview.
Case 11
 A 26 year old male who uses 1.5 cans of Skoal per day. He has tried before to cut
down on the amount he uses, but gets too irritable and has strong cravings. His
dental condition is noted as having multiple stained teeth and anterior recession. He
wants to know about switching to Snus. He also knows that he needs to stop using
tobacco because he is going back to college.
 No health issues noted during the health interview.
Case 12
Your 42 year old dental patient tells you that he switched from cigarettes to cigars in his
30’s. He now uses three to four cigars per day and always has one in his mouth even if not
lit. His wife does not smoke and his children are urging him to stop smoking. He does not
smoke inside the house any more and his wife quit smoking when she was pregnant. He
tells you that he just purchased an electronic cigarette ($27.49) from an online
advertisement as a way to cut down on smoking. He states that he wants to quit in a
“painless way".
No health issues noted in the health interview.
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Case 13
Your 50 year old patient is a community college English teacher who smokes 6-8
cigarettes per day (Virginia Slims). She has tried to stop smoking several times, but
gained 15-20 lbs. each quit attempt and went back to smoking. She does not smoke at
school, but has some nicotine gum she uses 1-2 times per day at school to avoid being
irritable. She lives with an ex-smoker boyfriend and does not smoke inside her house,
but out back on the porch.
No health issues noted in the health interview.
Case 14
Your dental patient is a 64 year old male truck driver who smokes two packs of
cigarettes (Marlboro lights). He has never been able to stop smoking, but was
recently aware he is having more difficulty climbing stairs and unloading his truck
because he is short of breath. His primary care physician told him that he has
emphysema and he is now on an oral Albuterol inhaler. He knows he needs to stop
smoking, but is it very difficult for him since he spends so much time alone driving his
truck and smokes to avoid boredom. His wife also smokes and is not interested in
quitting.
No other health issues noted in the health interview.