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AUTHOR Dr Mihir N. Shah BDS, MDS, PhD. Prof & Head, Dept. of Periodontics &Public Health Dentistry, Ahmedabad Dental College and Hospital, Gujarat State, India Email: mihirmihirshah@rediffmail.com drmihirshah@yahoo.co.in
CO-AUTHORS Cecily S. Ray, M.P.H. Sr. Research Assistant Healis-Sekhsaria Institute for Public Health. Navi Mumbai. Email: raycs@healis.org Monika Arora, M.Sc Director. HRIDAY-SHAN New Delhi. Email: monika@hriday-shan.org.in Disclaimer
The views expressed in this guide do not necessarily represent the official views of the Ministry of Health and Family Welfare, Government of India or the World Health Organization. The authors have done their utmost to ensure accuracy of all information, however, the inclusion of links and references does not entail recognition and endorsement of information given under these links nor can they be held liable for any wrong information. The responsibility for the interpretation and use of the material lies with the reader.
Published in May 2006
CONTENTS
Foreword I. 4, 5 6
THE MAGNITUDE OF THE TOBACCO PROBLEM A. Health consequences of tobacco use 8 B. Tobacco dependence 12 C. Role of the dentist 12
II. IN THE CLINIC 14 A. Benefits of interventions for cessation of tobacco use 14 B. Guide to counselling for tobacco cessation 16 1. Counselling those willing to quit: The 5 A method 16 2. Counselling those unwilling to quit: The 5 R method 26 3. Key counselling concepts 28 III. ACTION IN THE COMMUNITY AND NATION A. In the community 32 B. At the state and national levels 33 REFERENCES 36 32
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This guide aims to equip dental health practitioners with the latest scientific information and strategies to become important players in preventing and reducing tobacco use.
Smoking causes cancer of the oral cavity and tongue, larynx and pharynx, oesophagus, stomach, uterine cervix and lung.16 Many cases of lung cancer in India are due to smoking. Smokeless tobacco is known to cause oral cancer. There is some evidence that it causes some other cancers as well. Chewing of paan (with supari) with or without tobacco is a major cause of oral and oesophageal cancers in India.17 Smoking is a known cause of cardiovascular disease. Emerging evidence points to smokeless tobacco use also as a cause of cardiovascular disease.18 Smoking causes most cases of chronic obstructive lung disease emphysema and chronic bronchitis.19 Exposure of non-smokers to second-hand smoke is an important cause of respiratory infections, worsening of asthma and poor lung function. Many of the sufferers are women and children.20
Newer research findings indicate that smoking is a major risk factor for tuberculosis in India. Tuberculosis is about 3 times more common among ever-smokers than among never-smokers and mortality due to this disease is 34 times greater among smokers than non-smokers.21 Pregnant women exposed to passive smoke may deliver lower weight babies. Evidence is accumulating that pregnant women who use smokeless tobacco are more likely to have low birth weight or stillborn babies.22 The birth of an infant with congenital cleft lip or palate can be a consequence of cigarette smoking.23 Additionally, there are often long-term effects on surviving children born of mothers who smoke or are passively exposed to smoke.24 Men who smoke or use smokeless tobacco may develop reduced fertility and sexual impotence.25, 26
Males
Eastern Asia 7% Rest of World 47% S E Asia 4% Rest of World 36%
Females
Asia 8% SE Asia 6%
W Asia 1%
SC Asia 48%
Figure 1. Cases of oral cancer in the Asian Region, as a percentage of the world 27 (Globocan Estimates, 2002)
Oral precancers
Tobacco use in any form has been shown to have a marked effect upon the soft tissues of the oral cavity.28 Regular use of substances containing areca nut can cause oral submucous fibrosis (OSF), a painful, debilitating condition in which the mouth tissues gradually lose their elasticity and become tight. The diagnostic criterion is the presence of palpable fibrous bands. In this condition, the ability to open the mouth decreases gradually and can often reach an extent where only a straw can go inside the mouth. This condition is becoming increasingly common, especially in individuals between 15 and 40 years of age, due to the increasing popularity of products containing areca nut and tobacco.29 The use of these products (gutkha, mawa, paan masala) causes OSF in a shorter time than paan use.30 An 18-yearold man attending a hospital in Delhi, who had a history of chewing a mixture of tobacco and areca nut (gutkha) for two years, was reported to have developed severe OSF.31 Smoking and chewing tobacco can cause white patches in the mouth (preleukoplakia and leukoplakia) as well as red patches (erythroplakia), all of which are precancerous. Of these, erythroplakia, although rare, is the most likely to develop into cancer. Of the four types of leukoplakia (homogeneous, ulcerated, speckled and nodular), the nodular leukoplakias are the most likely to transform into cancer.32
10
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Mehta FS, Hamner JE III. Tobacco related oral mucosal lesions and conditions in IndiaA guide for dental students, dentists, and physicians. Mumbai: Basic Dental Research Unit, Tata Institute of Fundamental Research; 1993. Available from: http://www.eis.ernet.in/dental/dental.htm
Patients with leukoplakia, erythroplakia or OSF should be referred to a diagnostic facility such as a cancer hospital, as their lesion may already be cancerous.
0$-255,6.)$&7256)2525$/&$1&(5
Tobacco chewing/smoking Areca nut (supari) use Alcohol use Diet low in vegetables and fruits
Educational interventions have been found useful in reducing tobacco use and the consequent incidence of precancerous lesions.28
11
B. Tobacco dependence
Many tobacco users in India are unaware of the harmful effects of tobacco. Many believe that tobacco is good for health. On the other hand, there are users who know the dangers but continue to use tobacco. Some have even suffered the consequences but continue using it. Tobacco use is addictive. Tobacco causes an abnormally large flow of certain brain chemicals, followed by an abnormally reduced flow, causing cravings, which the addict relieves by repeated use of tobacco. The cravings induced in the brain by tobacco are strong enough to cause users to minimize, deny or temporarily forget the harm that tobacco causes. Many users say they are unable to quit. Some feel helpless. According to the policy recommendations of the World Health Organization, treatment of tobacco dependence should be part of a comprehensive national tobacco control policy.35
Dentists in the clinic36 See the harmful effects of tobacco on the mouth Are in an ideal position to counsel patients See children and youth as patients and can influence them to adopt a tobacco-free
lifestyle
Treat women of childbearing age and can inform them of the dangers of tobacco use during pregnancy Can spend more time with patients than other clinicians and use this time to counsel tobacco users to quit Can reinforce messages given to patients by physicians and other caregivers about the dangers of tobacco use and the need to quit Can build their patients interest in discontinuing tobacco use by showing them the actual effects in the mouth Have a duty to promote oral health and healthy lifestyles among their patients.
12
Can speak with authority in the community about the dangers of tobacco use; for example, the need to curb tobacco use in public and educate children about the dangers of tobacco use Can be effective advocates for tobacco control in the community.
13
Nearly half of 351 dental surgeons (48.7%) surveyed in Bangalore felt that it is the responsibility of the dentist to persuade patients to quit tobacco and just over half (54.4%) of the respondents were very willing to receive formal training on tobacco cessation and other intervention strategies.37 Most dentists are unfamiliar with counselling techniques for quitting tobacco use. Surveys of dental students in India under the WHO-sponsored Global Health Professional Survey found that very few schools train students in how to counsel patients for tobacco use cessation.14
14
Dentists can give brief advice to non-users of tobacco, especially adolescents, and counsel them to never take up tobacco use. To users of tobacco, advice and counselling by dentists on quitting tobacco use have been shown to be effective. Patients unwilling to quit also need to hear about the benefits of quitting. An adolescent is in a stage of experimentation and transition, especially during the ages of 12 to 15 years. They are curious and their desire to fit in with peers often leads to new behaviours. Dentists must build a rapport with adolescent patients so that their advice is well received.38 Advice against tobacco use fits well into oral hygiene education during a dental visit, since tobacco use among adolescents leads to early periodontal disease and tooth loss, along with bad breath. Quitting tobacco use improves oral health. The dentist can reinforce the fact that oral cancer and its treatment cause facial disfigurement.39 A good way to manage a variety of chronic oral conditions, including tobacco use and its consequences, is to work with patients to set goals and monitor therapies. Evidence shows that brief clinic-based interventions are effective in helping people to overcome tobacco dependence. Dentists must recognize that every interaction on tobacco use, however brief, can lead to a significant change in the patients attitude and behaviour. Smokers can be helped to recognize that temporary abstinence is a small success that can lead to greater success in quitting.
$%5,()72%$&&2,17(59(17,21 Takes only a few minutes Is practical for a busy office Assesses, diagnoses, educates, works with the patient Is preferred by patients Must encourage the patient and not be critical
15
7KH$PHWKRG 1. $VN about tobacco use at every visit. 2. $GYLVH non-users to never use tobacco. $GYLVHusers to quit. 3. $VVHVVthe patients readiness to quit. VVHVV 4. $VVLVW with quitting. 5. $UUDQJH for follow ups. $VNSDWLHQWVDERXWWKHLUXVHRI WREDFFRDW HYHU\YLVLW
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Based on a real-life situation in an oral health examination survey of adolescent students in Belgaum District, Karnataka. (Personal communication, Professor Shobha Deshpande, Paediatric Dentist, formerly Head of Paediatric Dentistry at KLE Dental College, Belgaum.
16
25$/6,*162)72%$&&286( Stained teeth Foul-smelling breath (halitosis) Gum disease Loose teeth Discoloured patches on the mucosa: White, red, darkprecancerous lesions
Mention your observations to the patientthis will help him or her face facts.
' Blood pressure 130/85 ' Weight 70 kg Height 170 cm ' Respiratory rate 65 per min ' Temperature 36.6 ' Tobacco use Current Former Never
o
Vital signs
(circle one)
Chewer highly dependent advised wants to quit in two weeks needs rigorous followup.
Medical/Dental history
- Gum disease - Seven teen fillings - Allergy to Novocain
17
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Advice for quitting should be clear, strong and personalized:
o Affirm and congratulate those who have quit tobacco use and offer support if
required.
18
If the patient is only thinking of quitting but not willing to quit now (in contemplation), If the patient is not preparing to quit
provide a tailored message to increase motivation.
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High level of dependence: Individuals who use tobacco within 30 minutes of waking up or who use it 25 or more times (e.g. smoke 25 or more cigarettes/beedis per day). Moderate level of dependence: Individuals who use tobacco more than 30 minutes after waking up or less than 25 times per day.
19
Low level of dependence: Those who neither use tobacco before 30 minutes of waking up nor use it more than 25 times a day. Patients highly dependent on tobacco will need longer and more frequent follow up.
An individual who has quit before, even for just 30 days, has a lower risk of relapse. Those with a higher level of dependence usually need a more intensive intervention to help them avoid relapse. Individuals with depression or a concurrent habit such as regular alcohol drinking may be at increased risk for relapse. Rigorous follow up reduces the risk of relapse on a schedule. Such patients could be referred to a counsellor or a tobacco use cessation facility.
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6et a firm quit date, ideally within 2 weeks. *et support from family, friends, co-workers. 5eview past quit attemptswhat helped, or led to
relapse.
,dentify reasons for quitting in writing and keep a
copy.
5educe tobacco use during the two weeks before
quitting.
$nticipate challenges, particularly during the first few
20
During morning toilet With coffee or tea After meals Drinking alcohol Using the telephone Driving Seeing others smoke
W W W W W W W
Tension/anxiety Before starting a task After completing a task Relaxing or taking a break Concentrating or wanting to stay alert Studying Watching TV
$pply faith
The dentist can suggest to the patient that he/she offer the last tobacco product in his/her possession at the altar of the deity he/she worships or to the spiritual teacher he/she follows, with the expressed intention of giving up tobacco permanently and having faith in quitting.
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Total abstinence is essential to quittingnot a single puff
or portion.
Drinking alcohol is strongly associated with relapse. Having
21
of the daily routine. No supari is allowed, as it is carcinogenic and may be mentally associated with tobacco by the patient.
Timing: Set a schedule. The first follow-up visit should occur within a week of the
quit datethat is why it is important to have the patient set the quit date a few days prior to the revisit date for dental work. A second follow-up visit is best within one month of the quit date. Further follow-up visits are helpful after 3 months, 6 months, 1 year.
Actions during follow-up contact Congratulate the patient on successes (even small ones). Empathize with difficulties. Ask the patient to suggest how he/she can overcome the
difficulties. Assess pharmacotherapy: Ask the patient about the severity of withdrawal symptoms and about any possible side-effects of medication being
taken, such as irritation of the mouth, dry mouth, confusion, abdominal pain, back pain, bodyache, sleep disturbance, dizziness, palpitations.
If a relapse occurs, encourage a new quit attempt. Tell the patient that relapse is part of the quitting process. Review the circumstances that caused the relapse. Use relapse as a learning experience. Reassess the use of pharmacotherapy and problems in general.
22
If the patient is interested, expresses the need or has had particular difficulty previously, intensive counselling is advisable. Patients especially needing it would include those with heavy tobacco use,
alcohol use, or depression. People using tobacco for a long duration may suffer from anxiety, restlessness, dysphasia or depressed mood, irritability, low selfesteem and poor coping with stressors; they may also have other addictions.43 Yet, anyone ready to quit can benefit from intensive counselling for cessation.
Preventive dentistry
If you have not already done so, introduce your patients to the concept of preventive dentistry and use these visits for tobacco cessation counselling as well. Six-monthly or yearly check-ups can catch dental and oral problems when they are easy to fix, avoiding the need for root canal treatment and extractions, and detect possible oral cancer at an early stage.
Use of pharmacotherapy42
Given the difficulties faced by people attempting to stop tobacco use, medical treatments have been developed to help them by lessening the intensity of withdrawal symptoms. Research is ongoing to develop a wider range of such medications and to determine the usefulness of medication for quitting tobacco. There are two main types of pharmacotherapy for tobacco use cessation:
W
Nicotine replacement therapies: These lessen craving and other withdrawal symptoms while the individual learns to stop the behaviours connected with tobacco use. Eventually, though, patients need to give up using nicotine replacement. Antidepressants: These function as anti-craving medications.
W
23
Many people have successfully quit using tobacco without any medication whatsoever (cold turkey). Patients who would benefit most from pharmacotherapy are those who have attempted to quit several times without success or those who suffer from chronic depression. Available therapies are shown below:
Antidepressants for tobacco use cessation First-line therapies WBuproprion SR WSelegeline Second-line therapies
WClonidine WNortryptiline
These can be combined with nicotine replacement therapies. Nicotine replacement therapies (NRT) for tobacco use cessation gum (available in India in 4 mg nicotine pieces: Gutkha or mint flavour) WNicotine patch WNicotine inhaler WNicotine nasal spray WNicotine lozenges
WNicotine
Basic principles for prescribing NRTs: Medical supervision is important. Use a lower dose for less dependent tobacco users. A combination of products can be helpful. This must be done with caution, as nicotine toxicity may develop with a combination of products or if patient has not yet quit using tobacco. Some users may have sideeffects. Precautions: Pregnancy, lactation, cardiovascular disease, peripheral vascular disease, endocrine disorders, inflammation of the mouth and throat, oesophagitis, gastric ulcers, diabetes. Brief guidelines for the use of pharmacotherapy are available in the Manual for tobacco cessation of the National Cancer Control Programme.44 Websites with guidelines on prescribing, precautions and side-effects: Suggestions for the clinical use of pharmacotherapies for smoking cessation. Available from: http://www.hhs.gov/surgeongeneral/tobacco/clinicaluse.pdf and the Public health service clinical practice guideline, Treating tobacco use and dependence, http://www.ahrq.gov/path/tobacco/htm.45
24
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'Personal relevance is highly motivating. The patients oral condition, age, gender,
other health concerns and family situation are all relevant. Ask the patient to indicate why quitting is personally relevant. Enlighten the patient on what he/she does not know.
26
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'Acute risks: Oral wounds do not heal well, periodontal disease develops, blood
cholesterol increases, there may be harm to pregnancy (in women), impotence and infertility (in men) and increased levels of carbon monoxide in the blood (in smokers).
'Long-term risks: Tooth loss, OSF in users of products containing areca nut 'Environmental
(supari), oral and other cancers; heart attack and stroke; lung diseases (in smokers); disability; financial losses due to prolonged healthcare needs.
risks: For smokers, there is an increased risk of the spouse developing lung cancer and heart disease. Women may give birth to low birth weight children; and children exposed to tobacco smoke are in danger of developing sudden infant death, respiratory infections, asthma, middle ear disease, among others. Chewers spread germs and make a mess by spitting.
Improved oral health: Healthier gums and teeth, better smelling breath Feel better/perform better Increased energy levels Food tastes better Money is saved Sets a good example to children Worry about quitting stops Longer and healthier life
27
Fear of withdrawal symptoms Fear of failure Lack of support Enjoyment of tobacco Fear of weight gain Depression
' '
Repeat the motivational messages each time an unmotivated patient visits. Tobacco users who have tried to quit previously and failed need to hear that most people make repeated attempts before they are successful.
Caring:
A caring attitude can be expressed through your words and motivates patients to follow your advice.
Empathy:
Your words affect the patients attitude. Use your words as therapy to motivate and encourage the patient to quit. Listen carefully and patiently to what the patient is saying. Listening also conveys empathy. Raise patients awareness levels about the negative
Listening:
Raising awareness:
consequences of tobacco use.
Prompting self-evaluation:
Ask the patient to think about how tobacco use fits in or conflicts with his goals and values in life. When the patient feels the benefits of quitting tobacco use outweigh the costs, he/she will be more motivated to change.
Offering support while emphasizing personal responsibility: Provide encouragement and assistance for quitting. At the same
time, the patient needs to accept personal responsibility for change.
28
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These help the patient to disclose his/her values and priorities, and to become more aware of those that conflict with each other. You can ask a question to be sure you have understood what the
Reflecting feelings: Rephrase the emotional content of what the patient has
said to assure him/her that you have understood.
Summarizing: Condense into a few words the essence of what you have heard. Affirming:
This conveys respect, acceptance and understanding of the patients position, even if it is not positive. Find out, on a scale of 0 to 10, how important quitting is to the patient. How optimistic are they about quitting? What difficult goals have they achieved in the past? Change the patients behaviour in stages by setting
Countering fatalism: Give a response that matches the patients attitude, but
contradicts the premise.
29
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Based on an experience at an oral check-up camp in Bhavnagar District, Gujarat.; the patients name has been changed (Personal communication, Dr Dinesh Daftry, Oral Pathologist).
When your patients test you with tricky questions or statements, you will need to come up with answers that will shock them into thinking.45
30
TAILOR MESSAGES AND GOALS TO THE PATIENTS STAGE OF CHANGE If the patient reports: Goals Get the patient to think about quitting Examples of messages
46
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Praise prior attempts Help him identify the Legitimize the challenge
Develop treatment plan (using the 5 A method) benefits of quitting
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counselling if needed
I quit recently
Review ways to
avoid slips supports
Identify social
Congratulate the patient Reassess the patients motivation
I relapsed recently
31
A. IN THE COMMUNITY15,4749
Dentists are highly respected, trusted and influential community leaders in any society. Their voices are heard across a vast range of social, economic and political arenas. Public education Dentists can display educational material on anti-tobacco themes in their clinics and hospitals, and prohibit the use of any kind of tobacco product within 100 metres of their hospitals. Dental organizations can reach out to different age and social groups to inform them on tobacco issues, and encourage them to recommend policies to the government on tobacco control. Dentists can link up with non-governmental organizations (NGOs) to spread health awareness about the ill-effects of tobacco and promote cessation in schools, colleges and communities. Dentists can sensitize youth groups to become efficient awareness generators in the community and monitor the implementation of tobacco control laws. Dentists need to keep themselves informed through professional publications and tobacco control organizations on the latest scientific information regarding the harmful effects of tobacco and measures for its control.
32
Media advocacy Dentists can actively engage the media in creating awareness among the masses about tobacco control issues. Dentists can prepare educational materials using up-to-date, scientifically accurate information such as posters and school health materials. Dentists can write articles in newspapers and magazines about the benefits of implementing tobacco control policies, including letters to the editor. Dentists can participate in talk shows on television and radio to talk about tobacco use issues. Dentists can bring into the limelight some success stories related to tobacco control.
B. AT THE STATE AND NATIONAL LEVELS Dentists can use their influence to encourage governments to put in place tobacco control measures. Dentists can be involved in both direct advocacy (influencing
decision-makers) and indirect advocacy (building support among the general public to put pressure on decision-makers to initiate change). As members of professional organizations, dentists can play an important role in tobacco control advocacy at the state and national levels. Making the profession and dental facilities tobacco-free Dental associations can prepare a national Code of practice on tobacco control for dentists. This code of practice would highlight the potential role of dentists and their organizations in the treatment of tobacco dependence and provide guidance on organizational changes and activities that can be undertaken to promote a tobacco-free profession. Dentists can provide the needed emphasis on tobacco-related health information in the undergraduate and postgraduate curricula and examinations. Dentists can motivate hospital administrators and fellow colleagues to keep the hospital environment tobacco-free and thus convey to the public that their institution is committed to protecting public health. Workshops can be organized to motivate all staff members to avoid tobacco use on the premises. All conferences and other events organized by associations of dental professionals should be declared completely tobacco-free by the organizers. Dentists should avoid accepting or allowing sponsorship of any kind from tobacco companies or their affiliates for professional conferences. All government/private healthcare and dental care facilities can carry anti-tobacco slogans on items of stationery.
33
Dental associations can share with their members new scientific research findings, new developments in tobacco cessation and new policy developments. As members of professional organizations, dentists can raise the issue of litigation against the tobacco industrys unfair marketing practices. Strong professional support in a legal suit can be crucial for the success of such litigations in India.
Advocacy with the state and national governments Dental associations can advocate for the inclusion of tobacco cessation as an important component in national health programmes such as the National Rural Health Mission, National Cancer Control Programme and Reproductive and Child Health Programme. Dental associations can join hands with civil society groups working in the area of tobacco control to develop a state and a national plan to create awareness among dental professionals on tobacco control issues. Dentists along with their professional organizations can lobby with the government to set up community-based tobacco cessation programmes. Dentists can request the government to appoint a nodal officer at district/block/state level for tobacco control. Dentists can advocate with the government to stop the subsidy on tobacco farming. Dentists can advocate for the levy of a health tax on the sale of every packet of tobacco, beedi, paan masala and cigarettes, which could be used for health education on the dangers of tobacco use. Dentists and their associations, along with other health professionals, can participate in the development of a national plan of action for tobacco control in accordance with the Indian Tobacco Control Act, 2003. A special section on tobacco control initiatives should be taken up during national and international conferences for dentists. All conferences and other events organized by associations of dental professionals should be declared completely tobacco-free.
34
35
REFERENCES
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