The Cessation of Tobacco Use: A Clinical Perspective
Cigarette smoking is responsible for approximately 419,000 deaths in the United States each year, and it is the single most preventable cause of premature mortality and morbidity.1,2 Numerous diseases that affect the gastrointestinal, pulmonary, cardiovascular, and reproductive systems have been connected to the use of tobacco; cancers of the lung, head and neck, esophagus, pancreas, and kidney alone result in an estimated 148,000 deaths per year.1 Smoking also has a direct impact on the provision of dental care. In addition to an increased risk of periodontal disease (2.5 to 7 times greater than nonsmokers), tobacco users may alter their immune response systems and decrease their capacity to respond to surgical procedures.
In 1996, the first comprehensive guidelines for the treatment of smoking were released by the Agency for Health Care Policy and Research (AHCPR).3 In these guidelines, the roles of primary clinicians, smoking cessation specialists, and healthcare administrators for the implementation of tobacco cessation programs were detailed. Programs for the identification and treatment of these patients in conjunction with either motivational or cessation procedures as follow-up were also presented. Outlined within the document were several therapeutic approaches that include nicotine replacement therapy (NRT), multiple problem-solving techniques, the attendance of social support sessions, and education and training programs on tobacco cessation. A primary objective of the guidelines was to alert healthcare providers that: 1) effective smoking cessation treatments are available, and every patient who smokes should be offered one or more of these treatments; 2) it is essential for all clinicians to determine and document the tobacco use of every patient; and 3) brief cessation treatments are effective, and at least minimal intervention should be provided to every patient who uses tobacco.
Since the AHCPR guidelines were initially published more than a decade ago, significant advances have occurred in the pharmacotherapy for smoking cessation. Specifically, nicotine chewing gum and two brands of NRT transdermal patches were approved as nonprescription medications. In addition, a nicotine nasal spray, a nicotine inhaler, and bupropion hydrochloride were approved as prescription medication by the US Food and Drug Administration. These advances have significantly increased the opportunities for successful cessation of tobacco use. While recommendations regarding cessation education programs in the dental office exist, they are not widely employed. Dental clinicians and their staffs routinely counsel patients on medical conditions and preventive healthcare issues. As a result of biannual examinations, dental healthcare providers are afforded the opportunity to evaluate patients with greater frequency than physicians. Consequently, smoking cessation counseling should be incorporated as a routine component of patient education programs and services from every dental healthcare provider.
Several avenues of patient education currently exist for the dental clinician. The first step involves the identification of cessation programs and resources within the community. Following enhancement of the clinician's personal knowledge, the tobacco use of all patients should be documented, and their desire to terminate tobacco use routinely assessed. Finally, those patients interested in discontinuing their use of tobacco should be counseled or referred to an appropriate resource. Further information on tobacco control may be obtained at the American Cancer Society's website at http://www.cancer.org.
- Centers for Disease Control and Prevention. Cigarette smoking - attributable mortality and years of potential life lost - United States, 1990. MMWR 1993;42:645-649.
- Centers for Disease Control and Prevention. Medical-care expenditures attributable to cigarette smoking - United States, 1993. MMWR 1994;43:469-472.
- Sacks JJ, Nelson DE. Smoking and injuries: An overview. Prev Med 1994;23(4):515-520.