Understanding Nicotine Addiction and Tobacco
Intervention Techniques for the Dental Professional
Arden G. Christen, DDS, MSD, MA; Jennifer A. Klein, RDH, MSA;
Stephen J. Jay, MD; Joan A. Christen, BGS, Ms;
James L. McDonald Jr., PhD; Christianne J. Guba, DDS, MSD
Continuing Education Units: 3 hours
The purpose of this course is to alert dental professionals to the harmful effects of tobacco, both to the oral
cavity and to the body. The course is also designed to teach professionals specific skills they may utilize
to help tobacco users become free of their addiction. A significant amount of the course material applies to
both smoked and smokeless tobacco; however, additional information on smokeless tobacco is presented
in the ADAA continuing educational course, “Understanding the Dangers and Health Consequences of Spit
Tobacco Use.”
Conflict of Interest Disclosure Statement
• The authors report no conflicts of interest associated with this work.
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The Procter & Gamble Company is an ADA CERP Recognized Provider.
ADA CERP is a service of the American Dental Association to assist dental professionals in identifying
quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses
or instructors, nor does it imply acceptance of credit hours by boards of dentistry.
Concerns or complaints about a CE provider may be directed
to the provider or to ADA CERP at:
http://www.ada.org/prof/ed/ce/cerp/index.asp
Overview
In recent years, the stage has been set for all dental professionals to become actively involved as facilitators
and leaders in tobacco education and control efforts.
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One goal of Healthy People 2020 is to “increase to at least 75% the proportion of the population of primary
care and oral health care providers who routinely advise cessation and provide assistance and follow-up for
all of their tobacco using patients.”
In this millennium, we expect an ever-increasing number of dentists, hygienists, and assistants to participate
in clinical and community interventions that focus on both tobacco prevention and cessation strategies.
Although 65% of general dentists advise most or all of their patients who smoke, only about 11-27%
provide patients with self-help materials or routinely record tobacco use. Many lack confidence in providing
cessation advice. The fact is, helping dental patients to quit using tobacco can be practically accomplished
in clinical settings by oral health care professionals. Twenty years of accumulated evidence has shown the
efficacy of this approach. Oral health care providers are able to offer this service with few interruptions in
their daily routine. Additionally, many patients whom they help respond with gratitude and loyalty.
Dental professionals, as well as other health care workers, have an ethical obligation to inform their patents
about the hazards of tobacco use and to encourage tobacco users to stop. Additionally, the dental team
needs to praise and support those patients (especially impressionable young people who have never
used tobacco). Currently, about 46 million Americans are smokers, and another 12 million are smokeless
tobacco users. About 440,000 tobacco-related premature deaths occur each year in the United States. A
vast majority of those who use tobacco would like to stop; in fact, about 50 million cigarette smokers have
given up tobacco since 1962. Still, about 25% of our population smoke cigarettes and evidence suggests
that heavy usage (the consumption of 25 or more cigarettes per day) occurs among a large proportion of
smokers.
The purpose of this course is to alert dental professionals to the harmful effects of tobacco, both to the oral
cavity and to the body. The course is also designed to teach professionals specific skills they may utilize
to help tobacco users become free of their addiction. A significant amount of the course material applies to
both smoked and smokeless tobacco; however, additional information on smokeless tobacco is presented
in the ADAA continuing educational course, “Understanding the Dangers and Health Consequences of Spit
Tobacco Use.”
Learning Objectives
Upon completion of this course, the dental professional will be able to:
• Summarize the harmful effects of tobacco on the body.
• Explain the addictive nature of nicotine.
• Discuss the psychological and sociocultural aspects of tobacco use.
• List the steps which can be initiated to create a smoke-free dental practice.
• Describe the dental professional’s role in a dental office smoking cessation program.
• Identify the cycle of change and its relationship to smoking behaviors.
• Demonstrate the supportive role oral healthcare professionals can have in helping patients to become
tobacco-free.
Course Contents
• Delivering the Smoke-Free Message: Programs
That Work
Findings and Recommendation
Tobacco Cessation Programs for the Dental
Office
• The Dental Professional’s Role in a Smoking
Cessation Program
• Stages of Change – What to Say
Suggested Dialogue
• Glossary
• Effects of Tobacco Use
Health Hazards of Tobacco Use
Oral Effects of Tobacco Use
• Nicotine Addiction
Addiction
Physical and Psychological Characteristics of
Nicotine Addiction
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•
•
•
•
Make Your Message Relevant
Fear of Weight Gain
The Cost of Smoking
Summary
Questions and Answers
Course Test
References
About the Author
which helps to reduce and control nicotine
cravings and withdrawal symptoms; generally
administered for a 3- to 6-month period, while the
addictive, psychological, and sociocultural aspects
of cigarette smoking are simultaneously being
addressed and overcome.
Relapse – the reactivation of addictive behavior
after abstinence has been achieved and
maintained for a significant period of time.
Glossary
Addiction – an overwhelming compulsion to
ingest a substance or engage in a process with
increasing frequency and intensity in order to
experience its mind-altering effects and/or to
avoid the pain of its withdrawal.
Slip – a temporary, minor reversal to former
addictive practices; of lesser intensity and
duration than a relapse. Also called: “A Slight
Lapse In Progress”.
Craving – an intense and often prolonged
desire, yearning, “hunger” or appetite for foods or
substances.
Sobriety – complete abstinence from cigarette
smoking; a term used by Smokers Anonymous.
Smokers Anonymous – a self-help program
adapted for smoking cessation and based on the
Twelve Steps of Alcoholics Anonymous.
Dependency, physiological – the physiological
reliance upon a drug or substance, resulting in
specific body cell alterations; a condition in which
continued usage becomes necessary to maintain
the body’s state of normalcy and balance.
Tolerance – a state which requires increasing
amounts of the addictive drug to achieve the
same effects.
Dependency, psychological – an emotional
reliance on addictive substances and/or ritualistic
behaviors.
Varenicline – Also known as Chantix™ in
America, or Champix™ in Europe. is a nonnicotine prescription medicine that comes in pill
form.
Erythroplakia – a particularly dangerous form of
oral cancer which appears as a red or velvetyappearing patch.
Vasoconstriction – a narrowing or constriction of
blood vessels.
Habit – a highly automatic behavior intensively
learned and practiced over a prolonged period
of time.
Withdrawal syndrome – predictable signs and
symptoms caused by altered central nervous
system activity, and appearing after a routinely
received drug dosage is discontinued or rapidly
decreased.
Leukoplakia – a white intraoral patch related to
all forms of tobacco usage and considered to be
precancerous.
Effects of Tobacco Use
Malignant – cancerous, and therefore potentially
life-threatening.
Health Hazards of Tobacco Use
According to the numerous U.S. Surgeon
General’s Reports on Smoking and Health, issued
since 1964, smoking has been causally linked to
heart disease, other vascular diseases, diabetes,
and cancer of the mouth, pharynx, esophagus,
lung, pancreas, and bladder. It is also implicated
in the development of gastric ulcers, chronic
obstructive lung disease, chronic bronchitis,
Nicotine – the principle alkaloid of tobacco and
its addictive agent.
Nicotine Replacement Therapy (“NRT”) – an
effective quit-smoking strategy which utilizes
nicotine-containing delivery devices (nicotine
gum, inhaler, nasal spray, patch, or lozenge
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emphysema, sinusitis and other respiratory
disorders. Pregnant women who smoke are more
likely to have premature, low birth-weight infants
or spontaneous abortions. There is now evidence
that nonsmokers who inhale the secondary sidestream smoke from tobacco products are also at
greater risk for these conditions.
personnel to identify. All dental health
professionals should deliver personalized stopusing messages to patients, especially when
they learn that these individuals have adverse
oral conditions that are linked to tobacco usage.
Dentists, assistants and hygienists have access to
“teachable moments” at chairside when they can
explain to their patients the tobacco-related, oral
ill-effects from which they are currently suffering.
Children raised in homes where parents smoke
are more prone to respiratory diseases. They
are also more likely to use tobacco than those
who are raised in tobacco-free homes. The
average age for experimentation with cigarettes
and smokeless tobacco is 12 to 13 but many
individuals start earlier. Teenage girls smoke
more than teenage boys – among 17- to
19-years-olds, the ratio is five females to every
four males.
Contrary to people pictured in advertisements of
tobacco products, people who smoke are very
likely to have bad breath (halitosis). The breath
of cigar and pipe smokers is more offensive than
that of cigarette smokers because of the intense
odors that emanate from cigar and pipe tobaccos.
Inhaled smoke can create lung odors which
often results in halitosis; its severity is generally
in direct proportion to the amount of tobacco
routinely consumed and the duration of the usage.
Tobacco use is a pediatric concern. Close to
80% of adult smokers started smoking before
the age of 18. In the United States, more than
6,000 children and adolescents try their first
cigarette each day. More than 3,000 children
and adolescents become daily smokers every
day, resulting in approximately 1.23 million new
smokers under the age of 18 each year. Among
adults who had ever smoked daily, 89 percent
tried their first cigarette and 71 percent were daily
users at or before age 18. Among high school
seniors who had used smokeless tobacco, 79
percent had first done so by the ninth grade.
By the time they are high school seniors, 22
percent of adolescents smoke daily. Young
people experiment with or begin regular use of
tobacco for a variety of reasons related to social
and parental norms, advertising, peer influence,
parental smoking, weight control, and curiosity.
Nicotine dependence, however, is established
rapidly even among adolescents — sometimes as
early as two weeks! Because of the importance
of primary prevention in this population, the dental
health care team should pay particular attention
to delivering these messages to its patients.
Specifically, because tobacco use often begins
during preadolescence dental professionals
should routinely assess and intervene with this
population.
A condition known as hairy tongue occurs when
the solids and gases in tobacco help prevent
the tongue’s surface cells from sloughing off
normally. As a result, yellowish, white, brown
or black papillae are formed. Resembling furlike projections, they trap bacteria and food
debris on the tongue’s surface (Figure 1). This
phenomenon also contributes to halitosis.
Figure 1. Hairy Tongue
(Black)
Used with Permission,
www.docspiller.com
Smokers have significantly more stains and
calculus deposits on their teeth than nonsmokers.
These discolorations may become heavy on
teeth, dentures and restorations. Smoking also
has a detrimental effect on gingival tissues.
Conditions such as acute necrotizing ulcerative
gingivitis (ANUG) are more common in smokers;
additionally, other periodontal conditions are
frequently seen in the mouths of tobacco users.
Dental providers need to inform their periodontic
patients who smoke that a definite link exists
between cigarette use and disease. While 44%
Oral Effects of Tobacco Use
Tobacco’s damaging oral effects are well
documented, and should be easy for dental
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of periodontic patients smoke, only 25% of the
general U.S. public smoke cigarettes. Scientific
evidence clearly shows that smokers have
more severe periodontal diseases (including
periodontitis) than do nonsmokers. In fact,
continued smoking is extremely detrimental
to the success of periodontal therapy. Ninety
percent of refractory periodontic patients (as
compared to twenty-five percent of the general
population) are smokers. With smokeless
tobacco use, recession and irritation of the
gingiva routinely occur adjacent to where the
quid, or tobacco product, is held.
Figure 2. Leukoplakia
Used with Permission, www.docspiller.com
white lesions of this nature should be considered
malignant until ruled out by microscopic
examination (biopsy). Some leukoplakia lesions
will regress if tobacco use is discontinued.
A 30-year study on 18,893 teeth has shown
that cigarette smokers are 70% more likely to
need root canal therapy than non-smokers. The
amount of time smoked and the amount of time
smoke-free was directly related to their risk.
Another condition commonly seen in smokers
is nicotine stomatitis or “smokers palate.” Here,
the roof of the mouth becomes thickened and
white, and elevated bumps, which look like
areas of cobblestone, form around the partially
blocked openings of salivary gland ducts. This
abnormality, most commonly seen in pipe and
cigar smokers, often disappears when the smoker
quits and rarely develops into cancer.
Over 4,000 chemicals and gases in tobacco
smoke as well as their by-products may irritate
the oral cavity. Chemicals such as ammonia,
aldehydes, arsenic, benzo(a)pyrene, volatile
acids, hydrogen cyanide, ketones, lead,
pesticides, hydrocarbons, and radioactive
polonium may all be present in smoke and
smokeless tobacco.
Epidermoid carcinoma (squamous cell carcinoma)
is the most common oral cancer (Figure 3).
Most typically seen in cigarette smokers, it
is frequently found on the buccal mucosa or
tongue. In addition, pipe smokers are more
likely than other tobacco users to develop lip
cancer. Erythroplakia, a red lesion, may also be
associated with malignancy (Figure 4). Any red
or white lesion, even those which are innocent
looking, must have biopsies performed if they
do not heal within a few weeks. Treatment of
oral cancers may consist of surgery, radiation,
chemotherapy or a combination of these
approaches.
Sinusitis is a potentially disabling condition that
causes an acute or chronic inflammation of the
tissues lining the maxillary and frontal sinus air
spaces. It occurs about 75% more often among
smokers than nonsmokers and may be related
to the chemical make-up of tobacco smoke.
As a powerful vasoconstrictor, nicotine also
reduces blood flow to many tissues. This
drug action may lead to delayed wound
healing following oral surgery. Additionally,
the incidence of dry socket among smokers
is more than four times greater than among
nonsmokers. This condition can occur when
negative oral pressure, created as smoke is
drawn into the mouth, disrupts the bloods clot in
the postoperative extraction socket.
Nicotine Addiction
Many U.S. Surgeon General’s Reports have
presented scientific evidence that cigarettes and
other forms of tobacco are addictive. Numerous
other studies on animals and humans have
verified this report, showing that nicotine is the
agent in tobacco that leads to addiction. A
major conclusion of these documents is that the
pharmacologic and behavioral processes that
Leukoplakia is an oral white patch or plaque
that cannot be characterized clinically or
pathologically as any other disease (Figure
2). Considered a precancerous condition, it is
often associated with tobacco use. Any intraoral
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physiologic effects, which are quickly experienced
by the user. Nicotine causes skeletal muscle
relaxation and cardiovascular and hormonal
alterations, including increased heart and
breathing rates, blood vessel constriction (which
raises blood pressure), and paradoxically, feelings
of both stimulation and relaxation, depending
on the circumstances under which it is used.
Smokers may use tobacco to aid concentration,
as an energy boost, or for its calming effects.
Figure 3. Squamous Cell Carcinoma of
the Tongue
Used with Permission, www.docspiller.com
Addiction
Addiction may be defined as an overwhelming
compulsion to ingest a substance or engage in a
process with increasing frequency and intensity,
in order to experience its mind-altering effects
and/or to avoid the pain of its withdrawal. As with
many other addictive substances, tobacco users
develop tolerance over a period of time; that is,
they begin to require increasing amounts of the
drug in order to achieve the same effects.
While human beings have no inborn need for
tobacco, they often learn to use tobacco during
childhood or adolescence. Initially, they may be
influenced by role models, the mass media, and
peers. Once they become accustomed to the
effects of the nicotine and the socially rewarding
aspects of tobacco use, their need to continue
usage becomes strongly reinforced. At this point,
both physiological and psychological factors begin
to exert a powerful influence on them.
Figure 4. Erythroplakia
Used with Permission,
www.docspiller.com
determine tobacco addiction are similar to those
that determine addiction to other drugs, such as
heroin and cocaine. Evidence of the addictive
nature of nicotine has existed in the medical
literature since the early 1900’s, but the concept
gained much greater acceptance and credibility
with the release of these important government
publications.
Physical and Psychological Characteristics of
Nicotine Addiction
The characteristics of nicotine addiction include:
• Stimulation – tobacco and nicotine help to
organize thoughts and actions.
• Handling – enjoyment in watching smoke and
manipulating cigarettes, cigarette packages,
matches, ashes, etc.
• Relaxation – nicotine has a tranquilizing effect
especially after a meal or sexual activity, or
during coffee or alcohol consumption.
• Craving – “hunger” for a cigarette when not
smoking.
• Tension reduction – short-term stress relief
caused by nicotine’s overall effect(s) on the
brain.
• Habit – reinforcement of certain behaviors by
associating them with pleasurable activities.
Nicotine is found chiefly in the tobacco plant and
all tobacco products contain significant amounts
of nicotine. This drug is readily absorbed into the
bloodstream either from tobacco smoke, which
enters the lungs, or from smokeless tobacco,
which is present in the mouth or nose. The blood
levels of nicotine are relatively similar among
subjects using different forms of tobacco. Once
in the bloodstream, this powerful pharmacologic
agent is rapidly distributed throughout the body in
a variety of ways.
Nicotine enters the brain within seven to ten
seconds after inhalation. It interacts with specific
receptors in brain tissue and initiates very diverse
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Delivering the Smoke-Free Message:
Programs That Work
Physiological dependency occurs when brain
cells adapt so completely to a drug that
they require it for “normal” functioning; when
sudden drug abstinence occurs, signs and
symptoms of withdrawal also occur. In
nicotine dependency, tobacco craving is often
the most predominant physiological symptom.
Other withdrawal manifestations include
irritability, restlessness, headache, drowsiness,
gastrointestinal disturbances, reduced heart rate,
sleep disturbances and impaired concentration,
judgment and psychomotor performance.
In 2008, an updated, 276-page clinical
practice guideline, Treating Tobacco Use and
Dependence, was released by the Public Health
Service. The guideline, a comprehensive review
of over 6,000 scientific articles, offers simple and
effective interventions for all current and former
tobacco-using patients and recommends that “all
patients should be asked if they use tobacco and
should have their tobacco-use status documented
on a regular basis.” For a copy, telephone
1-800-4-CANCER.
One out of every three smokers attempts to
quit each year, but only 7% are successful in
remaining smoke-free for more than one year.
Many people who have already stopped smoking
were never heavy users; they may not have
actually been addicted to nicotine. It is estimated
that about 33% of all male smokers and 20% of all
female smokers are classified as heavy smokers
(persons who use 25 or more cigarettes per day).
The percentage of heavy smokers has been
steadily increasing since 1965, while many of the
more casual, light smokers have quit.
Findings and Recommendation
The key recommendations of the updated
guideline, Treating Tobacco Use and
Dependence, based on the literature review and
expert panel opinion, are as follows:
1. Tobacco dependence is a chronic condition
that often requires repeated intervention and
multiple attempts to quit. Effective treatments
exist, however, that can significantly increase
rates of long-term abstinence.
2. It is essential that clinicians and health care
delivery systems consistently identify and
document tobacco use status and treat every
tobacco user seen in a health care setting.
3. Tobacco dependence treatments are
effective, across a broad range of populations.
Clinicians should encourage every patient
willing to make a quit attempt to use the
counseling.
4. Brief tobacco dependence treatment is
effective. Clinicians should offer every patient
who uses tobacco at least the brief treatments
shown to be effective in this Guideline.
5. Individual, group, and telephone counseling
are effective, and their effectiveness increases
with treatment intensity. Two components
of counseling are especially effective, and
clinicians should use these when counseling
patients making a quit attempt:
• Practical counseling (problem solving/skills
training)
• Social support delivered as part of
treatment
Because the obstacles to stopping are great, it is
important to offer sincere support to those who
are motivated to give up tobacco. Many smokers
try several times before they are successful.
Rather than viewing their previous attempts
as failures, smokers should be encouraged to
credit themselves for achieving any degree of
abstinence whatsoever. The most important
message that can be relayed to these people is
“Try, try again!” Additionally, by offering them
self-help materials and informing them of available
community smoking cessation programs, dental
health professionals can actively help these
persons to quit.
One of the most positive sociocultural changes in
recent years is the move toward smoke-free public
buildings, restaurants and bars, transportation,
and places of employment. This shift in our
national attitude exerts additional pressure to
give up tobacco. The public is becoming better
informed about the deleterious effects produced
by ETS (Environmental Tobacco Smoke).
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• ASK patients about their tobacco use at
every appropriate opportunity. Identify and
document tobacco use status for each patient.
• ADVISE all tobacco users to stop. In a clear,
strong and personalized manner, urge every
tobacco user to quit.
• ASSESS willingness to make a quit attempt.
Determine the patient’s readiness to make a
change.
• ASSIST patients in stopping. Use counseling
and pharmacotherapy to help a patient quit.
• ARRANGE for supportive follow-up
procedures. Schedule a follow-up contact,
preferably within the first week after the quit
date.
6. Numerous effective medications are available
for tobacco dependence and clinicians should
encourage their use by all patients attempting
to quit smoking – except when medically
contraindicated or with specific populations
for which there is insufficient evidence
of effectiveness (i.e. pregnant women,
smokeless tobacco users, light smokers, and
adolescents).
• 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 medications
identified as effective in this Guideline.
7. 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.
8. Telephone quitline counseling is effective with
diverse populations and has broad reach.
Therefore, both clinicians and health care
delivery systems should ensure patient access
to quitlines and promote quitline use.
9. If a tobacco user currently is unwilling to
make a quit attempt, clinicians should use
the motivational treatments shown in this
Guideline to be effective in increasing future
quit attempts.
10.Tobacco dependence treatments are both
clinically effective and highly cost-effective
relative to interventions for other clinical
disorders. Providing coverage for these
treatments increases quit rates. Insurers and
purchasers should ensure that all insurance
plans include the counseling and medication
identified as effective in this Guideline as
covered benefits.
Tobacco Cessation Programs for the Dental
Office
It is realistic for most dental practices to
incorporate tobacco education into existing
office procedures. Many patients will stop using
tobacco if they receive cessation advice from a
trusted health professional. By asking patients to
complete the necessary cessation-related forms
while waiting in the reception area, the staff will
need only a few appointment minutes to ask
about tobacco use and offer advice accordingly.
Additionally, when a lesion or any abnormality
which can be associated with tobacco use is
found, the dental professional has a unique
and potent opportunity, a teachable moment,
to present the tobacco-recovery message.
Cessation can be mentioned in some manner
at every dental visit, however brief the message
may be. Repetition is often a key factor in
success. Individual patients will need varying
amounts of time. Some people will be selfstarters, while others may need more guidance.
For instance, they may need to gain insight into
their personal strengths and support systems,
which can help them through the cessation
process, or they may need to create a group of
individualized quitting strategies.
By providing patients with a smoke-free
professional environment, the dental office and
other health care settings can exert a positive
influence on tobacco users and those in the
process of quitting. To establish credibility, a
dental office “no-smoking” policy is essential.
A prominent sign such as “Thank You for Not
Smoking” should be displayed in the reception
The basic intervention techniques chosen for the
above programs include the systematic use of a
protocol known as the “Five A’s.” These are:
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area. Free quit-smoking pamphlets and selfhelp material, published by the American Cancer
Society and American Lung Association, should
also be available for interested patients to read
and take home. Ashtrays should be removed
from all office areas. Because tobacco advertising
is very prevalent in popular magazines, those in
charge of reception room reading material might
consider displaying only those publications that do
not include tobacco ads.
can place an appropriate sticker on the chart of
each patient who smokes to remind the staff to
Ask about tobacco usage at every appropriate
opportunity.
During the oral examination, the dental team
can increase patient awareness by delivering
a personalized message about tobacco use,
and relating it to any pertinent systemic health
history finding or oral condition that has been
noted. These findings might include: chronic
bronchitis, sinusitis, heart disease, emphysema,
hypertension, respiratory disease, stains on the
teeth, calculus build-up, periodontal pocketing,
or suspicious soft-tissue lesions, such as
leukoplakia. A good time to recommend that a
patient stop smoking is at the end of a dental
procedure, when the person’s mouth is clean and
fresh. While some patients will appreciate this
concern and be ready to act, others will resist.
If the information is presented in a caring and
noncoercive manner, usually the patient will not
respond to it defensively, even those who are
not ready to quit. The suggestions given and
Dental professionals might choose to include
magazines that contain tobacco advertising
but cross out the ads with a taped or marked
blacked or red “X.” Those who use either of these
strategies are firmly declaring their office’s antitobacco philosophy.
The medical/dental health history must address
tobacco use by asking patients to note whether
they use tobacco, which forms of tobacco they
use, how long they have taken the product(s),
and how much they are consuming daily. After
reviewing this written information, the assistant
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the patient’s responses should be documented in
the dental record. Accurate record keeping will
remind the dental professional to ASK, ADVISE,
and ASSESS effectively and appropriately during
subsequent appointments.
The American Cancer Society, American Lung
Association, Seventh Day Adventists, Smoker
Stoppers and numerous community-oriented
quit smoking programs, such as State Health
Departments and telephone quit lines are involved
in effective cessation programs, which are offered
free or at nominal cost.
Without internal motivation, it is unlikely that
an individual will stop using tobacco. If a
patient’s quitting interest and drive are low,
dental professionals should simply state they are
available to help whenever necessary. Health
professionals should not badger patients to quit or
display any judgmental or condescending attitudes
when dealing with smokers or recovering smokers.
Smokers Anonymous support groups, based on
the same principles as Alcoholics Anonymous,
are active in many regions of the country and may
be helpful to the would-be quitter, as well as to
those who have already given up tobacco.
For heavy smokers who are highly motivated
to quit, nicotine reduction therapy is a viable
option. This approach is based on the use of
a nicotine-containing product. When nicotinecontaining gum is chewed slowly it gradually
releases nicotine directly into the bloodstream
through the oral mucosa. It is designed to
maintain blood levels that will help to offset
withdrawal symptoms, which are a common
cause of relapse during the first three months of
smoking abstinence.
Those who are highly motivated and ready to
stop smoking should be asked to select a quit
date. While most smokers who quit manage
to accomplish this on their own, some may
require assistance. At this point, patients and
dentists should discuss all available options. If
the patient is interested in a formalized quitting
procedure, s/he can be provided with a written
list of telephone numbers, dates and locations of
all reputable community programs and their fees.
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The prescription for certain nicotine-containing
medication can be obtained from the physician or
dentist. It is important to use current prescribing
guidelines and to carefully instruct patients on its
proper usage.
(decreasing the number of cigarettes smoked over
a period of time) and nicotine fading (e.g. using
filtered brands to gradually reduce the amount
of smoke inhaled). Switching to a lower tar or
nicotine cigarette is not advisable as studies show
that smokers who change to these brands usually
will compensate for the nicotine loss by either
inhaling more deeply, smoking more cigarettes, or
taking more puffs.
The American Dental Association (ADA)
Guide to Dental Therapeutics (third edition),
released in the fall of 2003, provides a 13-page
article which condenses information related to
the use of prescription and non-prescription
medications used by dentists to help their
patients quit using tobacco. Chapter 32, entitled,
“Cessation of Tobacco Use,” and authored
by a dentist, provides practical, “hands-on”
advice. It discusses all commercially available
products covering their generic and brand
names, indications for use, dosage ranges and
interactions with other agents. The American
Dental Association is firmly behind the utilization
of these products in clinical practice. Every
dental practice should have this publication for
office use. When dentists prescribe a tobacco
cessation product, they are actually treating
dental conditions.
Presently, a wide array of over-the-counter selfhelp products are also being developed and
marketed. However, most smokers can actually
quit on their own when their motivation becomes
strong enough.
The dental team must work together to help their
patients become smoke-free. But first, they must
cooperate with one another. The ASSIST protocol
can be applied to coworkers and patients alike.
Dental assistants frequently have chair side time
with patients and are in a unique position to show
concern, empathy, and encouragement toward
potential quitters. Those who are former smokers
can serve as credible role models of success.
According to the Public Health Service, at
present, long-term smoking abstinence rates are
currently and reliable being increased by six firstline pharmacotherapies: Buproprion SR; nicotine
gum; nicotine inhaler; nicotine nasal spray and
nicotine patch and nicotine lozenge.
Because of the traditional way in which dental
appointments are scheduled, it is relatively easy
to ARRANGE smoking cessation follow-up visits.
A telephone call to a client on the designated quit
day, notes in the office newsletter, and continual
reassurance at subsequent appointments can
all contribute to patient’s success. Fortunately,
a great deal of the damage caused by cigarette
smoking is reversible. Any positive changes in
oral health (such as less stain and calculus on the
teeth) can be noted during office visits.
Several days after the quit-smoking dates, dental
office personnel can contact these persons who
are using Nicotine Replacement Therapy and
re-emphasize proper medication usage. At this
time, it may be necessary to adjust dosages or
review usage techniques. Conduct follow-up
monitoring of the patient’s progress at monthly
intervals thereafter.
The Dental Professional’s Role in a
Smoking Cessation Program
Dental professionals can actively help patients to
stop using tobacco by taking the following actions:
While nicotine reduction therapy or the use of
Zyban are the only FDA approved clinically
proven approach for smoking cessation available
at this time, it is to be expected that the FDA
will approve new pharmaceutic agents for the
purposes of smoking cessation. Many other
methods have been used with varying degrees of
success. These include hypnosis, acupuncture,
laser therapy, aversion therapy (rapid smoking
or smoking in an enclosed chamber), tapering
• Become nonsmoking role models. Encourage
coworkers to become smoke-free, at least
during working hours.
• Promote a smoke-free environment throughout
the dental office. Remove all ashtrays from
reception areas, and provide patients with stopsmoking pamphlets and attractive smoking
cessation displays. The American Lung
Association, American Cancer Society, National
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•
•
•
•
•
•
•
Cancer Institute, and American Dental
Association are all excellent resources for free
or reasonably priced materials. Maintain an
inventory of appropriate educational handouts.
Make certain that medical/dental health
history forms include questions which address
tobacco use.
Identify charts of all tobacco users with an
appropriate sticker. Change the sticker to a
“Quit Smoking” sticker when appropriate to
reinforce and support them at each visit.
Provide information about practice-based
tobacco cessation efforts in the office
newsletter (e.g., a list of healthy, sugar-free
snacks, which those giving up tobacco may
enjoy).
Post or release via the newsletter an “I QUIT”
list of patients in the practice (after obtaining
their individual permission). This activity
can serve as a practice-builder as well as a
positive reinforcement to those who have been
successful.
Communicate to the whole dental team any
relevant personal information that might
positively or negatively influence the patient’s
ability to quit. Make written notes in the
patient’s chart.
Telephone potential quitters on or shortly
after their designated quit day to see how
they are doing. Answer any questions as
needed. This can be done at the same time
as appointments are being confirmed.
Compliment those (especially young patients)
who do not use tobacco in any form. Tobacco
is considered a “gateway drug” for marijuana,
since marijuana use is generally preceded by
tobacco use. Often, people initially become
addicted to nicotine through smokeless
tobacco use; as time passes, they frequently
switch to smoking products.
• Talk with tobacco-using patients about quitting
and support those who have already stopped.
Some health care professionals are concerned
that if they approach their smoking patients with
cessation advice, they will alienate or offend
them. In reality, a vast majority of tobacco users
would like to stop, but do not know how to go
about it. To relate to the smokers or recovering
smokers in a supportive nonthreatening way,
dental professionals need to understand the
general levels of quitting motivation, and their
specific applications to individual patients.
Stages of Change – What to Say
Prochaska and DiClemente have identified six
stages through which people pass in attempting
to stop using tobacco. As dental professionals
learn to meet individual patient needs, they should
be aware of these various motivational levels of
readiness for quitting smoking. The stages are as
follows:
• Precontemplation: The person has not yet
considered stopping.
• Contemplation: The person has thought
about stopping, but is not ready to act.
• Desire or Readiness: The person admits to
sincerely wanting to quit.
• Action: The person is ready to attempt the
quitting process, has selected a quit date and
individualized strategies.
• Maintenance: The person is no longer using
tobacco, is attempting to remain tobacco-free.
• Relapse: The person has returned to smoking
one or more cigarettes daily, after stopping for
a significant period of time.
Suggested Dialogue
The following scenarios suggest possible
dialogues which dental health professionals
can have with patients, after assessing their
motivational level or commitment to tobacco
cessation.
Precontemplation Stage
Question: “Have you thought about stopping
smoking (or using smokeless tobacco)?” If the
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Relapse Stage
Question: “Have you smoked (even taken a
puff) in the past seven days?” If the answer
is “yes”, ask “What seemed to cause the slip?”
“Is there a way you might have avoided it?”
Patients who have returned to smoking may
benefit from learning to distinguish between a
slip and a relapse. A slip involves the occasional
smoking of only a few cigarettes, while a relapse
is characterized by a return to former levels of
smoking, or in some cases, even higher levels.
Stress to the patient that a slip can be viewed as
“a slight lapse in progress”. Reassure patients
that relapses are common. The likelihood of
permanent success increases with repeated
attempts to stop.
answer is “no”, express your concern about
the patient’s health, and help identify health
advantages which would be gained by quitting.
(Use information from the health history form.)
Respect the patient’s right to continue smoking.
If they do not decide to quit, indicate that you will
inquire again at future visits.
Contemplation Stage
Question: “Have you thought about stopping?”
If the answer is “yes”, assess past experience
(“Have you ever quit before?”) and discuss
available recovery resources. “What has
worked for you previously, in past attempts
to stop?” Stress that most individuals make
multiple attempts to quit, and the chances for
success increase with each effort. “Would you
be interested in accepting our help?” Dental
professionals should express the desire to help
when patients are ready. Identify personal
barriers (such as fears of weight gain and failure),
and review all available resources that offer help
(e.g., self-help materials, office counseling, group
participation and outside referrals.
Question: “Are you still interested in becoming
tobacco-free?” Oral health providers must
continue to offer nonjudgmental, sympathetic
support and encouragement to those who have
relapsed; however, tobacco users must personally
confront and “own” their habit, and choose to
return to the action and maintenance steps of
the quitting process.
Desire/Readiness and Action Stages
Question: “Are you ready to set a future quit
date?” “Which strategies for stopping do
you prefer?” At this level, the dental team is
preparing to negotiate a recovery plan with the
patient. The patient should be asked to set a
reasonable quit date (e.g., within one to four
weeks in the future), and to consider a range
of possible cessation strategies for personal
use. Substitute activities for smoking (exercise,
hobbies, etc.) can be explored if the patient
shows interest or asks for help.
As an oral health professional, what do I say
to patients about smoking/tobacco cessation?
Many practitioners want to know what messages
will have the most impact, and how they can
be delivered in a meaningful and effective way.
An effective cessation message focuses on the
benefits of becoming a nonsmoker, rather than
the detriments of continuing to smoke. However,
when responding to this perspective, some
smokers may rationalize that the damage caused
by their smoking is already done. In keeping with
a positive theme of hope, the practitioner can say:
Maintenance Stage
Question: “How are you doing in your effort to
stop smoking?” “Is there something else we can
do to help?” A follow-up telephone call can serve
as a positive reinforcement to patients, offering
them needed reassurance and support. Even
when patients have not been successful, the staff
should interpret quitting attempts positively and
express empathy. If patients raise questions
about coping skills or proper use of nicotine
replacement products, address their concerns
immediately.
• “It is never too late to quit smoking.”
• “When you quit, most of the effects of smoking
are reversible.”
• “Smoking cessation is the single most
important step that you can take to enhance
the length and quality of your life.”
• “Your mouth will be a lot healthier and fresher
when you quit smoking.”
• “When you quit smoking, you will no longer be
inhaling more than 4,000 harmful chemicals
and gases.”
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Make Your Message Relevant
It is critically important for the dental team to
interact with patients who smoke, and to carefully
explain how their specific dental problems
are linked to their smoking behaviors. For
example, during treatment, if a team member
notes an oral condition related to tobacco use,
not only can they discuss the problem with the
patient, but also can encourage the patient to
observe this condition by using a hand mirror.
Additionally, the team member can assess the
individual’s readiness to set a quit date. Through
discussion with the auxiliary and a review of welldocumented notes (kept in the treatment record),
the dentist can make a diagnosis and arrange for
appropriate follow-up. As they gain experience
in discussing tobacco issues with patients, oral
health professionals can become as comfortable
with cessation issues as they are with details
concerning periodontal pocket depths and plaque
control.
• “Did you know that as many as a third of
people who quit smoking do not gain any
weight? And those who do generally gain only
5 to 9 pounds.”
• “The health risks that you are taking by
smoking are far greater than the risk of
nominal weight gain.”
• “If you exercise regularly, you can ease
withdrawal symptoms and counteract weight
gain.”
• “Now that you have given up smoking and
want to eat more often, you need to avoid
high-calorie snacks. Many of the foods that
are good for oral health will also help you
to avoid weight again. Be careful about
substituting high sugar items like gum or
breathe mints for tobacco.”
Encourage individuals with weight gain concerns
to closely monitor their calories, sugar, and
fat intake and to increase their activity levels.
Regular exercise not only speeds metabolism,
tones muscles, improves cardiovascular function,
reduces tension, and burns calories, it also
stimulates the release of endorphins, which can
positively affect mood and disposition.
During subsequent appointments, as dental
health care providers interact with their patients
who smoke, they can relay the following
messages:
• “As your dentist (dental assistant or hygienist),
I must advise you to stop smoking now.”
• “Have you ever thought about quitting? Have
you ever tried to stop before?” If so, “What
happened?”
• ”Did you know that you have periodontal
disease? Quitting smoking would really help
to slow down the rate of gum disease that is
developing in your mouth.”
• “You need to have gum surgery, but you will
not heal properly unless you quit smoking.”
• “Smoking is a common cause of bad breath.
You may be able to solve this problem
completely if you quit using cigarettes.”
• “How about choosing a quit date within the
next few weeks, now that you have decided to
stop smoking?”
While general health gains resulting from smoking
cessation are well documented and dramatic, the
psychological benefits associated with quitting
are equally valid and impressive. Compared with
current smokers, former smokers have a greater
sense of self-efficacy, freedom, and control over
their personal circumstances.
The following supportive comments may motivate
the patient who smokes to make a commitment to
cessation:
• “It sounds to me as if you would like to regain
control of your life again by quitting smoking.
That’s a worthy goal!”
• “Just think of all the freedom you’ll have when
you quit! Every cigarette that you do not
smoke represents a bit of freedom that you
have gained.”
Fear of Weight Gain
The fear of weight gain discourages many
smokers (especially women) from trying to quit.
Weight issues should be acknowledged and dealt
with openly. The following responses may help to
diffuse weight issues:
These encouraging statements can be offered
to patients from a health professional who is a
former smoker:
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Questions and Answers
• “Although this has been one of the most
difficult tasks that I have ever accomplished as
an adult, it is one of the most satisfying things
I have ever done.”
• “More than 3 million Americans quit every
year. In fact, there are now over 50 million of
us who are ex-smokers. I can tell you from
personal experience that it can be done. Why
not give it a try? I will be here to support you.”
Is there an up-to-date list of tobacco-use
control and cessation web sites?
Yes. Refer to these sites:
The CDC website - http://www.cdc.gov/tobacco/
quit_smoking/how_to_quit/index.htm
Top 5 Quit Smoking Websites - http://copd.
about.com/od/quittingsmoking/tp/Quit-SmokingWebsites.htm
The American Dental Association (ADA) - http://
www.ada.org/2615.aspx
The Office of the Surgeon General - www.
surgeongeneral.gov/tobacco/default.htm
This empathic response can be given to smokers
who tried to quit, but did not achieve cessation:
• “I really respect the fact that you gave quitting
a good try. Not everyone succeeds on their
first try, but many people are able to quit after
making several attempts. Why not try again?”
Where can I get authoritative information
relating to tobacco that can use at chairside?
The American Dental Association Annual Catalog
has a number of current pamphlets, posters
and videos relating to the ill-effects produced by
smoked and smokeless tobacco. Some are even
available in Spanish. This catalog is available
to ADA members at 1-800-947-4746. Example
- https://siebel.ada.org/ecustomer_enu/start.
swe?SWECmd=Start&SWEHo=siebel.ada.org
The Cost of Smoking
Although very few people quit smoking to save
money, they are quite surprised to discover the
actual cost of their tobacco use. The following
comments are examples of how a health
professional might motivate a resistant smoker to
a state of cessation readiness:
• “Do you realize that, as a pack-a-day smoker
($5.29 per pack multiplied by 365 days), you
are spending over $1900 a year on your
addiction?”
• “When you smoke, you pay three times- first,
with your money; second, with your health;
and third, with more money as you try to
regain your health.”
• “When you quit smoking, why not set aside
the money that you would have spent on
cigarettes, and on your first anniversary as
a nonsmoker, reward yourself with a special
purchase?”
For useful information, call The American Dental
Association’s Council on Access, Prevention
and Professional Relations (312-440-2860).
Also contact the National Institute of Dental and
CranioFacial Research’s Oral Health Information
Clearing House (301-496-4261).
At the time of this course revision in November
2010, The Family Smoking Prevention and
Tobacco Control Act is requiring tobacco
packaging to have larger and more visible
warnings. Final regulations will be designated no
later than June 22, 2011. Cigarette companies
will have to comply within 15 months of the
final ruling. The Act will require 9 warnings to
be placed on all surfaces of the package and
placement on the top 50% of the package.
Proposed warnings include high resolution, full
color graphics.
Summary
The dental team can use their professional
knowledge and skills to lead smoking patients
toward recovery; additionally, they can display
candor, sensitivity and empathy in helping these
individuals to make this positive choice. As
they work together cooperatively within these
parameters, the entire team’s efforts will be wisely
invested.
The following website has materials that can be
obtained to use for educational purposes: http://
www.tobwis.org/uploads/products/2010_Free_
List_Complete.pdf
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The senior author has prepared a 6“ x 9“ full
color, 8-page pamphlet that depicts tobacco’s
effects on the oral cavity. Designed for
dental office use, it contains twenty-four color
photographs, which show the nature and extent of
dentally-related tobacco-related problems. This
pamphlet, Tobacco and Your Mouth, is available
in bulk from The Health Connection, 55 West Oak
Ridge Dr., Hagerstown, MD 21740, Tel: 1-800548-8700.
This program is designed to educate the health
professional about care management for the
highly dependent tobacco user. The program
which includes lectures, case-presentations and
hands-on, skill-building workshops, teaches and
demonstrates how to assess, diagnose, and
develop treatment plans and deliver effective
tobacco cessation interventions. Participants will
learn how to use behavioral and pharmacologic
aids to promote cessation. Information
dealing with reimbursement issues will also be
presented. Dental participants will receive an
appropriate number of credit hours for attending
this workshop. For more details, contact the
Indiana University School of Medicine, Division of
Continuing Education: 1-800-622-4989.
Is there a continuing education course that
can teach the dental health care team about
office-based tobacco cessation programs?
Yes. The Indiana University Nicotine Dependence
Program, in conjunction with the Dental School
and the Indiana University School of Medicine,
conduct periodic workshops on State-of-the-Art
Smoking Cessation Interventions.
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Course Test Preview
To receive Continuing Education credit for this course, you must complete the online test. Please go to
www.dentalcare.com and find this course in the Continuing Education section.
1.
One out of every ______ smokers attempts to quit each year.
a. 3
b. 10
c. 17
d. 100
2.
Nicotine reaches the brain _______ seconds after inhalation.
a. 2
b. 7
c. 20
d. 60
3.
______ is a white intraoral patch related to the use of all forms of tobacco and is considered
to be precancerous.
a. Hairy tongue
b. Erythroplakia
c. Leukoplakia
d. Sinusitis
4.
Pregnant women who smoke are more likely to:
a. deliver their babies prematurely
b. produce low birth-weight infants
c. have spontaneous abortions
d. all of the above
5.
The incidence of ______ after oral surgery is four times greater in smokers than
nonsmokers.
a. dry socket
b. ANUG
c. hairy tongue
d. sinusitis
6.
________ are more likely to develop lip cancer.
a. Smokeless tobacco users
b. Cigar smokers
c. Pipe smokers
d. Cigarette smokers
7.
___________is not considered a symptom associated with nicotine withdrawal.
a. Irritability
b. Restlessness
c. Headache
d. All may be associated with nicotine withdrawal
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8.
Tolerance refers to ________
a. the reduction in tobacco use that occurs with increasing age
b. an emotional reliance on addictive substances or behaviors
c. the need for increasing quantities of a drug to produce the same effect
d. a prolonged, intense desire for nicotine
9.
__________ is NOT one of the first-line medications approved by the FDA for smoking
cessation:
a. Nicotine gum
b. Lobeline Sulfate
c. Bupropion SR
d. Nicotine nasal spray
10. A temporary minor reversal to former addictive practices (of less intensity than a relapse) is
known as ______.
a. precontemplation
b. contemplation
c. maintenance
d. a slip
11. _________________ is not one of the “5A’s” used in the National Cancer Institute’s tobacco
intervention program.
a. ACT
b. ADVISE
c. ASSIST
d. ARRANGE
12. A smoker who has thought about quitting smoking but has not yet stopped is in the stage
of change referred to as __________.
a. precontemplation
b. contemplation
c. action
d. maintenance
13. Close to____ percent of adult smokers began smoking by the age of _______.
a. 75/17
b. 80/18
c. 60/16
d. 90/19
14. __________is produced by smokers and inhaled by non-smokers.
a. Secondary smoke
b. Sidestream smoke
c. Carbon Monoxide
d. A and B are both correct
15. The addictive substance present in all forms of tobacco is __________.
a. tar
b. nicotine
c. heroine
d. cocaine
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16. Teenage girls smoke __________ teenage boys.
a. more than
b. less than
c. equal to
17. If fear of weight gain is a problem __________ can be discussed.
a. regular exercise to speed metabolism
b. facts vs. myths that 1/3 of quitters do not gain weight
c. the health risks of smoking are worse than the possibility of gaining 5-9 pounds
d. all of the above
18. Nicotine tends to ________ the vessels in the body.
a. dilate
b. constrict
c. open
d. pressurize
19. Acute health risks associated with smoking include __________.
a. syncope
b. diabetes
c. impotence and infertility
d. none of the above
20. The percentage of heavy smokers has been steadily increasing while the more casual,
light smokers are quitting. For heavy smokers who are highly motivated to quit, nicotine
reduction therapy is a viable option.
a. Both statements are true.
b. The first statement is true. The second statement is false.
c. The first statement is false. The second statement is true.
d. Both statements are false.
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References
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Prevention and Cessation: Dentistry’s Role in Promoting Freedom From Tobacco,” Journal of the
American Dental Association. 131(8):1137-1144. August 2000.
2. Christen, J.A., Christen, A.G., “Defining and Addressing Addictions: A Psychological and
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fda.gov/TobaccoProducts/Labeling/CigaretteProductWarningLabels/ucm231347.htm Accessed
November 23, 2010.
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136(8):1076-1078, 2005.
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Dental Association. 137(2): 170-179, February 2006.
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tobaccofreekids.org/research/factsheets/pdf/0072.pdf. Accessed June 30, 2010.
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3rd Edition, Chicago, Illinois, American Dental Association, 2003. pp.587-599.
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25. Stafne EE. The Role of the Dental Office in Tobacco Cessation: A Practical Approach. Northwest
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About the Authors
Arden G. Christen, DDS, MSD, MA
Arden G. Christen is Professor Emeritus, Department of Oral Biology; Co-director
Indiana University Nicotine Dependence Program and the Clarian Tobacco Control
Center, Methodist Hospital, Indianapolis, IN.
Jennifer A. Klein, RDH, MSA
Jennifer A. Klein is Associate Professor of Dental Hygiene, Indiana University, South Bend, IN.
Stephen J. Jay, MD
Stephen J. Jay, MD is Professor of Medicine and Public Health; Co-Director, Indiana University Nicotine
Dependence Program and the Clarian Tobacco Control Center, Methodist Hospital, Indianapolis, IN.
Joan A. Christen, BGS, Ms
Joan is Research Associate and Medical Editor, Department of Oral Biology, Indiana University School of
Dentistry, Indianapolis, IN.
James L. McDonald Jr., PhD
James L. McDonald, Jr. is Professor Emeritus Oral Biology, previously Associate Dean for Dental
Education, Indiana University School of Dentistry, Indianapolis, IN.
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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised January 6, 2012
Christianne J. Guba, DDS, MSD
Christianne J. Guba is Associate Professor, Department of Restorative Dentistry;
Director Clinical Assessment and Quality Assurance, Office of Clinical Affairs; Indiana
University School of Dentistry, Indianapolis, IN.
Cindy Gerber, CDPMA
Ms. Gerber is a Certified Nicotine Cessation Facilitator. She is currently listed with
ITPC (Indiana Tobacco Prevention & Cessation) and American Lung Association.
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Crest® Oral-B at dentalcare.com Continuing Education Course, Revised January 6, 2012