AMRITA SCHOOL OF DENTISTRY

1. TOBACCO CESSATION

2. Contents
• Introduction
• Steps in treating tobacco use and
dependence
• Psycho-behavioral therapy
• Pharmacotherapy
• Nicotine replacement therapy
• Antidepressants
• Key counselling concepts
• Action in the community
• Action at the state and national level
• Conclusion
• References
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3. Introduction
Prevention of oral cancer mainly focuses on modifying habits associated
with the use of tobacco.
Deaths
due to
tobacco
use –
800,000
Deaths
due to
smoking –
700,000
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4. 130 million
tobacco
users in
India
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5. Leading tobacco-producing countries worldwide in 2020 (in 1,000 metric tons)*
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6. • The first step in treating tobacco use and dependence is to identify tobacco
users.
• Screening for current or past tobacco use will result in four possible responses:
1.The patient uses tobacco and is now willing to make a quit attempt.
2.The patient uses tobacco but is not now willing to make a quit attempt.
3.The patient once used tobacco but has since quit.
4.The patient never regularly used tobacco.
How to quit?
Psycho-behaviouralTherapy
Pharmacotherapy
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7. For the Patient Willing to Quit
Guide to counseling for tobacco cessation (5 A’s)
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8. Check for the oral signs: stained
teeth, halitosis, periodontal
diseases, tooth mobility, discolored
patches on the mucosa(white, red,
dark precancerous lesions)
ASK
About patient’s habits
• Identify and document tobacco user
status of every patient at every visit
Encourage never-users to stay away
from tobacco.
Affirm and congratulate those who
have quit tobacco use.
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ADVICE
Of consequence of smoking
• Ina clear, strong and personalised
manner urge every tobacco user to quit

9. Level of
dependence
Description
High
Individuals who use tobacco
within 30 minutes of waking up
or who use it 25 or more times
per day
Moderate
Individuals who use tobacco
more than 30 minutes after
waking up or less than 25 times
per day
Low
Those who neither use tobacco
before 30 minutes of waking up
or use it more than 25 times a
day.
ASESS
Willingness to quit
• Is the tobacco use willing to make a quit attempt at this time?
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10. Assess the risk of relapse:
• Lower risk – quit before
or even for just 30 days
• Higher level of
dependence usually
needs a more intensive
intervention to avoid
relapse
• Individuals with
depression or habit of
drinking alcohol may
increase the risk of
relapse.
• Rigorous follow-up
reduces the risk of
relapse
Relevance - Encourage the patient to indicate
why quitting is personally relevant.
Risks - Ask the patient to identify potential
negative consequences of tobacco use.
Rewards - Ask the patient to identify potential
benefits of stopping tobacco use.
Roadblocks - Ask the patient to identify barriers
or impediments to quitting.
Repetition - The motivational intervention
should be repeated every time an unmotivated
patient has an interaction with a clinician.
Tobacco users who have failed in previous quit
attempts should be told that most people make
repeated quit attempts before they are
successful.
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11. Assist your patients with a quit
plan.
• Give advice on successful
quitting
• Provide resources for your
patient.
• Assist your patient to quit by
setting a quit date, ideally
within 2 weeks of the visit.
• Have the patient arrange
support from family, friends and
co-workers.
ASSIST
With cessation plan development
• For the patient willing to make a quit
attempt, use counselling and
pharmacotherapy to help him or her
quit
ARRANGE
For follow-up
• Schedule follow-up contact, preferably
within the first week after the quit date
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12. 1. Nicotine ReplacementTherapy:
Nicotine replacement therapies (NRT) for tobacco use cessation are :
• Nicotine gum
• Nicotine patch
• Nicotine inhaler
• Nicotine nasal spray
• Nicotine lozenges
Basic principles for prescribing NRTs:
• Medical supervision is important
• Use a lower dose for less dependent tobacco users
• Contraindicated in: pregnancy, lactation, cardiovascular diseases, peripheral vascular
disease, endocrine disorders, inflammation of the mouth and throat, oesophagitis, and
gastric
Use of Pharmacotherapy
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13. Nicotine gum:
Use under medical supervision for
a predefined limited period, e.g. 6
weeks after which the patient has
to face withdrawal
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Nicotine withdrawal
symptoms
Craving for
tobacco
Depressed
mood
Insomnia
Irritability
Frustration
Anxiety
Difficulty in
concentratio
n
Restlessness
Decreased
heart rate
Increased
appetite and
weight gain
2. Anti-depressants
• Function as anti-craving
medications
• Available therapies :
• First-line therapies
• Bupropion SR
• Selegeline
• Second-line therapies
• Clonidine
• Nortryptyline

14. Key counselling
concepts
A non-
judgmental
attitude Caring
Empathy
Listening
Raising
awareness
Prompting
self-
evaluation
Offering
support
Asking
open-ended
questions
Clarifying
Reflecting
feelings
Summarizin
g
Affirming
Eliciting self-
motivational
statements
Setting
realistic
goals
Responding
to tricky
questions
Tailoring
messages to
the patients
stage of
change
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15. • Public Education
• Media advocacy
Action in the Community
• Making the profession and dental facilities tobacco-free
• Advocacy with the state and national governments
Action at the State and National Levels
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16. 16
• 1975: Cigarette Act
• 1985: National Cancer Control Program
• 2003 : Cigarettes Products Act
• 2004: WHO-FCTC
Regulatory approach
• Screening
Service approach
• harmful effects of tobacco
• counsel patients
• tobacco-free lifestyle
• tobacco use during pregnancy
• spend more time with patients
• reinforce messages given to patients
• build their patient’s interest to discontinue
• promote oral health and healthy lifestyles
• speak with authority in the community
• effective advocates for tobacco control in the
community
Educational approach

17. Global Initiatives
• The Crete Declaration on Oral cancer Prevention 2005
• WHO Framework Convention OnTobacco Control (WHO FCTC)
• Bloomberg Initiative to ReduceTobacco Use
• Campaign for tobacco-free kids.
• Centre for disease control and prevention foundation.
• John Hopkins Bloomberg School of Public Health Education/training.
• WHO -Tobacco Free Initiative (TFI)
• World Lung Foundation.
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18. Conclusion
• A majority of cancer deaths worldwide
are due to tobacco.
• The suffering, disfigurement and death
due to oral cancer are easily avoidable
since the factors associated with the
disease have long been identified.
World NoTobacco Day theme (2022)
"Protect the environment"
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19. Suggested Reading
• Soben, Peter. "Essentials of
Public Health Dentistry."
(2014).
• Marya, C. M. A textbook of
public health dentistry. JP
Medical Ltd, 2011.
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20. "Protect the environment"
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