Medications to Assist in Tobacco Cessation for Dental Patients

Smoking is the leading cause of preventable illness in the United States. Without assistance, only 3% to 6% of smokers successfully quit after 1 year. Nicotine replacement therapy (NRT), buproprion, and varenicline are first-line pharmacologic therapies. These medications function by reducing nicotine withdrawal symptoms and the desire to smoke. When first-line therapy does not lead to successful smoking cessation, combinations of varenicline with NRT, buproprion with NRT, and varenicline with buproprion may be efficacious. Behavioral therapy also plays a role in smoking cessation and the combination of pharmacologic therapy with behavioral therapy is more effective than either therapy alone.

Key points

  • Smoking is the leading cause of preventable illness in the United States and accounts for approximately 20% of deaths.

  • Nicotine replacement therapy (NRT), buproprion, and varenicline are first-line pharmacologic therapies to assist with smoking cessation.

  • Varenicline and combination NRT are more effective than single NRT or buproprion for smoking cessation.

  • Combinations of varenicline with NRT, buproprion with NRT, and varenicline with buproprion have proved to be efficacious for users who have failed monotherapy.

Introduction

According to a US Centers for Disease Control and Prevention report published in 2014, 17.8% of adults in the United States currently smoke cigarettes. Smoking is the leading cause of preventable illness in the United States and accounts for approximately 20% of deaths. There are 16 million Americans living with smoking-related diseases such as cancers, cardiovascular diseases, and respiratory diseases. Smoking has been shown to decrease life expectancy by approximately 10 years. In 2010, 68% of adult smokers wished to quit smoking, whereas 52% had made an attempt to quit in the past year. Many smokers try to quit without assistance and only 3% to 6% are successful 1 year later without assistance.

This article reviews the current therapies available to encourage and assist patients with smoking cessation. It covers the 5 As (ask, advise, assess, assist, arrange) algorithm of counseling, pharmacotherapy, behavioral therapy, and combination therapy for smoking cessation.

Introduction

According to a US Centers for Disease Control and Prevention report published in 2014, 17.8% of adults in the United States currently smoke cigarettes. Smoking is the leading cause of preventable illness in the United States and accounts for approximately 20% of deaths. There are 16 million Americans living with smoking-related diseases such as cancers, cardiovascular diseases, and respiratory diseases. Smoking has been shown to decrease life expectancy by approximately 10 years. In 2010, 68% of adult smokers wished to quit smoking, whereas 52% had made an attempt to quit in the past year. Many smokers try to quit without assistance and only 3% to 6% are successful 1 year later without assistance.

This article reviews the current therapies available to encourage and assist patients with smoking cessation. It covers the 5 As (ask, advise, assess, assist, arrange) algorithm of counseling, pharmacotherapy, behavioral therapy, and combination therapy for smoking cessation.

Five A’s

Because such a significant percentage of the population smokes, dentists play an important role in identifying smokers and assisting them in their quitting efforts. The 5 As is an algorithm recommended by the US Department of Health and Human Services for clinicians to use to help their patients quit.

Ask

At each visit, it is important to ask about the patient’s tobacco use. For those who use tobacco, a thorough history should be taken that includes the amount, products used, and previous attempts to quit.

Advise

The US Department of Health and Human Services recommends that patients be advised to quit at each clinical encounter. There is evidence that brief clinician advice can increase quit rates by 1% to 3%.

Assess

At each visit, dentists should assess whether the patient is ready to quit at that moment.

Assist

For the patients who are ready to quit, the clinician should provide resources and information on treatment to help the patient quit. It is important to review whether the patient has previously attempted to quit and what methods have been used. It is also important to help patients address any barriers to quitting that they may have.

Arrange

For those patients who are willing to quit, it is important to arrange follow-up contact within 1 week in order to prevent relapse. The follow-up should provide reinforcement for the patient and assess the response to pharmacotherapy as well as any side effects the patient may experience. For those that are unwilling to quit, it is important to ask, advise, and assess at the next clinical visit, because this should be completed at every clinical visit.

Pharmacotherapy

Tobacco products contain the highly addictive substance nicotine, which causes dopamine release and leads to physical dependence and tolerance. After long-term use, patients may smoke to control withdrawal symptoms rather than for its positive effects. Common nicotine withdrawal symptoms include increased appetite, weight gain, dysphoria, insomnia, irritability, anxiety, restlessness, and difficulty concentrating.

Nicotine replacement therapy (NRT), buproprion, and varenicline are first-line pharmacologic therapies to assist with smoking cessation recommended by the US Department of Health and Human Services. Table 1 summarizes the dosing and side effects of these medications.

Table 1
First-line pharmacologic agents for smoking cessation
Drug Dosing Side Effects
Nicotine patch
  • Half a pack per day:

    • 21 mg patch/day for 6 weeks

    • 14 mg patch/day for the next 2 weeks

    • 7mg patch/day for the next 2 weeks

  • Half a pack per day or <45 kg (99lbs):

    • 14mg patch/day for 6 weeks

    • 7mg patch/day for the next 2 weeks

  • Headache

  • Nausea and vomiting

  • Diarrhea

  • Abdominal pain

  • Skin sensitivity and irritation

  • Vivid dreams

  • Insomnia

Nicotine gum
  • >25 cigarettes per day:

    • 4-mg dose

  • <25 cigarettes per day:

    • 2-mg dose

    • 1 piece of gum every 1–2 h for 6 wk

    • Tapered to 1 piece every 2–4 h then every 4–8 h over the next 6 wk

  • Headache

  • Nausea and vomiting

  • Diarrhea

  • Abdominal pain

  • Oral mucosa irritation and ulceration

  • Temporomandibular joint disease

Nicotine lozenge
  • Smokes within 30 min of waking:

    • 4-mg lozenge

  • Smokes after 30 min of waking:

    • 2-mg lozenge

    • 1 lozenge every 1–2 h for first 6 wk

    • Tapered to 1 piece every 2–4 h then every 4–8 h over the next 6 wk

  • Headache

  • Nausea and vomiting

  • Diarrhea

  • Abdominal pain

  • Oral mucosa irritation and ulceration

Nicotine inhaler
  • 6–16 cartridges per day for first 6–12 wk

  • Tapered gradually over the next 6–12 wk

  • Headache

  • Nausea and vomiting

  • Diarrhea

  • Abdominal pain

  • Local irritation to oropharynx

Nicotine nasal spray 1–2 sprays per hour for 3 mo
  • Headache

  • Nausea and vomiting

  • Diarrhea

  • Abdominal pain

  • Nasal and pharyngeal irritation

Buproprion
  • Begin 1 wk before quit date

  • 150 mg/d for first 3 d

  • 150 mg twice a day after first 3 d

  • Insomnia

  • Dry mouth

  • Nausea

  • Headache

  • Seizures

  • Neuropsychiatric symptoms

Varenicline
  • Begin one week before quit date

  • 0.5mg/day for first 3 days

  • 0.5mg twice/day for days 4–7

  • 1mg twice/day for 11 weeks

  • Nausea

  • Insomnia

  • Headache

  • Abnormal dreams

  • Neuropsychiatric symptoms

  • Cardiovascular events in patients with known cardiovascular disease

Only gold members can continue reading. Log In or Register to continue

Oct 28, 2016 | Posted by in General Dentistry | Comments Off on Medications to Assist in Tobacco Cessation for Dental Patients
Premium Wordpress Themes by UFO Themes