Tobacco Use and Cessation Topics

Tobacco Use Prevalence and Risks
  • Tobacco Use Prevalence/Risks/Benefits of Cessation


    In 1965...42% of the US population used tobacco. Now US adult tobacco use is 20%.

    • Male adult rates went down 24% and female rates went down only 11% and more women start smoking.
    • African Americans have a slightly higher rate than whites.
    • Hispanic rates have increased but are lower than whites (15%).
    • Native American rates are higher than all other groups (33%).
    • Asian Americans have the lowest adult rates (11%).

    The really bad news: In the US over 1,100 adolescents become regular smokers every day.

    The prevalence of tobacco use has declined less in those who are younger, female, non-caucasian, less educated, or poor and those with psychiatric or alcohol/drug problems.

    Smokeless (Spit) tobacco use:
    3% of adult Am males and less than 1% of females use Spit tobacco.
    25% of young users start by the 6th grade and 75% start by the 9th grade.
    8% of high school seniors used in last month & 2-3% use daily.

    Cigar use:
    From 1989-93 there was a 133% increase in cigar smokers.
    Since '93 premium cigar sales (marketed to higher educated/ income individuals) have ↑ 154% but have now started to decrease.


    Tobacco kills more than 400,000 people in the US every year.
    Tobacco use causes more premature deaths than the combined total resulting from: cocaine, heroin, alcohol, fires, auto accidents, homicides, suicides, and AIDS.

    Risk of death

    • from terrorism: 1 in a million;
    • as a pedestrian: 1 in 40,000;
    • from auto accident: 1 in 5000;
    • from tobacco use: 1 in 3.

    Tobacco is responsible for 38% of all US cancer deaths, 30% of coronary heart disease, and 80-90% of chronic obstructive pulmonary diseases (emphysema and bronchitis).

    More females start smoking and therefore lung cancer has surpassed breast cancer as the leading cause of female cancer death.
    Pregnant women who smoke have an increased risk of: spontaneous abortions, fetal & infant deaths, premature births, underweight children, children with decreased lung function, and triggering development of cleft lip/palate.

    Environmental (Passive, Secondhand) Tobacco Smoke

    Secondhand smoke is the 3rd leading cause of preventable early death (behind smoking and alcohol). Passive smoke is almost as bad for fetal development as active smoking by pregnant women.

    Children whose parents smoke have more: colds, bronchitis, pneumonia, worsened asthma, impaired development of lung function, risk of ear infections, and more caries in deciduous teeth.

    Nonsmokers living with smokers have a increased risk of developing lung cancer and greater risk of dying early of heart disease.

    For every 8 smokers who die from smoking, one innocent bystander dies from passive smoke.

    Benefits of Cessation:

    Stopping tobacco use decreases the risk of: lung (and many other) cancers, coronary diseases, stroke, chronic obstructive lung diseases and periodontal disease.

    Being tobacco-free reduces the risk of: damage to children's health, ulcers, premature wrinkling of skin, infertility in women and impotence in men, cataracts, macular degeneration, burning your house down, being turned down by the opposite sex, killing your pets prematurely, poor athletic performance and reducing your spending money... to name just a few.

    Cessation can reduce the enormous cost of tobacco use: health care costs of treating tobacco related diseases and cost of lost earning due to disability and early death...approach $167 billion a year in the US.

Adolescent Tobacco Use
  • Tobacco Use: A Pediatric Disease

    Studies show that if people don't begin to use tobacco during adolescence, there is a good chance they never will. Eighty-nine percent of daily adult smokers began by age 18.

    Cigarette Use

    • 22 % of high school students in the US are current cigarette smokers – 21.9 % of females & 21.8 % of males.
    • 25 % of whites, 18 % of Hispanics, and 15 % of African Americans in high school are current cigarette smokers.
    • 8 % of middle school students are current cigarette smokers - females 9 % & males 8 %.
    • 9 % of whites, 10 % of Hispanics, 8 % of African Americans, and 3 % of Asian Americans in middle school are current smokers.
    • Each day, 3,900 young people between the ages of 12 and 17 initiate cigarette smoking in the US. In this age group, each day 1,500 young people become daily cigarette smokers.

    Other Tobacco Use

    • Nationally, 13 % of high school students and 5 % of all middle school students are current cigar smokers.
    • 10 % of males in high school and 4 % of males in middle school are current smokeless (spit) tobacco users.
    • The use of bidis, kreteks (clove cigarettes), and pipes among high school students was each about 3%. Bidis are the latest craze among teens. Bidis are cheap, unfiltered, flavored mini cigarettes imported from India. They produce 3X the amount of CO and nicotine and 5X the amount of tar than American cigarettes.

    Teens who smoke are 3X more likely to use alcohol, 8X more likely to use marijuana, and 22X more likely to use cocaine than nonsmokers. Illegal drug use is rare among those who have never smoked.

    Smoking during pregnancy increases the chance of a:

    • low-birth-weight baby
    • miscarriage
    • premature birth
    • stillbirth
    • sudden infant death syndrome (SIDS)
    • 6X greater chance of cleft palate formation

    Secondhand (passive) smoke from parents has an effect on their children:

    Increased risk of:

    • colds, pneumonia, bronchitis
    • middle-ear infections
    • increased severity of symptoms in asthmatic children
    • reduction in lung function
    • delayed development of permanent teeth by as many as 4 months
    • more caries in their deciduous teeth

    Personal characteristics of adolescent tobacco users:

    • low self-esteem, low aspirations, depression/anxiety, sensation-seeking

    Behavioral characteristics of adolescent tobacco users:

    • poor school performance, school absences, school drop-out, alcohol and other drug use

    Environmental characteristics of adolescent tobacco users:

    • cultural messages (advertising, role models in movies and music), peer tobacco use, parental tobacco use

    Smokeless (Spit) tobacco use by adolescents

    • 25% of young users start by he 6th grade and 75% start by the 9th grade
    • regular use often begins by age 12
    • use is more common among:
      athletes, males living in rural areas, Am Indians & Alaska Natives, those employed in the military & lumber industry, white males between 18-35, those living in Arkansas, Kentucky, So. Dakota, W. Virginia, Wyoming

    The average spit tobacco user dips 1 1/2 cans per week

    • under 1/2 can per week = light use
    • over 2 1/2 cans per week = heavy use

    One can delivers as much nicotine as 3 packs of cigarettes
    Nitrosamine content in spit tobacco is higher than in cigarettes

    Types of Spit Tobacco Products: Snuff and Chewing tobacco

    Snuff: finely ground or shredded form of tobacco sold in round tin cans
    Moist (most common form used by adolescents)
    Sachet (packaged similar to teabags and marketed as starter kits for youth)

    Chewing Tobacco: coarsely cut tobacco
    Loose leaf (shredded form sold in pouches)
    Plugs (bricks)
    Twists (rope-like strands)

    Health Implications of Spit Tobacco:

    • Addiction (nicotine is as addictive as cocaine or heroin)
    • Disease

    Major carcinogens in Spit Tobacco:

    • Nitrosamines, polynuclear aromatic hydrocarbons, radioactive compounds, metallic compounds
    • Nitrosamine concentration exceeds by >1000X the nitrosamine content allowed by the FDA in products like beer and bacon

    Spit tobacco risk of oral cancer

    • Early users: risk 4X greater than nonusers
    • Prolonged users: risk 48X greater than nonusers

    Incidence of dysplasia or carcinoma:

    • leukoplakia 5%
    • erythroplakia 90%

    >90% of lesions occur at the site where the dip or chew is held
    ST is dangerous...but Smoking is 2x more likely to cause oral cancer than smokeless tobacco.

    Nicotine in spit tobacco is buffered (increased pH) to facilitate absorption

    • absorption is slower than with smoking
    • peak concentration at 30 minutes
    • persistent absorption for up to 60 minutes after tobacco removed (slow release from mucous membrane and from swallowed nicotine)

    Other health implications

    • Spit tobacco may be a risk factor for severe active periodontal disease
    • Spit tobacco use is associated with risk factors for cardiovascular disease (elevated blood pressure and cholesterol levels)

    Methods of Treating Spit Tobacco Use

    • Behavioral and pharmacotherapy

    Predictors of high nicotine dependence in ST users

    • using ST within 30 minutes of waking
    • using ST when sick/mouth sores
    • ST in mouth more than 30 minutes
    • intentionally swallowing tobacco juice
    • ST in mouth most of the day
    • strong cravings when abstinent
    • greater than 15 dips per day

    Behavioral treatment

    • record use patterns (cans or pouches per week)
    • determine stage of readiness to stop use
    • recognize cues to use
    • recognize urges and withdrawal
    • develop coping skills
    • managing stress

    Behavioral skills

    • Avoidance (oral substitutes, alternative activities/distractions)
    • Cognitive (delay use)
    • Emphasize (health consequences-oral exam & social consequences)

    Literature review conclusions (Meta-analysis)

    • Behavioral interventions are effective for ST users
    • Zyban is probably effective for ST users
    • NRT may be effective for ST users
    • Among behavioral interventions, the use of an oral examination appears to be associated with greater treatment effect
Effects of Tobacco Use on the Oral Cavity
  • Tobacco Induced & Associated Oral Conditions


    Effects on teeth

    Other oral conditions

    Possibly associated with tobacco

    Tobacco Effects on Clinical Practice

    Effects on diagnosis, prognosis, and therapy

    • Periodontal therapy
    • Delayed wound healing
    • Implants
    • Dry socket
    • Sinusitis

    Effects on fitness for treatment

    • Immune system
    • Disability
  • Tobacco and Periodontal Diseases

    Smoking is a major risk factor for periodontal diseases

    • Both current and former smokers have an increased prevalence and severity of periodontal diseases
    • There is a significant positive association between the amount smoked and the severity of periodontitis
    • There is a linear and direct correlation between smoking and attachment loss with effects even at a low level of smoking
    • The periodontal status of former smokers ranks between current smokers and those who have never smoked
    • 86-90% of refractory periodontitis cases are smokers

    Clinical appearance of smoking-associated periodontitis

    • Gingiva tends to be fibrotic with thickened rolled margins
    • Minimal gingival redness or edema relative to disease severity
    • Relatively severe and widespread disease (more probing depth, attachment loss, and tooth loss) compared to a person the same age who never smoked
    • Proportionately greater pocketing in anterior and maxillary lingual sites
    • Gingival recession in anterior segments
    • No association between periodontal status and plaque or calculus scores

    From: Haber J Current Opinion in Periodontology 1994

    Smokeless (Spit) tobacco use increases the risk of localized recession but its effect on periodontitis is unclear

    Nicotine and other tobacco products produce local and systemic effects

    • Locally the cytotoxic and vasoactive substances from tobacco smoke can inhibit tissue perfusion and cell proliferation and metabolism
    • Systemically smoking causes immuno-suppression and impairment of soft tissue and bone cell function
    •      Impairs serum antibody response to some periodontal pathogens
    •      Alters PMN leukocyte function (effects rate of chemotactic migration and/or phagocytic activity)
    •      ↑ TNF-a and PGE2 in GCF
    •      ↑ neutrophil collagenase and elastase in GCF
    •      May be associated with reduction of skeletal bone mineral content
    •      May interfere with fibroblast attachment


    • The possibility that smoking might favor a specific periopathogenic microflora is still unclear
    • There are conflicting studies but there may be ↑ levels of periodontal pathogens in smokers vs. nonsmokers.

    Smoking delays wound healing

    • There is impaired healing and poorer clinical results to both nonsurgical (S/RP, locally delivered antibiotics) and surgical periodontal therapy of smokers vs. nonsmokers
    •       Less reduction of bleeding on probing
    •       Less reduction of probing depths (even with good oral hygiene)
    •       Smaller gain of attachment
    • Studies have found that smokers have less success with open flap debridement, osseous resection, soft tissue and bone graft procedures, and guided tissue regeneration procedures
    • The implant failure rate in smokers is significantly higher than in nonsmokers
    • Cigar and pipe smokers have similar adverse effects on periodontal health as cigarette smokers
    • The following may contribute to impaired wound healing
    •       Smoking impairs revascularization of bone and soft tissue
    •       PMN altered chemotaxis, phagocytosis, and adherence
    •       Altered antibody production
    •       Negative effect on bone metabolism may influence osteoporosis and periodontitis by similar mechanisms

    Smoking status should be considered in periodontal diagnosis, prognosis, and treatment planning

    • Smoking status is a clinically useful predictor of future disease activity
    • Smoking cessation should be considered a part of periodontal treatment

    The benefits of smoking cessation

    • Periodontal status stabilizes for a majority of patients and attachment loss ceases or slows
    • It may take a number of years after cessation before the rate of tooth loss is similar to that of nonsmokers

    For more indepth information relevant to tobacco use and periodontal diseases, please refer to the the American Academy of Periodontology Position Paper.

    Tobacco use is an oral health problem and the dental office is a logical place for a tobacco cessation program….and the entire office team should be involved

Fact Sheets
  • Smokeless Tobacco Facts

    Types of Smokeless (Spit) Tobacco
    The two types of smokeless tobacco (ST) are chewing tobacco and snuff. Chewing tobacco is sold in loose leaf, twist and plug forms. Snuff comes in moist, dry and sachet forms. The most popular form of ST today is moist snuff.

    Of the estimated 10 million users of ST, 3 million are under the age of 21.
    Almost 25% of young users start by the 6th grade, and almost 75% start by the 9th grade. In 1970, young males ages 17-19 used ST the least of any age group. Today, usage by males of these ages is the highest of any age group.
    More than 3% of adult American males, and less than 1% of females, use ST.
    Among US youth in grades 9-12, 8% use ST at least once a month and 2-3% use daily.

    Tobacco Industry Advertising and Promotion
    The tobacco industry has targeted male adolescents with its aggressive advertising. Ads associate ST with rodeos, rock stars, and sports heroes. ST companies sponsor rock concerts, rodeos, auto racing and tractor pulls.

    Risks of Smokeless Tobacco Use
    Spit tobacco is not a safe substitute for smoking. It can cause oral cancers and lead to addiction.
    The major carcinogens in ST are nitrosamines, polynuclear aromatic hydrocarbons, and radioactive and metallic compounds. The nitrosamine content of ST exceeds beyond 1000X the nitrosamine content allowed by the FDA in products like beer and bacon.
    ST is also associated with cancers of the esophagus, larynx, and stomach, and an increased risk of heart attacks and other cardiovascular diseases.
    40-60% of ST users exhibit leukoplakia in the area where the quid is held, usually within a few months of beginning regular use.
    Leukoplakia is regarded as precancerous with a malignant transformation rate of 2-6%.
    Other oral side effects of ST include gingival recession, staining of teeth, loss of taste, and bad breath.
    Chewing tobacco users have an increase in dental caries due to the higher sugar content in this ST product.
    ST is dangerous...but Smoking is 2x more likely to cause oral cancer than smokeless tobacco.

    The nicotine in ST is absorbed directly into the bloodstream and is addicting.
    Spit tobacco users have similar, or even higher, levels of nicotine than smoker who use a pack or more a day.
    Withdrawal from regular ST use results in the same withdrawal symptoms and discomfort seen in heavy smokers attempting to quit.
    Manufacturers of ST products have altered the nicotine content and pH, added flavors, and packaged moist snuff in sachets as starter products. These products gradually move novice users on to higher levels of nicotine addiction as their tolerance increases.

  • Cigar Facts

    Cigar smoking is not a safe alternative to cigarette smoking..
    A cigar is a nicotine delivery device - a product with serious health risks.

    Types of Cigars

    Little (1.3-2.5g, 70-120mm)
    Small (Cigarillos)
    Regular (Large) (5-17g, 110-150 mm, 17mm diameter)
    Premium (can contain as much tobacco as 15-20 cigarettes)


    US consumption of cigars has increased dramatically since 1993. The fastest growing segment of the cigar market has been the premium cigar category where sales have increased by 154% since 1993 but have not started to decrease.

    In 1990 the small percentage of current cigar smokers was distributed fairly evenly by education status. By 1996 more educated males had increased their use of cigars. The most highly educated had more than doubled their rate of current cigar use.

    There has been an increase in cigar smoking among 18-24-year-olds (a threefold increase) and 25-44-year-olds (a twofold increase). There also appears to be an increase in cigar use in ages 14-19.

    Currently, cigar use among adolescent males exceeds the use of smokeless tobacco in several states. This use is occurring among both males and females.

    Risks of Cigar Use

    Compared to a cigarette, a large cigar emits 20X more ammonia, 10X more cadmium, and 90X more nitrosamines specific to tobacco.
    Cigar smoke contains more than 4,000 chemical components, including over 50 known human carcinogens.
    Cigar smokers have a 2-10X greater risk of oral, laryngeal, and esophageal cancers and a 5-11X greater risk of lung cancer than do non-smokers.
    Cigar smokers are 5X more likely to get emphysema than non-smokers.
    Cigars are also associated with coronary heart disease and the risk depends on the depth of inhalation and on the number of cigars smoked per day.
    Nicotine does not have to be inhaled to damage the heart and blood vessels. Mainstream cigarette smoke is slightly acidic. Mainstream cigar smoke is alkaline and therefore it is effectively absorbed into the blood stream through the oral mucosa.
    Cigar smokers have an increased risk of periodontal diseases (alveolar bone loss and tooth loss) similar to cigarette smokers.
    Cigar smokers often suffer from badly stained teeth and dental restorations, chronic bad breath, and impaired wound healing.
    Secondhand cigar smoke is more dangerous than secondhand cigarette smoke. A single smoking cigar in an unventilated room produces the equivalent air pollution of 42 burning cigarettes.
    The average cigar emits 3X as much carcinogenic cancer causing matter and 30X as much carbon monoxide as one cigarette.
    This secondhand smoke adversely effects the health of non-smokers including children, adults, and pets.

  • Secondhand Smoke Facts

    Secondhand smoke, also known as passive or environmental tobacco smoke (ETS), is a combination of:

    • Mainstream smoke: exhaled by smokers
    • Sidestream smoke: given off by the burning end of a cigarette, cigar, or pipe

    Between 70% and 90% of non-smokers in the American population, children and adults, are regularly exposed to secondhand smoke. It is estimated that only 15% of cigarette smoke gets inhaled by the smoker. The remaining 85% lingers in the air for everyone to breathe. If a person spends more than two hours in a room where someone is smoking, the nonsmoker inhales the equivalent of four cigarettes.
    Secondhand smoke is the third leading preventable cause of disability and early death (after active smoking and alcohol) in the United States. For every eight smokers who die from smoking, one innocent bystander dies from secondhand smoke.

    Secondhand smoke contains over 4000 chemicals including more than 40 cancer causing agents and 200 known poisons.
    Secondhand smoke has been classified by the EPA as a Class A carcinogen - a substance known to cause cancer in humans.
    Secondhand smoke contains twice as much tar and nicotine per unit volume as does smoke inhaled from a cigarette. It contains 3X as much cancer-causing benzpyrene, 5X as much carbon monoxide, and 50X as much ammonia. Secondhand smoke from pipes and cigars is equally as harmful, if not more so (Mayo Clinic release, Aug 97).

    Over the past two decades, medical research has shown that non-smokers suffer many of the diseases of active smoking when they breathe secondhand smoke.
    Secondhand smoke causes lung cancer and contributes to the development of heart disease. Never smoking women who live with a smoker have a 91% greater risk of heart disease. They also have twice the risk of dying from lung cancer.
    Never-smoking spouses who are exposed to secondhand smoke have about 20% higher death rates for both lung cancer and heart disease.
    Secondhand smoke increases heart rate and shortens time to exhaustion. Repeated exposure causes thickening of the walls of the carotid arteries (accelerates atherosclerosis) and damages the lining of these arteries.

    When a pregnant woman is exposed to secondhand smoke, the nicotine she ingests is passed on to her unborn baby.
    Women who smoke or are exposed to secondhand smoke during pregnancy:

    • have a higher rate of miscarriges and stillbirths
    • have an increased risk of low birthweight infants
    • have children born with decreased lung function
    • have children with greater risk of sudden infant death syndrome (SIDS)

    Children exposed to secondhand smoke are more likely to experience increased frequency of:

    • asthma, colds, bronchitis, pneumonia, and other lung diseases
    • middle ear infections
    • sinus infections
    • caries in deciduous teeth

    Ventilation systems and designated smoking sections do not protect patrons from ETS.
    Current estimates of how smoking increases the risk of various diseases are dramatically underestimated because the ill effects of secondhand smoke inhalation are not taken into account.

  • Hazardous Chemicals in Smoke

    If you are exposed to hazardous chemicals you have the right to be informed of their effects. Occupational Safety and Health Administration

    With each puff of smoke, the body is exposed to over 4000 chemicals, over 50 of which are know to cause cancer.

    A few of the chemicals in cigarette smoke are listed below.

    Compound Released Additional Information about Compound
    Nicotine Insecticide/addictive drug
    Cresol Main ingredient for industrial plastics and adhesives
    Pyrene A main constituent of coal tar
    DDT A pesticide that has been banned from use
    Carbon Monoxide Bonds with oxygen in blood cells to cause suffocation, Car exhaust fumes
    Ammonia Used for stripping wax from floors, removing varnish, Often a toilet bowl cleaner
    Hydrogen Cyanide A fumigation poison banned from international use
    Acetone Main ingredient in fingernail polish remover
    Methanol Used as rocket fuel
    Formaldehyde Embalming fluid
    Butane Cigarette lighter fluid
    Naphalene Moth balls
    Nitrobenzene Gasoline additive
    Arsenic Poison
    Cadmium Found in batteries
    Toluene Industrial solvent
    Isoprene Natural base for tire rubber

Nicotine Addiction & Stages of Change
  • Nicotine Addiction
    • Physiological dependence:
    • Tolerance
    • Dependence
    • Withdrawal symptoms
    • Psychological dependence:

    Smokers continue to smoke for a number of psychological reasons:

    • Stimulation
    • Tension reduction
    • Handling
    • Habit
    • Pleasurable relaxation
    • Craving

    • Sociocultural Factors:
    • Social activity
    • Numerous daily rituals
    • Family origin and cultural practices

    Human genetics, early family experiences, environmental factors and societal influences appear to work together in complex ways, to set the addictive cycle in motion.

    At times tobacco can act as a stimulant and at other times it may produce tranquilizing effects.


    Nicotine combines with a number of neurotransmitters in the brain and may contribute to the following effects:



    Pleasure, suppress appetite


    Arousal, suppress appetite


    Arousal, cognitive enhancement


    Memory improvement


    Mood modulation, suppress appetite


    Reduce anxiety / tension


    Tobacco is as addictive as heroin (as a mood & behavior altering agent).

    Nicotine is:

    • 1000 X more potent than alcohol
    • 10-100 X more potent than barbiturates
    • 5-10 X more potent than cocaine or morphine

    A 1-2 pack per day smoker takes 200-400 hits daily for years. This constant intake of a fast acting drug (which affects mood, concentration & performance).. eventually produces dependence.

    Pressures to relapse are both behaviorally & pharmacologically triggered.

    Quitting involves a significantly serious psychological loss... a serious life style change.

    Possible withdrawal symptoms (after stopping tobacco use):

    • Irritability, anger, hostility, anxiety, nervousness, panic, poor concentration, disorientation, lightheadedness, sleep disturbances, constipation, mouth ulcers, dry mouth, sore throat-gums- or tongue, pain in limbs, sweating, depression, fatigue, fearfulness, sense of loss, craving tobacco, hunger, and coughing (body getting rid of the mucus clogging the lungs).
    • Symptoms may last from a few weeks to several months. After withdrawal subsides... urges for nicotine (for the effects of the drug) occur in response to all kinds of cues to smoke or chew.
  • Stages of quitting

    Tobacco users go through stages of quitting:

    Pre contemplation (60% of users are in this stage)
    These tobacco users deny having a problem and have no intention of quitting. These are the "get out of my face" tobacco users. Raising their awareness of the oral effects of tobacco in a very low-key, sensitive approach may help. It is important to let them know that your office would be happy to help them if they ever do become interested in quitting.

    Contemplation (32% of users are in this stage)
    Contemplators know they have a problem. They would like to quit someday but they have no commitment to take action now. They may have indefinite plans to quit within 6 months or so. People can remain stuck in this stage for years.

    Preparation for Action (8% of users are in this stage)
    Tobacco users in this stage are ready to quit within the next month but they have not necessarily resolved their ambivalence. They have reasons to quit and may have tried in the past.

    Action (Normally takes 3 to 6 months to complete)

    Maintenance (May last for 6 months to a lifetime)

    Possible Relapse (and through the cycle again; the majority of relapsers do not go all the way back to pre contemplation)

    Our advice and support in the dental office can encourage tobacco users to go through the stages of change until they are successful.

    Even if they are unable to quit, they are further on their way -- for it takes many people a number of attempts, sometimes over many years, before they are successful.

    You must have patience, a sensitive manner, and a chronic mindset when trying to help tobacco using patients.

  • How to help in various stages of change


    • Increase awareness of need to change
    • Give personalized information (benefits of quitting)
    • Encourage thinking about change
    • Offer to help if they do decide to change


    • Motivate and increase confidence
    • Emphasize benefits of change
    • Explore concerns and fears
    • Help resolve ambivalence


    • Help individualize a plan for change
    • Set realistic goals
    • Provide options
    • Provide and have patient seek social support


    • Reaffirm commitment and follow-up
    • Teach behavioral skills
    • Provide educational materials
    • Note benefits
    • Celebrate success and use rewards
    • Continue follow-up


    • Encourage to plan for potential difficulties
    • Use support network


    • Assist in coping and facilitate another attempt
    • Overcome shame and guilt
    • Use relapse as a learning experience
    • Analyze what went wrong
    • Emphasize persistence
Benefits of quitting
  • Benefits of quitting
    1. You won't expose children, family, friends, and coworkers to secondhand smoke.
    2. The smell of tobacco won't cling to your clothes, hair, and fingers.
    3. You'll feel energized and have more stamina.
    4. The chance of causing a fire while you smoke is eliminated.
    5. The chronic irritation of your larynx (throat) is reduced. Your speaking voice may improve.
    6. Your shortness of breath and cough decrease.
    7. You reduce your risk of developing an ulcer.
    8. Your children are less likely to have bronchitis and pneumonia.
    9. Nonsmokers are more acceptable in public places and in homes of friends who don't smoke.
    10. If you are a woman using birth control pills, you reduce your risk of stroke.
    11. Nonsmokers on average have fewer colds.
    12. You'll reduce your risk of disability and death from coronary heart disease and lung diseases such as cancer, chronic bronchitis, and emphysema.
    13. Your circulation will improve.
    14. When you stop buying cigarettes, you'll have more spending money.
    15. You'll look and feel healthy and have a new sense of personal control.
    16. For women, your risk of having a low birth weight infant is reduced. Your infant's risk of SIDS (Sudden Infant Death Syndrome) will decrease.
    17. Your sense of smell and taste will improve.
    18. Women will reduce their risk of infertility and men their risk of impotence.
    19. You'll be less likely to develop deep lines around the corners of your mouth and eyes.
    20. Your teeth won't be stained and yellow.
    21. You'll reduce your risk for periodontal disease (bone loss around your teeth).
    22. Your wounds will heal quickly and you'll recover from surgery faster than a smoker.
    23. You'll save children the risk of increased caries in deciduous teeth and delayed formation of their permanent teeth caused by tobacco smoke exposure.
  • What happens after you quit smoking

    Within 20 Minutes...

    • Blood pressures drops
    • Pulse rate drops to normal
    • Body temperature of hand and feet increases to normal

    Within 8 hours...

    • Carbon monoxide level in blood drops to normal
    • Oxygen level in blood increases to normal

    Within 24 hours...

    • Chance of heart attack decreases

    Within 48 hours...

    • Nerve endings start regrowing
    • Ability to smell and taste is enhanced

    Within 2 weeks to 3 months...

    • Circulation improves
    • Walking becomes easier
    • Lung function increases up to 30%

    Within 1 to 9 months...

    • Coughing, sinus congestion, fatigue, and shortness of breath decrease
    • Cilia regrow in the lungs, increasing the ability to handle mucus, clean lungs and reduce infection
    • Body's overall energy increases

    Within 1 year...

    • Excess risk of coronary heart disease is half that of a smoker

    Within 5 years...

    • Stroke risk is reduced to that of a nonsmoker 5-15 years after quitting
    • Risk of cancer of the mouth, throat and esophagus is half that of a smoker

    Within 10 years...

    • Lung cancer death rate about half that of a continuing smoker's
    • Risk of cancer of the mouth, throat, bladder, kidney and pancreas decreases

    Within 15 years...

    • Risk of coronary heart disease is that of a nonsmokers
Dependency Questionnaires
  • Fagerstrom Nicotine Dependency Questionnaire

    1. How soon after you wake up do you smoke your first cigarette? (circle appropriate number)



    a. Within 5 minutes

    b. 6-30 minutes

    c. 31-60 minutes

    d. After 60 minutes





    2. Do you find it difficult to refrain from smoking in places where it is forbidden (such as churches, theaters, libraries, etc.)?

    a. Yes

    b. No



    3. Which of all the cigarettes you smoke in a day is the most satisfying?


    a. The first one in the morning

    b. Any other



    4. How many cigarettes do you smoke a day?




    a. 10 or less

    b. 11-20

    c. 21-30

    d. 31 or more





    5. Do you smoke more in the morning than during the rest of the day?


    a. Yes

    b. No



    6. Do you smoke if you are so ill that you are in bed most of the day?


    a. Yes

    b. No




    Your Score =



    Score Results:

    0-5 = low to moderate nicotine dependence

    6-10 = high nicotine dependence

  • Why Do You Smoke?
Pamphlets and Quit Programs
  • Tobacco Cessation Pamphlets

    Smoking Cessation:

    Pamphlet Name

    Pamphlet Number

    Clearing the Air

    NCI: 1-800-4-CANCER #P133 (free)

    Why do you smoke?

    NCI: 1-800-4-CANCER #P145 (free)

    Smart Move! A Stop Smoking Guide

    ACS: 1-800-227-2345 # 2515 (free)

    Thinking about quitting smoking?

    ADA: 1-800-947-4746 # W126 ($39/100)

    Tobacco & Periodontal Diseases

    AAP: 1-312-573-3253 ($50/100)

    Want 3 good reasons to quit smoking?

    ACS: 1-800-227-2345 # 2719 (free)

    Why start life under a cloud?

    ACS: 1-800-227-2345 # 2717 (free)

    The smoke around you

    ACS: 1-800-227-2345 # 2060 (free)

    When smokers quit

    ACS: 1-800-227-2345 #5602 (free)

    Cigar smoking

    ACS: 1-800-227-2345 #2603 (free)


    Smokeless Tobacco:


    Pamphlet Name

    Pamphlet Number

    Quitting spitting

    ACS: 1-800-227-2345 # 2090 (free)

    Smokeless Tobacco... THINK Before you Chew

    ADA: 1-800-947-4746 # W190 ($39/100)


    Telephone Counseling:

    Pamphlets describing the Minnesota's toll-free Tobacco Helpline (Quit Plan) can be ordered by calling 952-767-1400.

  • Quit Tobacco Programs

    The following list is an example of quit programs that can be given to tobacco users interested in being tobacco-free. Use the quit programs that are in your community.

    Community Programs

    Minnesota's toll-free Tobacco Helpline (Quit Plan: 1-888-354-7526)
    Free, one-on-one telephone counseling, a quitting plan designed for you, information on medications and quitting techniques. Free nicotine replacement products are provided to those without medical insurance coverage for tobacco cessation medications if they go through the tobacco counseling sessions.

    American Lung Association
    "Freedom from Smoking" 8 session program
    Metro & greater MN: 651-227-8014
    Classes available in your community. Call for locations.

    Nicotine Anonymous (12 step counterpart to AA) (click on meetings for a list of meetings in your area)

    Internet Programs

    For smokers:
    For smokeless tobacco users:

    Inpatient Program

    Mayo Nicotine Dependence Center
    8 day residential program
    Rochester, MN
    Referrals: 1-800-344-5984 or (507) 266-1930

    This list of Quit Smoking Programs is for your information. Please contact the program directly for information and to determine if it meets your needs.

Clinical Practice Guideline
  • AHRQ Clinical Practice Guideline

    The Agency for Healthcare Research and Quality guidelines were developed by a panel of tobacco dependence treatment experts. The panel reviewed over 6000 scientific articles that addressed the assessment and treatment of tobacco dependence, nicotine addiction, and clinical practice.

    Findings and recommendations for treating tobacco use and dependence:

    • Tobacco dependence is a chronic condition that often requires repeated intervention.
    • Because effective tobacco dependence treatments are available, every patient who uses tobacco should be offered at least one of these treatments.
    • It is essential that clinicians and health care delivery systems (including administrators, insurers, and purchasers) institutionalize the consistent identification, documentation, and treatment of every tobacco user seen in a health care setting.
    • Brief tobacco dependence treatment is effective, and every patient who uses tobacco should be offered at least brief treatment.
    • There is a strong dose-response relation between the intensity of tobacco dependence counseling and its effectiveness.
    • Three types of counseling and behavioral therapies were found to be especially effective and should be used with all patients attempting tobacco cessation:
    •      Provision of practical counseling (problem solving/skills training)
    •      Provision of social support as part of treatment (intra-treatment social support)
    •      Help in securing social support outside of treatment (extra-treatment social support)
    • Numerous effective pharmacotherapies for smoking cessation now exist. Except in the presence of contraindications, these should be used with all patients attempting to quit smoking.
    • Tobacco dependence treatments are both clinically effective and cost-effective relative to other medical and disease prevention interventions.

    For more in depth information relevant to the AHRQ Treating Tobacco Use and Dependence: A Clinical Practice Guideline, please refer to The U.S. Public Health Service Report

  • Why Be Involved / Barriers

    As oral health care professionals:

    • We have interviewing skills
    •      Ability to assess patient tobacco use and motivation to quit
    • We have educating skills
    •      We can relate tobacco use to medical and dental conditions and treatment results
    • We have motivating skills
    •      The trust and rapport we build with our patients is essential to help change behavior
    • We have counseling skills
    •      Listening, encouraging, and supporting skills
    • The patient follow-up procedures have always been an important part of dental practice
    • A system in the office / clinic can be brief, simple and does not need to disrupt the practice routine.
    • Expanding our professional skills to include tobacco use cessation is an excellent practice builder. This service can strengthen the office / clinic-patient bond and lead to increased patient referrals.
    • Helping patients to free themselves of their addiction is extremely rewarding and can give the dental team members a deep sense of satisfaction. Brief tobacco cessation interventions may take only a small amount of office time, but when successful, may greatly improve disease and treatment prognoses while adding years and improved quality to patients' lives.

    Major barriers to using tobacco cessation in practice


    Some health care professionals:

    • Don't believe it is their area of responsibility...But tobacco use is a significant oral health problem
    • Are concerned patients will complain / or leave their practice...But patients appreciate the help and concern if approached in a low-key, nonjudgemental, and sensitive manner.
    • Think it takes too much time...But interventions can be brief, simple and do not need to disrupt the practice routine.
    • Feel that they can't be reimbursed for this service...But fees can be included in initial exam or treatment services, or if more time is spent, separately charged.
    • Are concerned about effectiveness of the program...But don't see efficacy of multiple interventions.
    • Feel uncomfortable because of lack of training...But this is slowly beginning to change.
Successful Patient Interactions
  • How To Help Your Patients To Be Tobacco Free

    Ways To Ensure Successful Interactions With Patients

    1. Create a non-threatening, caring interpersonal atmosphere.
          Friendly facial expressions.
          Soothing environment.
          Calm voice
    2. Approach inquiry about tobacco use as you would other routine health history questions.
    3. Be gentle when advising the patient to abstain.
    4. Establish direct eye contact with the patient and verbalize your concerns for his/her well-being.
    5. Personalize your advice.
    6. Address the benefits of cessation. Dwelling only on potential harm from continued use may place the patient on the defensive or arouse guilt.
    7. When showing the patient oral effects from tobacco use, present the findings in a gentle non-threatening, informational manner. Assure the patient that the condition will likely improve after s/he quits, if indeed that prospect is expected.
    8. If the patient is not interested at this time, let the patient know that you would like to be contacted should s/he reconsider. Be kind and non-judgmental when delivering this message.
  • Tobacco Users Common Questions & Concerns

    I want to quit but a cigarette is my closest companion and friend. I have them with me wherever I go. What am I going to have to do to get them out of my life?

    One thing that you can do is to list your reasons for wanting to quit and review them during the quitting period. Making plans for how to deal with problems you will encounter before you quit is important. Think about your triggers to smoking and what you can do instead of lighting a cigarette at those times. Think about the routines and rituals associated with your smoking that you will need to change during the process of quitting. If you are interested, study some of the quit tips and suggestions in the pamphlets that you may take with you.

    I just don't think I can do it. I tried to quit once. I was so irritable and was only able to stop for two weeks.

    Most people do not succeed the first time they try to quit, but many are successful if they continue to try. Most users make several attempts before succeeding. The fact that you have tried, and were able to go for two weeks is very positive. You are closer to being tobacco-free. Think about your quit attempt. What worked---what didn't---and use that experience to plan for your next attempt. There are a number of medications that can help to reduce the withdrawal symptoms. We can talk about the different options if you like.

    This is a bad time for me to try to quit. I am way too busy and have too much stress in my life right now.

    Using tobacco doesn't help with stress. It just relieves the nicotine withdrawal symptoms when you haven't used tobacco for a while. It is common to use tobacco when things get tough because of your dependence on nicotine. Once you are tobacco-free your stress levels will eventually fall below what they were as a stressed-out tobacco user.

    I smoke only low tar/nicotine cigarettes. I know they are healthier for me.

    People who use low tar/nicotine cigarettes smoke more cigarettes and inhale more often and more deeply to compensate for low nicotine levels in these cigarettes. They end up getting the same tar/nicotine levels as they would with higher tar/nicotine brands.

    My spouse (closest friend) smokes.

    Is he/she willing to stop when you do? If not, ask him/her to assist you in your effort. Ask him/her not to smoke or leave cigarettes around you. Establish no smoking zones in the home. Explain that you are doing this for yourself and not to put any pressure on them.

    Won't I gain weight if I stop smoking?

    Many tobacco users gain weight when they quit, but it is usually less than 10 pounds. Don't attempt to diet when first stopping-that can be done when you are an established nonuser. Avoid high-calorie snacks. Exercise is an effective technique to help cope with withdrawal symptoms and life stress and also to help reduce weight gain. Some of the medications to help you quit may limit weight gain while you are taking them.

    My friend who quit smoking was very irritable and had a hard time concentrating. Will that happen to me if I quit?

    Irritability and loss of concentration are normal symptoms of nicotine withdrawal. Some users have few or no withdrawal and some have a number of symptoms. Some other physical and psychological withdrawal symptoms are nervousness, lightheadedness, sleep disturbances, fatigue, constipation, mouth sores, headache, hunger, depression, and cravings. Most symptoms pass within two to four weeks after quitting. If you do decide to quit, we can talk about different medications that can help to reduce withdrawal symptoms.

    I'm 60 years old. My body is too old to recover from years of smoking.

    Many of the effects of tobacco use are reversible after cessation, at any age. After quitting there is a decreased risk of many of the effects of tobacco use including cancer, heart conditions, lung diseases, and gum disease.

    Should I tell other people I'm trying to quit?

    Yes. You should enlist family, friends and coworkers who would be supportive.

    I use Copenhagen snuff. I thought I would be able to quit anytime I wanted to. I tried cold turkey but didn't last two days.

    Smokeless tobacco is as addictive as smoked tobacco, heroin, and cocaine. If you are interested, we will be glad to talk with you about another quit attempt, refer you to a helpline, and suggest to you some smokeless tobacco alternatives and medications that might be helpful. If we could help you quit, would you be interested?

  • How to communicate with tobacco using patients
  • Nicotine Replacement Products

    Developed to reduce or eliminate withdrawal symptoms so we can help individuals interested in quitting to plan for and deal with the psychological and behavioral (social) components of their addiction.

    Contraindications for nicotine replacement products: under age 18, women who are pregnant or nursing (nicotine gum is FDA approved for use in pregnancy), immediate post-myocardial infarction period, severe arrhythmias, severe or worsening angina. Use caution: hyperthyroidism, insulin-dependent diabetes, and active peptic ulcers. Stable coronary artery disease is not a contraindication.

    Nicotine Transdermal Patch

    Nicoderm CQ (OTC) 24 hr.......... 21, 14, 7mg......................6 wks / 2 wks / 2 wks
    Generic (OTC) 24 hr...........21, 14, 7mg..........4-8 wks / 2-4 wks / 2-4 wks
    Patch Contraindications: skin disorders; Side effects: itching, burning and/or
    erythema at the site of application, abnormal dreams, joint or muscle pain
    Cost: $3-4 a patch; Generic $2-3 a patch

    Nicotine Gum

    Nicorette polacrilex (OTC) 2mg if smoke <25 cigarettes per day; 4mg if smoke >25 per day
    Generic (OTC)
    Wk 1-6: (1) piece q 1-2 hrs; Wks 7-9 (1) piece q 2-4 hrs; Wks 10-12 (1) piece q 4-8 hrs
    Gum Contraindications: TMJ dysfunction; Side effects: GI distress, jaw soreness, burning in throat, hiccups
    Cost: $135-225 / month for 12 pieces per day

    Nicotine Nasal Spray

    Nicotrol NS (Rx) 10 ml bottles (10mg / ml)
    .5 mg each nostril..(do not inhale while spraying - nicotine absorbed in the nasal mucosal)
    1-2 doses/hr (up to 5) for 4-8 wks, 4-6 wks gradual reduction or abrupt; Bottle = 100 doses - lasts about 1 wk
    Spray Contraindications: chronic respiratory problems; Side effects: coughing, sneezing, nose running, eyes water
    Cost: $45-50 / bottle

    Nicotine Inhaler

    Nicotrol Inhaler (Rx) Kit with 42 cartridges...
    6-16 cartridges/day, gradual reduction after 12 wks..Nicotine is absorbed in the mouth - not the lungs
    Puff 1 cartridge for 5 minutes x 4
    Inhaler Contraindications: allergy to menthol; Side effects: throat irritation, coughing, headaches
    Cost: $45-50 for kit and 42 cartridges

    Nicotine Lozenge

    Commit nicotine lozenge (OTC) Kit with 72 lozenges
    2mg if first tobacco used 30 min. after waking; 4mg if first tobacco used within 30 min. of waking
    For first 6 wks use at least 9 lozenges per day. Let dissolve in mouth slowly (don't chew or swallow it)
    Move occasionally. Dissolves in 20-30 min. Do not eat or drink 15 min. before or during use.
    Lozenge Contraindication and Side effects are the same as for nicotine gum (except for jaw soreness)
    Cost: $ 145 / month for 9 pieces per day

  • Nicotine Transdermal Patch


    In the dental office, tobacco cessation can be offered as a natural extension of the other routinely delivered preventive and oral treatment procedures. If a patient has a desire to stop using tobacco, dentists may want to consider prescribing nicotine transdermal patches. Addicted patients may include those who smoke more than 25 cigarettes per day (or a can of snuff every 2 days); those who use tobacco within the first one-half hour of arising; those who find it difficult to refrain from smoking in nonsmoking areas; and those who have had withdrawal symptoms in previous attempts to quit.

    Nicotine patches were developed to help reduce or eliminate withdrawal symptoms for heavy tobacco users. These patches may help patients stop by allowing them to cope with the social and psychological aspects of not using tobacco without also going through nicotine withdrawal.

    It is important to note that patients seldom are successful in stopping tobacco use when using nicotine patches in the absence of appropriate advice, guidance, and follow-up. Dentists should have office tobacco cessation plans that include these services.

    Clinical trials assessing the nicotine patch have not turned up any severe adverse reactions. Transdermal nicotine is well tolerated systemically and topically. The most commonly reported side effects are temporary itching, burning, and/or erythema at the application site.

    Some symptoms (e.g., headaches, insomnia, dizziness) are found to occur as a result of nicotine withdrawal and not as a reaction to the medication. The dose-related adverse effects of transdermal nicotine therapy are mild-to moderate sleep disturbances (e.g., insomnia and abnormal, vivid dreams), dyspepsia, various myalgias and body aches, and increases cough. The incidence of almost all side effects decreases after a few days of treatment. Fewer than five percent of tobacco users stop patches due to side effects.

    The patch only provides nicotine at about half to two-thirds the level a person obtains by smoking, and without the more than 4,000 chemicals and gases found in cigarette smoke.

    Suggestions for Use:

    • Stop using tobacco before use of patch.
    • Patch is applied once every 24 hours to non-hairy, clean, dry site on the upper body or arm. Skin site should not be reused for a least one week.
    • Different brands vary in nicotine dose and recommended length of use.
    • All brands recommend a higher dose (21-22 mg) for the first 4-6 weeks. Some then use lower dose patches.
    • Lower initial dose may be used for patients with cardiovascular disease or those weighing less than 100 lbs.

    CONTRAINDICATIONS for Nicotine Patches

    • Under age 18
    • Women who are pregnant or nursing
    • Immediate post-myocardial infarction period
    • Patients with severe arrhythmia
    • Patients with severe or worsening angina pectoris
    • Use with CAUTION:
           insulin-dependent diabetes
           active peptic ulcers
           very high blood pressure
           severe skin conditions
           and kidney or liver disease
  • Using Nicotine Patch



    • This medicine should be kept out of the reach of children and pets.
    • Women: Nicotine patches should not be used with women who are pregnant or nursing.
    • When the patch is worn, nicotine is released through the skin into the bloodstream. Nicotine patches may help relieve symptoms of nicotine withdrawal such as irritability, frustration, anger, anxiety, difficulty in concentration, and restlessness.

    How to Apply a Patch

    (Read patient instructions that come with patches)

    1. Choose a non-hairy, clean, dry area of your body or the upper, outer part of your arm.
    2. Remove the patch from its protective pouch.
    3. Hold the patch at the edge and apply the sticky side to your skin. Press firmly with the palm of your hand for about 10 seconds. Wash your hands.
    4. After approximately 24 hours, remove the patch you have been wearing. Choose a different place on your skin to apply the next patch. Do not return to a previously used skin site for at least one week.
    5. Fold the used patch in half with the sticky side together. After you have put on a new patch, take its pouch and place the used, folded patch inside of it.

    If Your Patch Gets Wet

    Water will not harm the patch. You can bathe, swim, use a hot tub, or shower while wearing a patch.



    What to Ask Your Dentist

    Ask your dentist about possible problems with nicotine therapy. Be sure to tell your dentist about any medical problems including:

    * recent heart attack * overactive thyroid * skin diseases

    * severe or worsening heart pain * kidney or liver disease * stomach ulcers

    * rashes from adhesive tape or bandages * irregular heart beat * diabetes (insulin)

    * high blood pressure * allergies to drugs


    If You Are Taking Medicines

    Patch use, together with stopping smoking, may change the effect of other medicines. It is important to tell your dentist all the medicines you are taking.


    What to Watch For (Adverse Effects)

    You should not smoke while using the patch. It is possible to get too much nicotine (an overdose), especially if you use the patch and smoke at the same time. Signs of an overdose might include bad headaches, dizziness, upset stomach, drooling, vomiting, diarrhea, cold sweat, blurred vision, difficulty with hearing, mental confusion, and weakness. An overdose might cause you to faint.

    If Your Skin Reacts to the Patch

    When you first put on a patch, mild itching, burning, or tingling is normal and should go away within an hour. After you remove a patch, the skin under the patch might be somewhat red. Your skin should not stay red for more than a day. If you get a skin rash after a patch, or if the skin under the patch becomes swollen or very red, call your dentist. Do not put on a new patch.

  • Using Nicotine Gum

    Instructions for Use

    • No smoking or smokeless tobacco use while using nicotine gum
    • No acidic or hot beverages during or immediately before using Nicorette (ex. soft drinks, fruit juices, milk, beer, coffee, or tea)
    • Nicorette is not chewed like regular gum
    •        Chew very slowly until you sense a peppery taste or feel a slight tingling in your mouth - then stop chewing and "park" the Nicorette between cheek and gums
    •        After the taste or tingling is almost gone (about one minute), chew slowly again until the taste or tingling returns - then stop chewing and "park" the Nicorette again using a different location in the mouth
    • Chew each piece for 20-30 minutes and discard
    • Use adequate amounts, depending on your addiction
    •        10-16 pieces to no more than 30 pieces of 2-mg or 20 pieces of 4-mg gum per day
    • Maintain similar daily use patterns
    • Use for at least 3 to 6 months and then gradually reduce
    • Keep a supply available to prevent relapse

    Contraindications for Nicorette Use

    • Under age 18
    • Immediate post heart attack period
    • Life threatening arrhythmia and people with severe or worsening angina
    • Active TMJ disease
    • Pregnancy and those who may become pregnant
    • Use with caution: hyperthyroidism or insulin dependent diabetes

    Side Effects

    • GI distress: hiccups, nausea, gas (from chewing too fast)
    • Chewing problems: jaw ache, biting cheek, excess saliva, loss of fillings, loosened dentures
    • Other: burning sensation, bad taste, mouth ulcers
  • How to Use Nicotine Nasal Spray and Nicotine Inhaler

    How to Use Nicotine Nasal Spray

    Nicotrol NS

    Directions: Use nicotine nasal spray at the beginning of an urge to smoke. Do not sniff, swallow, or inhale while spraying. Tilt head slightly back while spraying. Wait two or three minutes before blowing your nose. Nicotine nasal spray is best absorbed through the lining of the nose, and it is not absorbed in the lungs.

    Dose: 1mg (one spray [0.5mg] in each nostril) at each application. Starting dose is one or two applications per hour (minimum of 8 applications per day and maximum of 40 per day). Do not use more than five times in one hour.

    Side effects: Nose and throat irritation, coughing, sneezing, nose running, eyes watering. These side effects usually lessen after using the spray for the first few days.

    How to Use Nicotine Inhaler

    Nicotrol Inhaler

    Description: The nicotine inhaler kit includes a plastic, reusable mouthpiece with nicotine impregnated plugs that are inserted into the mouthpiece for use. A better term for this product would be nicotine "puffer" since the nicotine is delivered through the lining of the mouth rather than the lungs.

    Directions: Separate the plastic mouthpiece into two parts. Place one nicotine cartridge into the mouthpiece and reassemble. Pushing the two pieces back together breaks the seal on either end of the cartridge. Puff on the mouthpiece when you experience a craving for a cigarette or begin to feel other withdrawal symptoms. Do not drink beverages just before or during use. The puffer is not as effective in cold weather.

    Dose: Usual dose 6-12 cartridges per day. Use at least 6 cartridges a day for the first 3-6 weeks. Puff one cartridge for 5 minutes x 4. Gradually taper use as withdrawal symptoms are reduced.

    Side effects: Throat irritation, coughing, headaches.

  • How to Use the Nicotine Lozenge

    Commit Nicotine Lozenge


    2mg if first tobacco is used 30 minutes after waking.
    4mg if first tobacco used within 30 minutes of waking.
    For first 6 weeks use at least 9 lozenges per day. Do not exceed 20 per day.


    Do not eat or drink 15 minutes before or during use.
    Let dissolve in mouth slowly...moving occasionally. Don't chew or swallow it.
    Dissolves in 20-30 minutes.

    Side effects:

    The most common side effects are insomnia, nausea, coughing and headache.
    If you consume the lozenge too fast or chew or swallow all or part of it, you may experience heartburn or indigestion.

  • Zyban: A Tobacco Cessation Aid

    Zyban is a non-nicotine aid to help people who want to quit using tobacco. It was initially developed and marketed as an antidepressant (Wellbutrin [bupropion hydrochloride]). Zyban is chemically unrelated to tricyclic, tetracyclic, selective serotonin re-uptake inhibitor, or other known antidepressant agents. It is presumed to act on the dopaminergic and/or noradrenergic pathways involved in nicotine addiction and withdrawal.

    Studies suggest that Zyban may be effective in helping people who want to stop using tobacco. Participating in a tobacco cessation program increases the chances of success.

    You should not use Zyban if you:

    • Have had seizures in the past
    • Have epilepsy or have a family history of epilepsy
    • Have had significant head trauma
    • Have had a stroke
    • Have had a brain tumor or brain surgery
    • Have or have had an eating disorder (bulimia or anorexia)
    • Are taking Wellbutrin/Wellbutrin SR antidepressants
    • Are taking a monoamine oxidase inhibitor (MAOI) antidepressant


    It is usally not recommended that Zyban be taken with other agents that may lower seizure threshold (e.g., antipsychotics, other antidepressants, theophylline and systemic steriods) or with Parkinson's disease medication.


    The most common side effects include:

    • Difficulty sleeping
    • Dry mouth

    Other possible side effects:

    • Headache, drowsiness, decreased appetite, dizziness, sweating, nausea, increased or iregular heart beat, agitation/anxiety

    Dose Instructions

    Start taking Zyban a week before you stop using tobacco
    Starting dose: one 150mg tablet in the morning for 3 days
    Then 2 tablets a day: one 150mg tab in the morning and one 150mg tab at least 8 hrs later
    Length of treatment will vary from 7-12 weeks
    May be taken with or without food
    Never take an "extra" dose of Zyban

  • Chantix: A Tobacco Cessation Aid

    Chantix (Varenicline) is a selective α4β2 nicotinic acetylcholine receptor partial agonist. Chantix has the potential to aid tobacco cessation by reducing the symptoms of nicotine withdrawal and blocking dopaminergic stimulation.


    • Use caution with Chantix in subjects with impaired renal function
    • Not recommended for use in patients under 18
    • Use during pregnancy only if the potential benefit justifies the potential risk to the fetus
    • Chantix has no clinically meaningful pharmacokinetic drug interactions

    Side Effects

    • Nausea (30%)
    • Sleep disturbances
    • Constipation / Voiting / Gas
    • Some reports of depression, agitation, and suicidal thoughts (although rare)
    • May cause worsening of psychiatric illness or cause an old psychiatric illness to reoccur

    Dose Instructions

    Chantix dosing should start one week before the quit date. Take after eating. Most people will keep taking Chantix for up to 12 weeks.

    • Day 1 to Day 3 . . . . . . . . . . White tablet (0.5 mg), 1 tablet each day
    • Day 4 to Day 7 . . . . . . . . . . White tablet (0.5 mg), twice a day, (1 in the morning and 1 in the evening)
    • Day 8 to end of treatment . . . . . Blue tablet (1 mg) twice a day, (1 in the morning and 1 in the evening)
  • Smoking and Drug Interactions

    Smoking cigarettes can alter the way individuals respond to various medications. Cigarette smoke contains hydrocarbons that can induce enzymes in the liver to make some drugs less effective.

    Smoking may reduce the effect of the following medications...and therefore a reduced dose may be required after smoking cessation:

    Analgesics: Smoking may reduce the effect of pain medications such as pentazocine (e.g.,Talwin) and propoxyphene (e.g.,Darvon).

    Antianxiety Agents: Smoking may reduce the effect of chlordiazepoxide (e.g.,Librium) and diazepam (e.g.,Valium).

    Antidepressants: Smoking may reduce the effect of tricyclic antidepressants such as imipramine, amitriptyline, desipramine, and nortriptyline.

    Antipsychotics: Smoking may reduce the effect of chlorpromazine, clozapine, and olanzapine.

    Propranolol: Smoking may inhibit the effect of propranolol (e.g.,Inderal). This is especially important if the propranolol is being used to reduce angina pectoris.

    Theophylline: Smoking may reduce the effect of this anti-asthmatic drug.

    Heparin: Smoking may reduce the effect of this anticoagulant drug. The response to oral anticoagulant drugs such as warfarin does not appear to be affected by smoking.

    Insulin: Nicotine suppresses insulin out from the pancreas.

  • Tobacco Cessation Pharmacotherapy Prescriptions
    Rx   Nicorette   2 or 4 mg
    Disp   starter kit (108)
    Sig   use as directed
    Refill 4 times

    Rx   Nicoderm CQ   21 or 14 or 7 mg
    Disp   # 14
    Sig   apply 1 Q 24 hrs
    Refill 4 times

    Rx   Nicotrol inhaler
    Disp   kit with 42 cartridges
    Sig   use as directed
    Refill 4 times

    Rx   Nicotrol NS
    Disp   10 ml bottle
    Sig   ad libitum
    Refill 3 or 4 times

    Rx   Commit lozenge   2 or 4 mg
    Disp   #72
    Sig   use as directed
    Refill 4 times

    Rx   Zyban 150 mg
    Disp   # 60
    Sig   one tab b.i.d.
    Refill 2 times

    Rx   Chantix
    Disp   Starting month PAX
    Sig   take as directed
    Refill 2 times: Continuing month PAX
  • Combined Use of Pharmacotherapy in Tobacco Use Cessation


    1st consider using the patch (better compliance & fewer side effects) before other NRT


    BUT certain pt characteristics such as:     pt preferences
    pt experiences (success or failure) with prior pharmo.
    co morbidities (e.g., psychiatric treat)
    degree of nicotine dependence
    may warrant use of gum, lozenge, spray, inhaler, or Zyban initially

    Method for using the patch recommended by the Mayo Clinic Nicotine Dependence Center:

    for less than 1/2 PPD.......7-14mg   < can/pouch ST per wk........14-21mg
    for 1/2 to 1 PPD..............14-22mg   1-2 per week.......................21-35mg
    for 1 to 2PPD..................22-44mg   2-3 per week.......................35-42mg

    Patch delivers 0.9mg/hr of nicotine...reaches daily peak approx 6 hrs
    If use more than 1 patch a day, put on at different times of the day

    Studies have shown better quit rates with combined therapy. Possible options include:

    For some you may consider:
     2 or 4mg gum or lozenge plus a nicotine patch
    The gum or lozenge gives a jump start + the patch
    Use the gum or lozenge for 2-4 wks...then patch only & gum or lozenge for back up as needed

    Can use: Zyban alone or Zyban plus a patch

    For those where handling is important: Nicotine inhaler plus a patch

    For highly dependent or where other comb. have not worked: Nicotine nasal spray plus a patch

    Addictive potential: 5-20% of nicotine gum users continues use after 1 year or more
    43% of nasal spray users continue to use at 1 year
    Not a problem with patch, inhaler, or Zyban

    Keep in mind compliance: Patch 82%, Gum 38%, Spray 15%, Inhaler 11%

    Clinical use CHECK LIST:
         Provide written instructions on proper use and give self help material
         Individualize the dose and duration
         Base the initial dose on smoking rate (or blood cotinine)
         Usual length of therapy is 6-8 weeks
         Return visit or phone calls at 1-2 week intervals
         Adjust dose and determine length of pharmo treatment based on patient response

    Pharmaceutical companies have developed support materials for those who purchase products
    NicodermCQ & Nicorette= Committed Quitters program
         (call 800#, answer Q's & receive personalized plan & calendar,
         newsletter, tip/strategies brochure)
    Zyban= Advantage Plan (1-800-822-6784) call or fill out Q that comes with starter kit

The Tobacco Industry Wars
  • Tobacco Industry Influence

    Tobacco is the only drug when used as intended by the manufacturer, leads to disability and early death.

    The tobacco cartel has a license to kill and these merchants of death are very much alive and flourishing. This industry has lied, defrauded, deceived and contributed to the early deaths of millions of people over the last 50 years. The tobacco companies kill Americans at the rate of one World Trade Center tragedy every 5 days. Tobacco products are without question the greatest weapons of mass destruction.

    The tobacco industry is in the nicotine delivery and addiction business and their only concern is profit...they are not concerned with the disability and premature deaths caused by the use of their products. The tobacco industry has known for over 40 years that nicotine is addicting and causes cancer, lung and heart diseases. They have altered the nicotine content and pH to make sure users become addicted early and stay addicted.

    The tobacco industry loses close to 5,000 customers EVERY DAY in the U.S. (3,500 who manage to quit and 1,200 who die from tobacco related diseases). They need new customers so they invest millions in philanthropy, public relations, grassroots organizing and political campaigns / lobbying.

    • Politicians are addicted to tobacco money. For many years the tobacco industry has had a stranglehold over Congress: political lobbying has led to tobacco being the least regulated consumer product in the U.S. - exempt from virtually every major U.S. health and safety law, until 2009.
    •        In 2009 the FDA was given authority to regulate tobacco products that may include banning harmful chemicals and reducing nicotine.
    •        Some of the hazardous chemicals released from tobacco are:
    •                    Carbon monoxide (car exhaust), ammonia (toilet cleaner), HCN (gas chamber poison), acetone (polish remover), methanol (rocket fuel), arsenic (poison), formaldehyde (embalming fluid), DDT (pesticide), butane (lighter fluid), naphthalene (moth balls), toluene (industrial solvent), methane (swamp gas), just to name a few.
    • Advertising and promotion - the tobacco industry continues to entice adolescents and adults into tobacco dependence by spending 11 billion a year (that is a "B" not an "M") on advertising and promotion: free samples/coupons, catalog mail order promotions, sponsorship of sports and cultural events. Ads make smoking look enjoyable, relaxing (stress reducing), fun, slim and sexy. Some 86% of adolescents who smoke prefer the three most heavily advertised brands. The FDA authority will try to eliminate ads and promotion to adolescents but the tobacco industry will continue to find ways around that.
    • Philanthropy - the tobacco cartel supports civil rights groups, women's groups, charities for homeless, literacy programs, and minority scholarships. These groups are heavily targeted by the industry for use of its products. Contributions are also made to organizations favored by key legislators.
    • Public relations / grassroots organizing - the industry attempts to create a positive image and a less negative image of their products by promoting themselves as champions of freedom to choose... but they can't defend continued tobacco use as free choice if the users were addicted. The industry paid researchers to alter scientific evidence - refuting the dangers of tobacco and secondhand smoke. Although today they have finally had to admit that tobacco use does lead to disease...but they still promote and sell their products.

    The U.S. tobacco companies are manufacturing more of their products overseas and use more foreign-grown tobacco in the cigarettes they make both here and abroad. This has allowed the U.S. companies to dramatically increase their overall sales, revenues and profits. Nearly 90% of all American-style cigarette tobacco (flue-cured and burley) is now grown by foreign farmers in at least 78 countries. Instead of just killing Americans, the tobacco companies can now kill people in China, Russia, Africa and many other countries by hooking them on tobacco when they're young.

    The Tobacco Wars

    The public health community and tobacco control organizations face the political, legislative and economic strength of the tobacco industry built over time by the incredible cash flow and profitability of their business. A number of organizations and groups are working on tobacco control. Their emphasis has been to:

    • reduce youth access to tobacco
    • reduce tobacco advertising and promotion and develop counter-advertising
    • increase the tobacco excise tax
    • eliminate secondhand tobacco smoke in all worksites
    • increase access to tobacco cessation programs & quitlines
    • increase cessation training of healthcare providers
    • recommend strong FDA authority over tobacco products
    • expand tobacco use prevention and cessation research
    • expand global tobacco control activities

    All of these have been shown to decrease tobacco through both prevention and cessation.

    Some of the organizations that are involved with tobacco control are:

    • Smokefree coalitions, Association for Nonsmokers (ANSR), ACS, ALA, AHA, Departments of Health, National Cancer Institute, Public Health Service, the World Health Organization and a number of youth against tobacco groups, to name a few.

    In the 1990s, states sued Big Tobacco and settled for $254 billion over 25 years. The portion of total state tobacco revenues (including settlements and taxes) used toward smoking prevention and cessation are a shameful 3 percent, nowhere near the federal guideline...and it continues to go down. After the settlement, the fall in consumption that resulted from the price increase may turn out to be temporary unless it is followed up with serious efforts by the states to fund anti-tobacco efforts.

    The state lawsuits against the tobacco industry were based on the fact that the tobacco companies engaged in antitrust conspiracy and consumer fraud. Some of the most important revelations of the State of Minnesota & BC/BS lawsuit were contained in the million of pages of previously secret internal documents made public in the trial.

    The tobacco industry has all the money and the lies, the tobacco control organizations the truth but little money. A number of positive things have come out of tobacco control efforts- but a great deal more needs to be done. The battle goes on.

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  • Last modified on June 28, 2012