Dr K Hill Senior Lecturer in Behavioural Science and Dental Public Health 2011-12

1. Dr K Hill Senior Lecturer in Behavioural Science and Dental Public Health 2011-12

2. Plan (smoking lectures) • Lecture 1- • Smoking prevalence & its health impact • Smoking behaviour • Why should dentists be involved with smoking cessation advice? • Lecture 2 Perio & smoking

3. Plan (cont) • Lecture 3 • types of interventions • 3 A’s • Lecture 4 • Practical approaches for the team & your patients (including nicotine replacement therapy & bupropion) • Small group teaching • Assessment ~ OSCE

4. Aims and objectives • Aim: to present an overview of smoking cessation and its relevance to dentistry. • Objectives – to: • Describe patterns of tobacco use in the UK • Summarise the health consequences of tobacco use • Outline a range of factors influencing smoking

5. Opportunities • Strong links between tobacco use and oral health • Pathology – reversible early stages • Appearance/social attractiveness • Contact with public • ‘Healthy’ adults • Young people • Pregnant women • High level of awareness within dental profession

6. PATTERN OF TOBACCO USE

7. Pattern of tobacco use • Epidemiology of tobacco use in UK in 2009: • Smoking fell to its lowest recorded level in 2007 – 21 per cent of the population of Great Britain aged 16 and over.• 66 per cent of smokers said they wanted to give up.• 17 per cent of smokers said they lit up within five minutes of waking. • Heavy smokers are more likely to light up immediately and 35 per cent of those smoking 20 or more a day do so, compared with 3 per cent of those smoking fewer than 10 a day

8. Pattern of tobacco use • In England in 2009 • three in ten secondary school pupils (29 per cent), had tried smoking at least once and 6 per cent were regular smokers (smoking at least one cigarette a week). • Girls were more likely to smoke than boys; 10 per cent of girls had smoked in the last week compared with 8 per cent of boys.

9. Pattern of tobacco use • In England in 2008/09 • two thirds (67 per cent) of current smokers reported wanting to give up smoking, • with three quarters (75 per cent) reporting having tried to give up smoking at some point in the past. • Around two thirds (69 per cent) of adults report that they do not allow smoking at all in their home, an increase from 61 per cent in 2006. • Four in five people (81 per cent) agree with the smoking ban in public places.

10. Pattern of tobacco use • In England in 2008/09 an estimated 462,900 hospital admissions of adults aged 35 and over were attributable to smoking. • This accounts for 5 per cent of all hospital admissions in this age group. • In England in 2009 an estimated 81,400 deaths of adults aged 35 and over were attributable to smoking. • This accounts for 18 per cent of all deaths in this age group.

11. Pattern of tobacco use • Smoking and social class (ONS, 2004)

12. Pattern of tobacco use • Smoking and age group (ONS, 2004)

13. HEALTH CONSEQUENCES OF TOBACCO USE

14. Health consequences of tobacco use • Smoking and disease • Number of deaths per year in the UK? 114,000 • Number of deaths per year in the world? 4.9 million • Average loss of life expectancy? 10 years • Average loss of healthy life? 12 years (West, 2004)

15. Health consequences of tobacco use • Health risks of smoking (DH, 1994)

16. Health consequences of tobacco use • Oral health consequences • Oral cancers • Leukoplakias • Peridontal diseases • Acute necrotising ulcerative gingivitis • Poor wound healing • Smoker’s melanosis • Smoker’s palate • Oral candidosis • Tooth staining • Halitosis • (Johnson and Bain, 2000)

17. Health consequences of tobacco use

18. Health consequences of tobacco use

19. UNDERSTANDING SMOKING BEHAVIOUR

20. Starting to smoke Why? • Environmental factors • Behavioural factors • Personal factors • Image

21. Reasons for Continued Smoking Subjective reasons for smoking • Stress relief • Boredom relief • Enjoyment • Weight control Regular Smokers • Addicted/can’t give it up • Enjoyment • Stress relief Occasional Smokers • Don’t smoke enough to do harm • All my friends smoke

22. Nicotine withdrawal symptoms • Craving for nicotine – frequency falls over 4/52 • Mood swings • Difficulty concentrating • Increased hunger – average weight gain 5-6kg (10-12lbs) Each symptom affects 60-70% smokers (clinical trial reports)

23. Less frequent withdrawal symptoms • Sleep disturbance • Oral ulceration, respiratory tract infections • Constipation • Productive cough

24. Have you thought about/ever tried stopping smoking?

25. Stage 6- termination– successfully changed behaviour. Stage 5 – maintenance -They have succeeded in their behaviour change but still need support. Stage 4 – action – Actually trying to change Stage 2 – contemplation -These people are weighing up the pros and cons (do I want to change?) Stage 3 – preparation –These people are ready to change and it is the Health Care Professional’s role to help them set realistic targets and not to change too much at once. Stage 1- pre-contemplation -Those who do not want to change their behaviour

26. The Health Benefits of Quitting Immediate Effects: 20mins- blood pressure drops, pulse returns to normal, temperature in hands & feet return to normal 8hrs- O2 levels in the blood return to normal, chances of a heart attack start to fall 24hrs- carbon monoxide is eliminated from the body, lungs start to clear mucus & other debris 48hrs- sense of taste & smell are significantly improved, stale smoke odours on the breath & body disappear

27. The Health Benefits of Quitting Long Term Effects: 1-5yrs- 50% reduction in chance of oral, pharyngeal or oesophageal cancers, risk of coronary heart disease falls to 50%that of a smoker 10-15yrs- lung cancer death rate about 50% that of a continuing smoker, risk of coronary heart disease falls to about the same as someone who has never smoked

28. The case for the dental team • We have interviewing skills • We have educating skills • We have motivating skills • We have counseling skills • Follow-up procedures • Intervention can be brief • A practice builder (?) • Rewarding

29. The team approach • Smoking Kills – a white paper on tobacco (DoH 1998) • Modernising NHS dentistry (DoH 2000) • NHS dentistry: options for change (DoH 2002) • Smoking cessation guidelines for health professionals: an update (West et al., 2000) • Smoke free and smiling – DoH 2007

30. The team approach 3 Dentist: • Lead team • Identify training needs/job responsibilities • Routinely take/update smoking history • Assess smokers’ motivation to quit • Refer those motivated to NHS Stop Smoking Services/in-practice NRT, Zyban • Monitor/review progress

31. The team approach 4 Hygienist: • Assess patients’ interest/ motivation for quitting • Provide quit strategies • Review & monitor progress

32. The team approach 5 Dental nurse: • Reinforce advice from dentist/hygienist • Provide opportunistic advice eg. post-op Receptionist/practice manager: • Display information on local stop smoking services & ensure appropriate information is available • Ensure local information is up to date • Reinforce the advice from the rest of the team

33. Perceived barriers in the dental setting (1995-’present’) • ADH 22% smoked only 9% had received smoking information from their dentist • Time • Lack of materials & training • Patient disinterest 73% patients expected dentists to be interested in their smoking status Over 60% expected dentists to discuss smoking with them (Rikard-Bell, 2003 – Australia) • Ineffective/poor success rate • UDAs

34. Conclusions • Tobacco use is a recognised risk factor for a host of oral (+ other) diseases • Dental professionals should establish the smoking status of their patients on a regular basis • We should advise all smokers to stop and emphasize the oral health benefits of quitting • Smokers who are interested in quitting should be given appropriate assistance • Evidence-based guidelines implemented in primary dental care settings would have a significant impact on smoking rates • Appropriate training & reimbursement remain significant barriers

35. ONS Reports • ONS publishes two reports on smoking attitudes and behaviour each year. Smoking and Drinking Among Adults is drawn from the long-running General Household Survey, and presents trends in cigarette smoking according to personal characteristics such as sex, age, socio-economic classification and economic activity status. It also comments on the prevalence of cigarette smoking in different parts of Great Britain.A second report, Smoking Related Behaviour and Attitudes, forms part of a series of studies carried out by ONS for the Department of Health and NHS Information Centre for health and social care. The study is conducted as part of the National Statistics Opinions (Omnibus) Survey and focuses on people's attitudes to smoking and smoking behaviour. Targets relating to the prevalence of smoking are monitored by other surveys, but the Opinions survey has been used to monitor changes in attitudes towards smoking in general and towards smoking in public places.

36. Reference for latest stats • http://www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles/smoking/statistics-on-smoking-in-england-2010-%5Bns%5D