[Smoking cessation: Pharmacological strategies different from standard treatments]. / Sevrage tabagique : les stratégies pharmacologiques différentes des traitements standards.

INTRODUCTION: Three drugs are used as an aid for smoking cessation: nicotine replacement therapy (NRT), varenicline and bupropion. Standard pharmacological strategies have proven their efficacy but may have poor efficacy, especially among "Hard-core smokers" who display low smoking abstinence rates and high relapse rates. OBJECTIVES: Systematic literature review of data on pharmacological strategies for smoking cessation which are different from standard treatments. RESULTS: Sixteen studies were included. Higher dose of nicotine patchs increases smoking abstinence rates. Increasing varenicline dose in smokers who do not respond to the standard dose is associated with high success rates. Extended treatment with nicotine patchs is associated with higher abstinence rate at 6 months but not in the long term. Results of studies on extended treatment with oral NRT are conflicting. Extended treatment with varenicline increases smoking cessation rates. Results of studies on extended treatment with bupropion are conflicting as regards smoking cessation rates. Combination therapy of varenicline with nicotine patchs or with bupropion are more effective than varénicline alone. Varenicline using a flexible quit date have similar efficacy compared with previous fixed quit date studies. Pre-cessation treatment with nicotine patchs or with varenicline increases abstinence rates. There is no difference in smoking cessation effectiveness among bupropion, nicotine replacement therapy and their combination. Similarly, there is no differences in abstinence rates between the active bupropion and nicotine gum and the active bupropion and placebo gum groups. Retreatment with varenicline is efficacious in smokers who have previously taken it. CONCLUSION: Pharmacological strategies different from standard treatments maybe useful for smoking cessation aid.

Tobacco Cessation Strategies: It Takes a Village.

Smoking is the leading cause of preventable death and chronic diseases in the U.S. Identifying smokers and providing appropriate intervention is therefore an integral part of each clinic visit. A combination of pharmacotherapy as well as behavioral counseling provides the best results. Pharmacotherapy includes nicotine replacement (patch, gum, lozenges), bupropion and varenicline. More recently, electronic nicotinic delivery systems (such as e-cigarettes, vaporizers/vape pens, and hookah pens) have become popular. Behavioral counseling includes identifying barriers to quitting or risk factors for relapse, and developing effective strategies to deal with these issues. A successful program requires a team-based approach, enlisting the help of adjuvant staff to reinforce cessation counseling and provide support services. The South Dakota Quitline is one of many good resources that the clinician can utilize to help with cessation and has one of the best quit rates in the nation.

Smoking cessation and the role of the dental practitioner.

As dentists we are uniquely positioned to influence the rate of tobacco smoking and could contribute to a decrease in the associated mortality and morbidity. The detrimental effects of smoking on oral health are well established; thus, a structured approach to initiate smoking cessation, help to manage the initial phase of withdrawal symptoms, and provide long-term support is an important role for our profession. It has been shown that smoking cessation advice for even a few minutes increases long-term smoking abstinence rates by 5%, which can be increased by 50-70% with the use of adjunctive pharmacotherapy, e.g., nicotine replacement therapy, for withdrawal symptoms. This article aims to give a brief overview of smoking in relation to oral health, review the management of tobacco smoking dependence, and discuss how we as dentists can help our patients to quit smoking.

Tobacco dependence education in U.S. Dental assisting programs' curricula.

The aim of this study was to assess the level of tobacco dependence education (TDE) in the curricula of U.S. dental assisting programs and to compare the findings to those from a similar assessment of dental hygiene curricula. In the 2012-13 academic year, a 51-item survey was sent to directors of all 298 accredited dental assisting programs. Assessed were curricular TDE content, time spent on each topic, expected levels of clinical competence, and resources used. Of the 298 potential participants, 89 programs returned completed surveys, for a response rate of 30%. Of the 13 TDE-related content areas, those most often covered were oral disease related to tobacco use (100%) and general diseases related to tobacco use (93%); those least often covered were stages of (behavior) change (29%), how to develop a comprehensive tobacco intervention program in a private office setting (23%), and strategies for community-based tobacco control (22%). Responding program directors indicated the following levels of tobacco cessation intervention at which students should demonstrate competence: brief, 44%; moderate, 55%; intensive, 8%. Less than half of the reporting programs conducted a formal assessment of clinical competence in any TDE-related skills; however, skills in assessing patient tobacco use and associating head and neck findings to tobacco use were formally or informally assessed by 74% and 61%, respectively. Compared to dental hygiene programs, TDE appeared to play a smaller role in the curricula of dental assisting programs, and dental assisting programs were less likely to formally assess clinical competence in TDE.

Survey of Australian oral health practitioners and their smoking cessation practices.

BACKGROUND: Smoking is a significant health and economic burden in Australia. Studies of smoking cessation practices in dental settings have primarily concentrated on dentists rather than other oral health practitioner (OHP) groups (dental hygienists, dental therapists and oral health therapists). The aim of this study was to measure Australian OHPs' attitudes, behaviours, interest and barriers to delivering smoking cessation interventions. METHODS: Members of the two peak professional bodies representing Australian OHPs were invited to participate in an anonymous online questionnaire. RESULTS: There were discrepancies between practitioner attitudes and current smoking cessation practices. While the majority of practitioners (90.1%) frequently screened for smoking behaviour, fewer (51.1%) assisted patients to quit smoking. The principal form of assistance was referral to Quitline (45.7%) or to a general medical practitioner (44.4%). The most prevalent barriers identified were lack of knowledge of pharmacological treatments (45.8%) and lack of access to smoking cessation resources (44.2%). Contrary to international studies, time and financial incentive were not commonly cited barriers to delivering smoking cessation interventions. CONCLUSIONS: This survey identifies a need for continuing education in smoking cessation practice. Dissemination of policies, guidelines and resources may assist OHPs to become more engaged and confident in delivering smoking cessation interventions as part of their routine practice.

Is nicotine still the bad guy? Summary of the effects of smoking on patients with head and neck cancer in the postoperative period and the uses of nicotine replacement therapy in these patients.

Smoking has long been implicated in the development and progression of numerous postoperative complications. The cause is largely thought to be the presence of reactive oxygen species (ROS) in cigarette smoke, which attenuates inflammation and affects neutrophil function. Wound healing is further compromised by deficiencies in vitamins C and E, which result from a higher vitamin turnover secondary to the oxidative stress produced by smoking. However, studies recently have found that the effects of nicotine may benefit healing if used in isolation. We summarise the effects that smoking and abstaining from smoking can have on inflammation and wound healing, and describe the possible benefits that nicotine replacement and antioxidant supplements can give.

Smoking cessation in patients with respiratory disease: existing treatments and future directions.

Tobacco use is a leading cause of preventable death worldwide. Respiratory diseases, including chronic obstructive pulmonary disease (COPD) and lung cancer, account for a large proportion of tobacco-related deaths. Smoking cessation benefits almost all smokers, irrespective of the age at which they quit, making smoking cessation a core component of prevention and treatment of respiratory diseases. Evidence shows that psychosocial counselling and pharmacotherapy are effective smoking cessation methods and are most effective when used together. The first-line drugs licensed to aid smoking cessation (nicotine replacement therapy, bupropion, and varenicline) are effective in patients with COPD. Efforts are underway to improve the efficacy of existing treatments and increase the proportion of smokers who try to quit, and who use treatment when doing so. However, existing smoking cessation counselling and drugs are among the most cost-effective clinical preventive services available. Incorporation of such treatment into routine clinical practice is essential for provision of high-quality care to all patients, especially those with respiratory disease.

Tracking dental patient tobacco use and intervention in the academic clinical setting.

The purpose of this study was to illustrate one method of tracking patients' tobacco use and monitoring cessation interventions with electronic dental records in an academic dental setting. Records from 465 tobacco users were analyzed to assess patients' tobacco use and providers' intervention techniques. The results indicate that 75 percent of the patients whose records were analyzed had used tobacco for more than ten years and the cold turkey approach was the most common cessation method. Ninety-seven percent of the patients whose records were analyzed used cigarettes. The most common pharmacotherapy recommended in combination with counseling for smoking cessation was the nicotine patch, followed by nicotine gum, varenicline (Chantix), the nicotine lozenge, bupropion SR (Zyban), and the nicotine oral inhaler. Incorporating tobacco use questions into the electronic dental record can ensure that tobacco use and intervention techniques are addressed and documented in dental records. Electronic dental records provide an opportunity to collect data related to tobacco use and intervention techniques for purposes of further evaluation and research.

Pharmacologic approaches to smoking cessation.

Cigarette smokers experience greater rates of morbidity and mortality. Despite the known health risks, use of tobacco products remains high throughout the United States (approximately 19.3% of adults). Tobacco use is associated with higher rates of cardiovascular illness, cardiovascular risk factors (ie, hypertension and atherosclerosis), chronic obstructive pulmonary disease, emphysema, and various types of cancer. Pharmacologic smoking cessation therapies have been used to facilitate abstinence from smoking. This article provides clinicians with instructions for the use of pharmacologic agents for smoking cessation, including considerations for special populations.

Randomized controlled trial to evaluate tooth stain reduction with nicotine replacement gum during a smoking cessation program.

BACKGROUND: In addition to its general and periodontal health effects smoking causes tooth staining. Smoking cessation support interventions with an added stain removal or tooth whitening effect may increase motivation to quit smoking. Oral health professionals are well placed to provide smoking cessation advice and support to patients. The objective of the present study was to evaluate the effect of Nicorette(®) Freshmint Gum used in a smoking cessation programme administered in a dental setting, on extrinsic stain and tooth shade among smokers. METHODS: An evaluator-blinded, randomized, 12-week parallel-group controlled trial was conducted among 200 daily smokers motivated to quit smoking. Participants were randomised to use either the Nicorette(®) Freshmint Gum or Nicorette(®) Microtab (tablet). Tooth staining and shade were rated using the modified Lobene Stain Index and the Vita(®) Shade Guide at baseline, weeks 2, 6 and 12. To maintain consistency with other whitening studies, the primary end-point was the mean change in stain index between baseline and week 6. Secondary variables included changes in stain measurements and tooth shade at the other time points the number of gums or tablets used per day and throughout the trial period; and the number of cigarettes smoked per day. Treatments were compared using analysis of covariance (ANCOVA), using treatment and nicotine dependence as factors and the corresponding baseline measurement as a covariate. Each comparison (modified intention-to-treat) was tested at the 0.05 level, two-sided. Within-treatment changes from baseline were compared using a paired t-test. RESULTS: At week 6, the gum-group experienced a reduction in mean stain scores whilst the tablet-group experienced an increase with mean changes of -0.14 and +0.12 respectively, (p = 0.005, ANCOVA). The change in mean tooth shade scores was statistically significantly greater in the gum-group than in the tablet group at 2 (p = 0.015), 6 (p = 0.011) and 12 weeks (p = 0.003) with greater lightening in the gum-group at each examination period. CONCLUSION: These results support the efficacy of the tested nicotine replacement gum in stain reduction and shade lightening. These findings may help dentists to motivate those wishing to quit smoking using a nicotine replacement gum. TRIAL REGISTRATION: NCT01440985.

Improving tobacco dependence education for dental and dental hygiene students at Loma Linda University School of Dentistry.

In a general effort to facilitate dental professionals' effective tobacco-dependence education (TDE), the student part of the project reported here had three purposes: 1) to promote tobacco cessation activities in the dental school clinic, 2) to evaluate dental and dental hygiene students' confidence level in treating tobacco-dependent patients, and 3) to determine the frequency, duration, and depth with which the students assisted tobacco-dependent patients. Surveys of senior dental and dental hygiene students at the Loma Linda University School of Dentistry were conducted in 2008. Of the twenty-seven questions on the survey, nineteen related to the procedures students performed and questions asked of patients, one question asked how many minutes students spent counseling patients, and seven questions related to barriers to incorporating TDE activities. Only 56.5 percent of the responding dental students reported they routinely "asked and advised" about their patients' smoking behaviors, but 87.5 percent of the responding dental hygiene students reported they routinely did so. After the curricular intervention, the follow-up survey found that the dental students more frequently showed their patients the effects of tobacco on the oral mucosa and more frequently discussed pharmacotherapy options and made referrals during routine care. Until all dental and dental hygiene students are required to meet written board and clinical competencies in TDE and given adequate mentoring by clinical faculty to treat tobacco-dependent patients, the likelihood of seeing major improvements in tobacco-cessation treatment in dental practices is low.

[Electronic cigarette--a safe substitute for tobacco cigarette or a new threat?]. / Elektroniczny papieros--bezpieczny substytut papierosa czy nowe zagrozenie?

The aim of this paper was to summarize up-to-date data on the new emerging nicotine containing product 'electronic cigarette', commonly referred as e-cigarette. We presented data on prevalence and popularity of various brands and models on domestic markets. Development of the new products with technical and chemical modifications was also described. We reviewed studies on chemical composition and efficacy of nicotine delivery from e-cigarettes and discussed its potential use as nicotine replacement for tobacco cigarettes. Regulatory policies on e-cigarette sale as nicotine containing product were also discussed. We concluded that e-cigarette might be an effective harm reduction tool but little is known about its safety, especially when used for a long time. Despite many positive findings from surveys among e-cigarettes users, there is need for comprehensive state-of-the-at clinical trials to show efficacy of e-cigarette as smoking cessation tool.

Which form of nicotine replacement therapy is more effective for quitting smoking? A study in Tehran, Islamic Republic of Iran.

Nicotine replacement therapy can double the chance of success for smokers attempting to quit. This observational study aimed to compare quit rates of different formulations of nicotine replacement among clients referred to a smoking cessation clinic in Tehran, Islamic Republic of Iran. Clients entering the study (n = 308) participated in 4 sessions of behavioural therapy, chose a type of nicotine replacement to use (patches, chewing gum, tablets or both patches and gum) and were followed up for 12 months. After 4 weeks of quitting, 88.2% (246/279) reported abstaining from smoking. Self-reported maintenance rates for quitting were 54.9% after 6 months and 36.2% after 12 months follow-up. A significant correlation was found between type of nicotine replacement and quit rate. Use of nicotine patches and chewing gum together had the highest quit rate (95.2%) after 4 weeks and at 12 months follow-up (62.5%). Consuming 2 forms of nicotine replacement in therapy could result in enhanced rates of long-term quitting.

[Harm reduction strategy in tobacco control]. / Esistono sostituti delle sigarette a rischio ridotto per chi non riesce a smettere?

Potentially reduced exposure products (PREPs), already sold in USA and in some European Countries, are low-nitrosamine cigarettes, low-nitrosamine smokeless tobacco (e.g., the Swedish Snus), cigarette-like products, and medicinal nicotine products. Even e-cigarette delivers nicotine. With the exception of snus and medicinal nicotine, studies on the health effects of PREPs have not been carried out, although some PREPs are already sold and promoted as products that effectively reduce health risks. Thus, a second disaster similar to that occurred for light cigarettes could happen in the next years. Only medicinal nicotine and snus could be valid candidates to become PREPs, even if they pose some significant health risks. The World Health Organization, following a precautionary approach, has recently published a list of 9 carcinogens or toxicants recommended for mandated lowering (the tobacco-specific nitrosamines NNN and NNK, acetaldehyde, acrolein, benzene, benzo[a]pyrene, 1-3 butadiene, carbon monoxide, formaldehyde), and 9 carcinogens or toxicants for monitoring in usual cigarettes (not PREPs), underlining that tobacco companies cannot use this reduction strategy as a promotional message, as it occurred for light cigarettes in the 70s and 80s. The present status quo, in which cigarettes are freely available, medicinal nicotine, being a drug, is available under a regulated market, and Snus is prohibited, actually denies smokers the right to choose safer nicotine products. The solution suggested by the UK Royal College of Physicians is to balance the nicotine market, framing tobacco products and medicinal nicotine in the same regulation system; establishing a nicotine and tobacco regulatory authority;making medicinal nicotine more available; evaluating the feasibility of the introduction in the English market of Swedish Snus. California Government remarks that the nicotine maintenance is not a valid strategy, because it could induce smokers not to try to quit.Thus, California Department of Health Services prohibits promotion of snus and medicinal nicotine as a harm reduction strategy. However, the US Federal Family Smoking Prevention and Tobacco Control Act, signed by President Obama in 2009, places tobacco products under FDA jurisdiction: FDA must define criteria for lowering carcinogens and toxicants in tobacco products, making more available medicinal nicotine, evaluating PREPs, creating a federal Tobacco Control Agency.Which approaches is Italy going to follow?