Daily Health and Medicine News

EU launches new quit smoking campaign

Ex-smokers have more money, more freedom, better health and less stress than smokers, argues the European Commission in its new campaign, ‘Ex-smokers are unstoppable’. Launched on 16 June, it emphasises the advantages of quitting, whereas the previous two campaigns – ‘Feel free to say no’ (2002-2004) and ‘HELP’ (2005-2010) – stressed the dangers of smoking. This new action focuses on the benefits to smokers of kicking the habit and provides practical aid through the free iCoach platform, which also aims to help those not planning to quit and those in danger of taking up smoking again.

“As a former smoker myself, I know how hard it is to quit, but most importantly how gratifying it is. We need motivation and practical help, two things provided by this new campaign,” commented Health Commissioner John Dalli at the kick-off of the campaign in a park near the European Commission.

The campaign will run from 2011 to 2014 and specifically targets smokers between 25 and 34-years-old, which represents nearly 28 million people in the EU. Smoking is the leading cause of avoidable illness in the EU and the cause of death of more than 650,000 people in the Union every year. To date, 15 member states have passed laws that protect citizens on the whole from exposure to tobacco smoke.

Up in smoke: Tobacco issues

This year, more than 5 million people will die from a tobacco-related heart attack, stroke, cancer, lung ailment, or other disease. That does not include the more than 600,000 people who will die from exposure to second hand smoke.(1) Countries throughout the world are instituting tobacco control measures, such as the WHO Framework Convention on Tobacco Control, to help reduce the harm caused by smoking. World No Tobacco Day was May 31. Ashtrays with fresh flowers are a common symbol of World No Tobacco Day. Is an International Tobacco Control Project: Evaluating the impact of the WHO treaty across the globe, the answer?

Do you consider it your responsibility to help your patients quit smoking? If so, then you are in good company. The American Dental Hygienists’ Association (ADHA) thinks so as well. Also, a recent study that surveyed 231 periodontists found that 92% believe that tobacco-cessation interventions are a responsibility of the dental profession.(2) While the topics surrounding these issues are many, this issue will highlight how to reach younger smokers with a quit message, second hand smoke and risk for periodontitis, a message from the Smoking Cessation Leadership Center, and the hookah and its effects on oral health.
The Mexican pharmacy
In addition to systemic health issues, tobacco use and dependence causes oral health problems and has a great impact on the development and progression of periodontal disease. There is a clear causal relationship between smoking and periodontal disease and the negative effects of smoking on wound healing.(3) Smokers present tougher bacterial challenge to periodontal treatment than non-smokers.

Periodontal disease is difficult to successfully treat in any dental patient. One patient type that can be especially challenging is smokers. Smokers are up to 6X more likely to experience periodontal destruction compared to non-smokers.(4) A new study has found that smoking may pose other problems.(5) In patients with moderate-to-severe chronic periodontitis, researchers in this study found that smokers consistently demonstrated lower levels of health-protective bacteria, and significantly higher levels of disease-related bacteria subgingivally. These included higher levels of the red complex Treponema and Tannerella species, which have been linked to more severe and refractory periodontitis.(6,7)

This may help to explain why smokers are less responsive to scaling and root planing (SRP) alone, exhibiting smaller pocket depth reductions and fewer clinical gains resulting in deeper periodontal pockets.(4,8,9,10,11,12) In addition to other types of treatment, minocycline microspheres improve healing in patients who smoke. A study demonstrated that at 9 months, patients experienced 32% greater reduction in pocket depths with Arestin+ SRP vs. SRP alone.(9) Another study demonstrated that Arestin+ SRP was nearly 4X more likely to reduce pockets to <5 mm than SRP alone.(13) **

Tobacco-dependence treatment and tobacco cessation programs are vital components of clinical practice, and tobacco cessation programs should be incorporated into practice protocols. The use of tobacco cessation interventions by dental hygienists, general dentists, and oral maxillofacial surgeons has been reported in the literature. There is an ADA code for tobacco counseling in dental practice, D1320, and this can be used when cessation programs are implemented.

The primary barriers to providing tobacco-cessation interventions were low patient acceptance of treatment, lack of time, and lack of training. The following were other barriers cited: lack of reimbursement; believing that there was little chance of success in providing tobacco-cessation intervention; believing that patient acceptance of treatment is low; possibility of offending and losing patients; and lack of personal interest by the provider.

The basic steps of a tobacco-dependence treatment protocol can be implemented in three minutes or less. If the dental hygienist is familiar with community or state resources for tobacco-dependence treatment, like 1-800-QUIT NOW quit hot line, patients can be given information on these resources and referred for further assessment and assistance in quitting.

Ask, advise, refer is a shortened form of the 5 A’s (ask, advise, assess, assist, and arrange) — a series of steps to be used in a healthcare setting to treat tobacco use and dependence — and for promoting tobacco cessation. For more information, go to ADHA’s www.askadviserefer.org. When it comes to lack of reimbursement, while many insurance plans do not provide coverage for cessation counseling, this seems to be changing.

In a newly updated Cochrane Review, Cahill and Perera summarize the effectiveness of incentives for smoking cessation.(14,15) Their disappointing conclusion is that, while there is some evidence that incentives work in the short term, the effects generally dissipate, and there is still insufficient evidence to recommend their adoption into routine practice. Much therefore remains to be discovered, but what are the particular questions that this review highlights?

Behavior change has been divided into “simple” or single actions at a point in time, and “complex” behavior change are those requiring effort over a sustained period.(16) Adherence to medication is an example of a simple behavior change. A systematic review in the British Medical Journal (BMJ), which assessed financial incentives to motivate adherence to medical instructions, identified 11 randomized controlled trials.(17) The incentives ranged from USD 5 to about USD 1,000. Of the 11 studies included in the review, 10 demonstrated a positive effect. The studies incentivized several types of interventions, such as immunization, engaging with antihypertensive treatment, attending postpartum appointments, completing cocaine dependency treatment, and dental care for children.

Complex behavior change requires both sustained effort and typically the adoption of multiple strategies to achieve change. Tobacco and smoking cessation, and weight loss to reduce obesity, require complex behavior change. A systematic review of trials of incentives for weight loss found that larger incentives seemed more effective but that the effectiveness of interventions seemed to decline when the incentive was withdrawn, paralleling the data in the Cahill and Perera review.(18)

Should we conclude that incentives are effective for simple but not complex behavior change? This conclusion does not take into effect the strong evidence for the efficacy of incentives for the management of drug misuse.(19) There is also evidence for improved abstinence from problem drug use, clearly a complex behavioral change. Although ceasing to use illicit drugs does require complex change, some actions are simple. Deciding to engage in a treatment program and partaking in programs for supervised dispensing of methadone are simple behaviors. These are part of the set of behaviors that have been effectively rewarded in previous trials of incentives in drug misuse.

The shining exception to the rather negative findings in the Cochrane Review of incentives for smoking cessation is the trial by Volpp and colleagues.(20)

In the Volpp study, participants obtained rewards for attending a smoking cessation clinic and for validated abstinence. As a result, nearly three times as many in the intervention group attended as in the control group. The intervention also increased the rate at which participants achieved abstinence at short-term follow-up. Though a somewhat lower proportion of people who achieved early abstinence returned to smoking in the intervention group than the control group, it seems the main effect was inducing two simple behavior changes. One prompted individuals to decide to quit smoking, and the other prompted individuals to use evidence-based treatment.

Smoking in pregnancy is a difficult public health problem. A Cochrane Review of smoking cessation in pregnancy found that many of the interventions that are known to be effective in adult smokers are not known to be effective in pregnant women.(21) Financial incentives seemed the most effective intervention, increasing abstinence over three-fold. However, the outcomes of these trials were abstinence for the previous seven days, so the data are preliminary. According to the authors, many women who smoke in pregnancy are among the most disadvantaged in society. If incentives have a place in smoking cessation, it is perhaps this group who might be seen as the most deserving.

Both this review and the Cahill and Perera review show us the potential value of incentives. They appear to work sometimes for some smokers. Understanding how they work, whether the benefits are sustained, and that their effects are not due to gaming the system, is a public health priority.

Tobacco use is the single most preventable cause of disease, disability, and death in the United States. Each year, an estimated 443,000 people die prematurely from smoking or exposure to second hand smoke, and another 8.6 million live with a serious illness caused by smoking. The CDC issued a brief entitled “Tobacco Use: Targeting the Nation’s Leading Killer, At A Glance 2011”.(22)

The tobacco use epidemic can be stopped. The Institute of Medicine (IOM) report, “Ending the Tobacco Problem: A Blueprint for the Nation”, presents a plan to “reduce smoking so substantially that it is no longer a public health problem for our nation.(23) Foremost among the IOM recommendations is that each state should fund a comprehensive tobacco control program at the level recommended by CDC in Best Practices for Comprehensive Tobacco Control Programs–2007.(24) This publication is a guide to help states plan and establish effective tobacco control programs to prevent and reduce tobacco use.

Evidence-based, statewide tobacco control programs that are comprehensive, sustained, and accountable have been shown to reduce smoking rates, tobacco-related deaths, and diseases caused by smoking. A comprehensive program is a coordinated effort to establish smoke-free policies, reduce the social acceptability of tobacco use, promote cessation, help tobacco users quit, and prevent initiation of tobacco use. This approach combines educational, clinical, regulatory, economic, and social strategies. Research has documented the effectiveness of laws and policies to protect the public from second hand smoke exposure, promote cessation, and prevent initiation by young people.

CDC also promotes MPOWER, a package of six proven strategies identified by the World Health Organization (WHO) that can help reduce tobacco use and tobacco-related illness and death.(26) Monitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help to quit tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising, promotion, and sponsorship; and Raise taxes on tobacco.

CDC, in partnership with the National Cancer Institute, the North American Quitline Consortium, and state tobacco control programs, has developed the National Network of Tobacco Cessation Quitlines. By calling 1-800-QUIT NOW, callers from across the nation have free and easy access to tobacco cessation services in their state.(27)

So what are you waiting for? With all these resources, there is no excuse not to assist your patients with tobacco cessation. If not you, who? If not now, when?

Will Quitting Smoking Make You Fat?

Many smokers who want to quit are afraid they will gain weight, so they rather not kick the habit. The fear of getting fat after quitting is not altogether unwarranted. Many ex-smokers do put on some extra weight, about five pounds on average.

Now, scientists think they know why. Recent studies have shown that nicotine helps suppress appetite by activating certain receptors in the brain, especially those in the so-called “reward regions,” where we sense pleasure and from where many of us also develop addictions.

A team of researchers at Yale University School of Medicine now found that nicotine can also bind regulator neurons to these receptors, which send out satiety messages, much like the signals our brain receives when our stomach is full to make us stop eating.

This mechanism may explain why smokers are usually not as hungry when they smoke and why they tend to eat more after quitting.

Considering the implications of their study results, some scientist now hope to develop a drug that can simulate the effects of nicotine on the brain, thereby eliminating the health hazards commonly attributed to tobacco use. Appetite-controlling drugs, like cytisine, to help quitters avoid unwanted weight gain are already available in Eastern Europe but not in the U.S.

Developing drugs that target specific receptors in the brain is a difficult challenge. Some scientists involved in this kind of research have warned that even if drug treatments were to prove effective, they may also trigger some unwanted side effects. The reason is that the receptors in charge of regulating appetite are also closely connected to the body’s stress responses, which normally are only mobilized in times of acute danger. Activating these receptors on an ongoing basis through medication could lead to symptoms similar to chronic stress and, over time, to diseases like high blood pressure and heart disease.

Of course, everyone agrees that fear of gaining weight should not ever prevent smokers from quitting. Instead of waiting for a wonder drug that might help people stay slim, there are many better ways to regulate one’s appetite and manage one’s weight more naturally.

A good way to start is to be more conscious of the metabolism. Smoking raises the metabolic rate and also increases the heart rate up to 20 times of normal. This is one reason why many smokers suffer from high blood pressure and heart disease.

When smokers quit, their metabolism slows down considerably. It can take weeks or even months before metabolic levels stabilize at normal levels. Meanwhile, calories are being burned at a much lesser rate. At the same time, many recovering smokers eat more food to cope with withdrawal symptoms or boredom. Senses of taste and smell come back to life after quitting, which may increase appetite as well.

Alcohol is often used to “take the edge off” when the cravings become more intense. Alcoholic beverages, of course, have lots of calories, and all too often these are not taken into account.

Another reason for increase of food intake is what smokers call “oral gratification.” Many ex-smokers miss the feeling of “having something to do with their mouths and hands.” Frequent snacking often serves as a substitute to fill the void.

Many people reach for food for similar reasons smokers reach for cigarettes, namely to handle stress, to reward or comfort themselves, to pass time, deal with boredom or to be social. For smokers trying to quit, the choice of means may change but not necessarily their behavioral tendencies.

So, is there a special regimen for ex-smokers to avoid falling into the weight gain trap? Not really. Ultimately, they have to act just like the rest of us who try our best to stay in shape: Healthy eating, limiting portion sizes, no snacking, regular exercise, stress reduction and enough sleep. Following all these measures combined should render any wonder drug of the future obsolete right now.