1 What if anything to do about smoking and oral tobacco use in your patients University College London October 2013 Robert West

Declaration of competing interest I undertake research and consultancy for companies that develop and manufacture smoking cessation medicines and licensed nicotine products I am a trustee of the charity, QUIT I am an honorary co-director of the National Centre for Smoking Cessation and Training My salary and most of my research is funded by Cancer Research UK 2

Aim To provide ‘state of the science’ guidance on the best way of approaching the issue of smoking and oral tobacco use in dental patients 3

Objectives To describe 1.when and how best to raise the topic of tobacco use 2.latest evidence on best ways of quitting cigarettes and oral tobacco including consideration of electronic cigarettes and the safety and effectiveness of varenicline 3.optimal referral options 4

Poll What is your current practice when it comes to smoking and tobacco use in your patients? (Multiple response) 1.I don’t do anything 2.I make sure I have an up to date record of whether they smoke or use tobacco 3.I have leaflets which smokers can pick up if they want 4.I occasionally raise the topic with patients if it seems right 5.I try and make a point of talking about it and advising them to stop 6.I try and make a point of talking about it and advising them on the best ways of stopping 7.I have a system in place for referring patients who smoke or use tobacco to the local stop-smoking service 5

Poll On average how many hours of healthy life do smokers lose each day they continue to smoke after their 30s? (One response)

Smoking and mortality 7 Source: Doll et al (2004) BMJ, 328, 1519.

Poll Which of the following is true? (One response) 1.Cigarettes are much more harmful than oral tobacco 2.Cigarettes are slightly more harmful than oral tobacco 3.Cigarettes and oral tobacco are equally harmful 4.Oral tobacco is more harmful than cigarettes 8

Smokeless tobacco and oropharyngeal cancer 9 Lee et al (2009) BMC Medicine, 7, 36 Relative risks from smoking: Lung cancer: 9.0 Laryngeal: 7.0 Pharyngeal: 6.8 Digestive tract: 3.6 Oral: 3.4 Gandini et al (2008) In J Cancer, 122, 155

Poll Which of the following are true? (Multiple response) 1.Smokers who can go on a long flight without experiencing strong cravings can’t be addicted 2.Most smokers could easily stop if they tried hard 3.Addiction to cigarettes is mainly psychological 4.Nicotine from cigarettes trains the brain to light up in situations where smoking normally occurs 5.Smokers who light up soon after waking find it harder to stop than those who typically wait longer 6.Headaches are a common nicotine withdrawal symptom 10

11 Addiction to cigarettes Cigarettes deliver nicotine rapidly to the brain via the pulmonary circulation in a form that is convenient and palatable Nicotine delivered in this way is highly addictive The primary mechanism is ‘operant learning’ –Smoking is rewarded (‘positive reinforcement’) –Abstinence is punished (‘negative reinforcement’)

12 Positive reinforcement Nicotine binds to nicotinic acetylcholine receptors in the Ventral Tegmental Area

13 Positive reinforcement This increases NDMA- initiated burst firing of the mesolimbic dopamine pathway

14 Positive reinforcement This increases release of dopamine in the Nucleus Accumbens Nicotine also affects the operation of metabotropic glutamate receptors 5 (mGluR5) found in the nucleus accumbens and may play a role in modulating the post- synaptic response to both glutamate and dopamine

15 Positive reinforcement The dopamine release ‘teaches’ the smoker to repeat the action of puffing on a cigarette just like feeding a dog teaches it to sit up and beg

16 Negative reinforcement Prolonged exposure to nicotine results in neural adaptation Nicotine is rapidly removed from the body by metabolism and excretion with a half life of about 120 minutes Even short periods of abstinence lead to ‘withdrawal symptoms’ Smoking a cigarette alleviates these symptoms This ‘teaches’ the smoker to smoke when symptoms of this kind occur

17 Negative reinforcement Withdrawal discomfort, craving Puff on a cigarette Withdrawal relief More puffs

18 Nicotine withdrawal symptoms

19 The double ‘whammy’ Smoking is rewarded and abstinence is punished Both of these processes tap into ancient motivational systems that evolved millions of years before humankind When a smoker ‘decides’ to try to stop, he or she is fighting these processes

20 Addiction to cigarettes I really want to stop smoking: it’s costing me money and it will probably kill me Just smoke

Poll Which of the following has been found in general practice to be most effective in prompting smokers to try to stop? (One response) 1.Giving strongly worded advice to stop for health reasons 2.Encouraging smokers to reflect on why they smoke and whether they might want to stop 3.Offering support with stopping to all smokers without first asking whether they want to stop 21

22 GP advice to stop smoking Percentage of smokers and recent ex-smokers for whom …; data from Smoking Toolkit Study, N=7611

23 Attempts to stop according to GP advice to stop smoking N=7611, p<0.001 for difference between offer of support/prescription and others

Poll Which of the following have been shown in randomised controlled trials to help smokers to stop? (Multiple response) 1.Varenicline (Champix) 2.Bupropion (Zyban) 3.Nicotine replacement therapy (NRT) 4.Fluoxetine (Prozac) 5.Cytisine (Tabex) 6.Acupuncture 7.Individual counselling (behavioural support) 8.Group-based behavioural support 9.Telephone support 10.Electronic cigarettes 24

Poll Which two of the following have been found in randomised controlled trials to be most effective in helping smokers to stop? (Multiple response) 1.Varenicline 2.Bupropion 3.A combination of nicotine patches and a faster acting nicotine product 4.A combination of bupropion and nicotine patches 5.High dose nicotine patches 6.Electronic cigarettes 25

Poll What is the best advice for a patient who is not ready to stop smoking right now? (One response) 1.Do nothing until they feel ready to stop 2.Try and cut down 3.Try and cut down and use one of the licensed nicotine products to help them 26

Medications: efficacy 27 Stead et al 2008, Cahill et al 2012, Cochrane Varenicline: N=6,166 Single NRT: N=51,265 Dual NRT: 4,664 NRT for ‘reduce to quit’: N=3,429 95% confidence intervals from meta-analyses Hughes et al 2008, Cahill et al 2012, Cochrane Bupropion: 11,440 Nortripyline: N=975 Cytisine: N=937 95% confidence intervals from meta-analyses

Behavioural support: efficacy 28 Stead et al 2012, Cochrane 1 Pro-active telephone vs reactive: N=24,994 Individual vs brief advice: N=7,855 Group vs self-help: N=4,375 Internet vs nothing: N=2,960 Text messaging versus control messages: N=9,110 Written materials: N=15,117 95% confidence intervals from meta-analyses

Poll Newspaper reports have claimed that varenicline increases risk of depression and suicide. What is the truth behind these reports? 1.A small increase in risks of both has been found in patients with depression 2.A small increase in risk has been found regardless of pre-existing depression 3.No increased risk has been found in any patient group 29

Varenicline and suicide risk 30 Gunnell et al (2009) BMJ, 339, 3805

Poll Newspaper reports have claimed that varenicline increases risk of cardiovascular events. What is the truth behind these claims? (One response) 1.One meta-analysis of RCTs found a significant increase in risk but later ones have not 2.Three meta-analyses have now shown a small but significant increase in risk of non-fatal MIs 3.There is a slight increase in risk of fatal MIs but the risk is far less than from continuing to smoke 31

Varenicline and cardiovascular events 32 Prochaska et al (2012) BMJ, 344, 2856

Poll Which of the following is true? (One response) 1.Electronic cigarettes are almost as harmful to health as tobacco cigarettes 2.Electronic cigarettes carry about half the risk to health as tobacco cigarettes 3.Electronic cigarettes carry very little risk to health compared with conventional cigarettes 4.We do not know yet whether electronic cigarettes are less hazardous than smoking 33

Carcinogen levels in e-cigarette vapour 34 Goniewicz et al (2013) Tob Control, Online early

Referral options The goal –to encourage tobacco use cessation attempts in patients –to encourage use of optimal methods of stopping 35

Helping smokers to help themselves by bring the science of stopping to smokers 36

Poll What do you plan to do about smoking and tobacco use in your patients in the future? (Multiple response) 1.Nothing 2.I will make sure I have an up to date record of whether they smoke or use tobacco 3.I will have leaflets which smokers can pick up if they want 4.I will occasionally raise the topic with patients if it seems right 5.I will try and make a point of talking about it and advising them to stop 6.I will try and make a point of talking about it and advising them on the best ways of stopping 7.I will have a system in place for referring patients who smoke or use tobacco to the local stop-smoking service 37