Prof Dr Roslan Saub

Faculty of Dentistry
 Introduction to tobacco use
 Health Risk of Smoking
 Nature of nicotine dependence
 Nicotine withdrawal symptoms
 The 5 A’s Approach and 5R’s
 Smoking cessation medication
 Tobacco products are products made entirely
or partly of leaf tobacco as raw material,
which are intended to be smoked, sucked,
chewed or snuffed. All contain the highly
addictive psychoactive ingredient, nicotine.
http://www.who.int/topics/tobacco/en/ Access 5 Sept 2008

• Nicotine belongs to a family of compounds called

alkaloids and occurs naturally in several varieties of
plant – including tomatoes, aubergines and potatoes –
but is found at its highest levels in the tobacco plant.
• We don’t add nicotine to our conventional cigarettes
and the nicotine in our e-liquids for our vapour
products is extracted from tobacco leaf.
CLICK
 No. of Smoking Smoking
smokers Prevalence Prevalence
(Millions) Male (%) Female (%)
Developed 380 42 24

Developing 870 48 7

World 1,250 47 12
NHMS 1986 1996 2006
Overall 21.5% 24.8% 22.8%
Male 40.9% 49.2% 48.8%
Female 1.9% 3.5% 4.1%
Urban 19.2% 21.7% 18.9%
Rural 22.7% 28.6% 26.2%
Malay 23.7% 27.9% 24.0%
Chinese 17.7% 19.2% 16.2%
Indian 15.2% 32.4% 13.7%
Others 32.8% 32.4% 23.8%
Ref: Institute for Public Health (IPH) 2011. National Health and Morbidity Survey 2011 (NHMS 2011). Vol. III: Health Care Demand And Out-Of-
Pocket Health Expenditure.
NHMS 1986 1996 2011*

Overall 9.8% 16.9% 15.2%

Male 12% 30.7% -

Female 1% 4.8% -

* Below 19 years old

STICKS IN MILLIONS

20000
18000 18807 18653
16000
16389
14000
12000
10000
8000
8277
6000
4000
2000
0
1970 1980 1990 2000
 Smoking – leading preventable cause of
disease and death
 10
10
9
8
7
6
millions 5 4.2
4
3
2
1
0
2001 2030

WHO World Health Report 1999.

 Others
10% CHD
25%
COPD
15%

Stroke
20%
Lung Ca
Other Ca 25%
5%
 Results From a Study of Male Physician Smokers in the UK
97
100 91 Physician Nonsmokers
94 81 Physician Smokers
80 81
59 59
Survival At 60
Each Age
10 years
Point (%) 40
24
20 26
2
4
0
40 50 60 70 80 90 100
Age (Years)

1. Doll R, et al. BMJ. 2004;328:1519–1527.

 Periodontal disease

Ref: Lindle et al, 2008

 Periodontal Therapy – poor responses to the
treatment among the smokers
◦ Meta Analyses: Garcia 2005; Labriola et al 2005)
 Oral mucosal lesion
 Smoker’s palate (nicotinc stomatitis
 Smoker melonosis
 Lichen Planus
Oral Cancer

Ref: Lindle et al, 2008

 Dental Implants
 Tobacco stains
 Bad breath
 Dental caries – lower pH and buffering
capacity

Ref: Lindle et al, 2008

Dr. Hj. Sallehudin Bin Abu Bakar
 Initiation – social reason
 Maintenance – biological reason
 Tobacco
Tobacco smoke – 4000 components
Nicotine
•automatically tells the smoker to repeat the action
•creates an urge to smoke in the future – rather like a
feeling of hunger
•convinces the smoker that smoking is a rewarding
experience

Dr. Hj. Sallehudin Bin Abu Bakar

 Irritability, frustration, or anger (< 4 weeks)
 Anxiety (may increase or decease)
 Insomnia/sleep disturbance (< 4weeks)
 Increase appetite or weight gain (>10 weeks)
 Difficulty in concentration (< 4weeks)
 Less frequent
◦ Night-time awakening
◦ Constipation (17%, 9% severe)
◦ Mouth ulcers (40%, 8% severe)
◦ Productive cough – improve within a month
 The WHO Report on the Global Tobacco
Epidemic 2008 recommends a comprehensive
and effective approach to control tobacco in
the 21st century: MPOWER
 M- Monitor tobacco use and prevention
policies Tobacco
 P- Protect people from tobacco use control
policies lies
 O- Offer help to quit tobacco with the health
 W- Warn about the dangers of tobaccocare sector
 E- Enforce bans on tobacco advertising,
promotion and sponsorship
 R- Raise taxes on tobacco

30
 Behavioural therapy
◦ 5 A’s
◦ ABC – (Ask, Brief Advice, Cessation Support)
◦ 3 A’s (brief advise)
 Pharmacotherapy
◦ Bupropion
◦ Veranicline [champix]
◦ NRT
 Individual Counseling
 Meta Analysis from 21 trials included > 7000
participants, individual counseling
significantly increase the probability of
smoking cessation at follow-up (≥ 6 months
after the start of counseling) compared to
control (OR, 1.56; 95% CI, 1.32 to 1.84)
 There was no significant benefit gained with
intensive compared with brief counseling.
 Ref: Niaura, 2008
 • the action of looking thoughtfully
at something for a long time.

•Has no intention to quit smoking within the next 6

Pre-Contemplation months

Contemplation •Intends to quit smoking within the next 6 months

Preparation •Intends to quit smoking now or within the next month

Action •Has quit smoking for less than 6 months

Maintenance •Has quit smoking for more than 6 months

Relapse •Regression to earlier stage

 ASK all patients about their smoking and
document smoking status in patient note
 ADVISE to quit at least once per year. Link
smoking to reason for patient visit, costs, and/or
impact on others
 ASSESS are they ready to make a quit attempt? If
yes, offer help. If not, say you are available if they
decide to quit in future
 ASSIST those interested in making quit attempt –
e.g refer to quit clinic, seld-help material etc.
 ARRANGE follow-up
 The 5A’s was found to be more effective in
initiating positive behaviour change
compared to BA. However, after controlling
other factors, there was no difference in the
effectiveness although the odds ratio was
slightly higher in 5A’s.

Ref: Dr Nurul PhD Thesis

 10% relapse after 1 year of abstinence
 7% relapse after 4-5 years
 After 5 years most remain tobacco free
 65% of self-quitters relapse after the first
week – the intensity of withdrawal symptoms
during the first week after quitting
 Those who are unwilling to change
◦ RELEVANCE
◦ RISKS
◦ REWARDS
◦ ROADBLOCKS
◦ REPETITION
One of the key factors in people changing
their behaviour is having a helping
relationship with someone who they feels
really cares, understands and is committed
to helping them.
One important way of building a helping
relationship is to listen carefully and actively
to what people have to say about themselves
and their problems.

Dr. Sallehudin Abu Bakar 40

 Good eye contact
 Appropriate gestures
 Relaxed body posture
 Leaning forward
 Allowing silence
 Reflecting client’s movement
 Noticing client’s body language
 Verbal prompts ‘ mm’ etc
 Repeating key words
 No physical barriers

Dr. Sallehudin Abu Bakar 41

 Looking away from client
 Fiddling with pen etc
 Physical barrier
 Clock watching
 Judging
 Jumping to conclusion
 Talking too much
 interrupting

Dr. Sallehudin Abu Bakar 42

 Nicotine replacement treatment (NRT)
◦ Inhalator
◦ Gum
◦ Patch
◦ Nasal spray
◦ Lozenge
 Bupropion (Zyban)
 Varenicline (Champix)