The chiropractic profession has always distinguished itself among the health specialties as being preventative in nature, taking the lead in public education and awareness for many health related issues. The dangers of tobacco use and tobacco cessation therapy should be no different. In addition, education regarding the dangers of smoking, as well as smokeless tobacco use and tobacco cessation therapy is beginning to be addressed more seriously in the chiropractic practice as well as by other medical and dental health care providers. This article focuses on the need, diagnosis and treatment of patients addicted to tobacco products.
The Department of Health and Human Services recently issued new guidelines asking all health professionals to try to help their tobacco-using patients to quit. The guidelines, issued by a panel of smoking cessation experts urge dentists, physicians, nurses and other clinicians to find out if their patients smoke and recommend treatments to help them quit. The 125 page Clinical Practice Guideline entitled, “Smoking Cessation” offers several recommendations such as asking every patient at every visit if s/he smokes, writing a patient’s smoking status in his or her chart under vital signs and prescribing therapy to help patients quit.
As with the dental profession, where the American Dental Association House of Delegates passed a resolution stating “members are encouraged to inform patients of the health hazards of the use of tobacco and especially with young people, warn against acquiring the habit of cigarette smoking.” The chiropractic profession shares this same responsibility.
Certainly the facts are compelling. Smoking is the leading preventable cause of death in the United States. According to the Food and Drug Administration (FDA) and American Cancer Society, tobacco use is responsible for more than 400,000 deaths each year due to cancer, respiratory illness, heart disease and other health problems. Cigarettes kill more Americans than AIDS, alcohol, auto accidents, murders, suicide, illegal drugs and fires combined.
In fact, it is with children and adolescents that smoking has its greatest impact and where we as health professionals can do the most good. Currently, more than three million children and adolescents smoke, and one million adolescent boys use smokeless tobacco. Sadly, due to the addictive nature of nicotine, those who start smoking or using smokeless tobacco are not likely to be able to easily quit on their own-even if they wanted to do so. The US Surgeon General reported that nicotine is more addictive than heroin and cocaine. Moreover, for every person that will quit this year, two others will start smoking. Cigarette smoking is also the number one cause of cancer deaths in men.
There can be no argument concerning the consequences of tobacco use. There are forty-three carcinogens in every cigarette. Among the poisons found in cigarette smoke are ammonia, arsenic, methane, cadmium, carbon monoxide, formaldehyde, butane and hydrogen cyanide. Sadly, the smokeless tobacco alternative to smoking is no healthier. Chewing and dipping tobacco are equally addictive due to their nicotine content.
In addition to the health risks, tobacco products result in a high social cost as well. The Office of Technology Assessment calculated the social costs attributable to smoking to be $68 billion dollars yearly between direct health costs and lost productivity from disabilities and premature death. The cost to the smoker is also high-with a one pack per day smoker paying an average of $728 yearly to support his or her habit. Also, the cost to an employer to keep a smoking employee-due to increased time off due to sickness, smoking-related breaks and diminished productivity-has been estimated to exceed $4,500 yearly.
There are a number of ways for the chiropractic team to support patients in being tobacco-free. Providing this much-needed service can be a great practice-builder, as well as an additional office profit center. Two of the most common means of therapy involve a nicotine replacement strategy with the nicotine patch or gum. Studies show a success rate of about 20% using these products as contrasted with a 10% success rate for those attempting to quit without any support. Side effects and negatives such as bad taste and oral lesions with the gum and irritability, rashes, discoloration and welts with the patch in addition to continued nicotine use makes these less than perfect alternatives.
A nicotine dental floss has also been developed FDA approval. Alternately, an herbal-based nutritional tobacco cessation system is rapidly gaining in popularity. Results and feedback on this five-part program marketed through health professional offices and smoking cessation providers have been promising. One study conducted on several hundred female inmates resulted in a more than 90% success in kicking the habit. Further studies are currently underway on this and similar programs. Doctors recommending these programs report similar success rates with committed users with minimal side effects.
Another advantage of these herbal programs is the absence of continued nicotine dependence with most reporting the ability to be free from tobacco after seven days’ use. Companies offering products such as these usually offer a money-back guarantee when simple guidelines are followed.
Other techniques to quit include hypnosis, acupuncture and group therapy (Smoke Enders, Stop Now, and so on) and have generally mixed rates of success. Unfortunately, the most common methodquitting cold turkeyalso has limited success among most tobacco users who quit and then relapse, trying to quit on several occasions. The National Cancer Institute recommends implementing the four steps outlined in Figure One.
The point I most emphasize is that it is the obligation of the health care provider to assume responsibility for the education of the tobacco-using public while supporting those who choose to be free from their addiction. It is with this goal in mind, and the vision of all health professional offices providing this valuable public service that I founded the Doctors for a Smoke-Free World program. We envision the day when, thanks to our efforts, the public will be clear about the dangers of tobacco use and will see our profession as an ally in their fight to quit and remain tobacco-free.
The National Cancer Institute recommends:
- Asking about tobacco use. Again, the telltale signs of tobacco odor or stained teeth should be followed by asking questions about frequency of tobacco use and the patient’s desire to quit.
- Advising tobacco users to stop. Emphasize the social and personal benefits of stopping, as well as educating the patient about the dangers as relayed by the statistics around tobacco use and health effects.
- Assist patients by helping them set target dates to quit, discussing strategies to be tobacco-free.
- Arrange for continued follow-up visits to monitor their progress and offer support and encouragement.
Recommendations for clinicians
- Identify smokers. Ask every patient at every visit if they smoke.
- Implement a tobacco-user identification system in every clinic.
- Record smoking status as a vital sign.
- Encourage smokers to quit.
- Ask smokers about their desire to quit and reinforce their intentions.
- Give motivational messages to those who aren’t ready to quit.
- Help motivated smokers set a quit date.
- Prescribe nicotine replacement therapy.
- Offer specific, practical advice about how to deal with life as a nonsmoker, particularly how to handle situations or emotional states that may cause relapse.
- Encourage relapsed smokers to try to quit again.
Recommendations for smokers who want to quit
- Be committed. Make sure you’re ready to work hard to quit.
- Talk with your clinician. Discuss nicotine replacement strategies to deal with wanting to smoke again. Do everything you can to maximize the chances for success.
- Set a quit date. Don’t try to “taper off.”
- Build on past mistakes. If you have tried to quit before, think about what helped and what hurt.
- Enlist support. Tell your family and friends you’re quitting. Create a network you can turn to for help.
- Learn how to avoid or cope with situations and behavior that make you want to smoke.
Adapted from the US Department of Health and Human Services’ Smoking Cessation: Quick Reference Guide for Smoking Cessations Specialists