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Howard Speaks

Are You Really a Physician
of the Oral Cavity?



Howard Farran, DDS,
MBA, MAGD
Publisher,
Dentaltown Magazine 		Every healthcare provider knows all too well the diseases caused from smoking. Whether you are a cardiologist doing coronary artery bypass grafts, treating diabetics with amputations, an oncologist treating lung cancer, an emergency room physician treating pneumonia from a patient whose lungs are trashed from smoking, or a periodontist treating someone with severe periodontal disease, everyone in healthcare understands that smoking equals disease with premature death and loss of teeth. So what do you do about it?

There are now two new drugs out for helping people/patients to stop smoking. If you are truly a physician of oral health, you should be prescribing them. Sure there is no insurance code and you won’t make a dime from doing it, but man will you sleep better at night. There are not too many more rewarding things from being a dentist as when a patient comes in and says, “Wow! Dr. Farran it worked! I haven’t smoked in 27 days,” or when a spouse comes in and says, “I can’t believe you got my wife to quit smoking! I thought she would never quit and all because I brought her to you for a cleaning.”
Here are the top 10 reasons you should stop smoking now, according to the World Health Association.

Lung Cancer &
Other Types of Cancer
One of the reasons that smokers are more likely to develop and die from lung cancer is that nicotine suppresses mechanisms in the immune system that would normally prevent the growth of cancerous tumors. Thus, smokers and those who use other forms of tobacco are more likely to develop cancers of all types than a person who does not use tobacco.

Emphysema
In emphysema, the lungs are damaged to the point that they are no longer elastic. It becomes difficult to exhale. It is accompanied by wheezing and shortness of breath and is irreversible. Even if you have been told or you believe that you are in the early stages of this disease, it is still one of the most important reasons to stop smoking, because when people with emphysema stop smoking and avoid all exposure to cigarette smoke, the progression of the disease slows down dramatically.

Heart Disease
Smoking leads to reduced blood flow in the arteries. Eventually this can lead to a heart attack. After one year of not smoking, your risk of developing heart disease is reduced by more than half.

High Blood Pressure
The nicotine and other chemicals in cigarette smoke increase your blood pressure. Over time, this can damage the large arteries and tiny blood vessels. Eventually this can lead to one of the other reasons to stop smoking.

Stroke
Uncontrolled high blood pressure is the number one risk factor for having a stroke. Number four is cigarette smoking. Number two is heart disease, which can be caused by cigarette smoking. After only a few days of not smoking, your blood pressure will be lower, reducing your risk of having a sudden stroke that can end your life or cause permanent brain damage.

Blindness
Smokers are four times more likely to become blind because of age-related macular degeneration than non-smokers. Macular degeneration is a severe and progressive condition in which the central vision is lost. It is one of the most common causes of blindness in the elderly. Former smokers, those who have quit, have only a slightly greater risk than those who never smoked.

Alzheimer’s Disease
The rate of mental decline is five times faster in smokers than in non-smokers. If you have any family history of Alzheimer’s or other neurological conditions, this should be one of your top reasons to stop smoking now, unless you want to be a burden to your family or simply forget them.

Lupus, Rheumatoid Arthritis & Other Auto-immune Diseases
Lupus is a chronic disease that causes pain and inflammation. Eventually there can be tissue damage throughout the body. Current smokers have an increased risk for the development of lupus, but for those who have quit, there is no increased risk.

Rheumatoid arthritis (RA) is a chronic and sometimes disabling disease characterized by painful, swollen joints. Scientists have identified several genetic risk factors for developing RA. Smokers with one of these genetic risk factors are 16 times more likely to have rheumatoid arthritis.

Reasons for Men to Stop Smoking
Infertility, erectile dysfunction and prostate cancer have all been linked to cigarette smoking.

Reasons for Women to Stop Smoking
Increased risk of infertility, an increased chance of miscarriage, an increased risk of giving birth prematurely, giving birth to children with low birth weight, giving birth to children who have colic and losing your child to SIDS. 		The two drugs are Varenicline, also named Chantix; and Bupropion, which for antismoking is called Zyban, and for depression is called Welbutrin. Have you ever prescribed them? Why not ?! You are the physician of the oral cavity, so start acting like one. Personally, what sold me on Chantix was when my chain-smoking baby brother went on it, quit by the eighth day and never looked back.

Jonathan Foulds, MA, MAppSci, PhD, the director of the Tobacco Independence Program, has written several blogs about the effects of Chantix on people who quit smoking. According to his April 15, 2007, blog,

“Chantix appears to target the nicotine receptors in the brain that are involved in producing the rewarding effects from smoking. Chantix is believed to work via two mechanisms:”

1. Chantix binds to nicotine receptors and blocks them so that nicotine can no longer activate those receptors (an effect that pharmacologists sometimes call an “antagonist” effect). This means that when someone is trying to quit and they lapse and smoke a cigarette, they probably won’t get much satisfaction from smoking it, and will be less likely to smoke another.

2. When Chantix binds to nicotine receptors it also triggers some of the same effects that nicotine has (an effect pharmacologists call an “agonist” effect). This includes a small release of dopamine, the reward neurotransmitter in the brain. In this way Chantix dampens down nicotine withdrawal symptoms and cravings.

The results of clinical trials of Chantix have been very encouraging. In all the trials published to date, smokers treated with Chantix had a significantly higher quit rate than smokers treated with a placebo pill (Note: these were “double blind” trials in which no one knew who got the real drug and who received the “dummy” pills until the end). In some of the trials, Chantix was compared to Bupropion (the drug marketed as Zyban for smoking cessation, or Welbutrin for depression). In those trials, more people quit with Bupropion than placebo pills; but Chantix produced higher quit rates than Bupropion. The other interesting finding was that the longer people use Chantix, the more likely they are to “Stay quit.” The standard treatment consists of one week before the “Quit Date” (in which the dose is gradually increased while the person gets used to the drug) and then 12 weeks after the quit date at the full dose (two 1mg pills per day; one with breakfast and the other with dinner). But people who took it for an extra 12 weeks were less likely to relapse. Just recently, a new trial was published. It reported that among smokers who took Chantix for a year, 37 percent remained smoke-free, compared with eight percent among those receiving placebo pills.

Importantly, Chantix appears to have a good side-effect profile. Mild to moderate nausea is the most frequent symptom but it only infrequently leads to discontinuation. Sleep disturbance and abnormal dreams were the next most common side-effects but again these were typically mild.

Although this medicine appears to be very promising, it is important that people don’t expect a magic bullet that makes it easy to stop smoking. While Chantix appears to reduce cravings and withdrawal symptoms and to triple quit rates, people using it still have to put up with some continued urges to smoke. They should use all the usual helpful strategies (preparation, counseling, online support, get rid of tobacco, etc.) to quit smoking as well as the medicine.1

In a later blog, Dr. Foulds writes, while he was at the fourth annual meeting of the Society for Research on Nicotine and Tobacco, David Gonzales of the Health and Sciences University in Portland, Oregon, “presented data on immediate quitting (i.e. those who succeeded in quitting on their target quit date with no lapses) and delayed quitting (i.e. those who had some lapses after the initial target quit date but then managed to get quit and stay quit) among patients treated with either varenicline (Chantix), bupropion (Zyban), or placebo.” Dr. Foulds continues,

For me the interesting thing was that Chantix and Zyban each improved the proportion who initially quit (over placebo), but Chantix also increased the proportion who managed to achieve abstinence after their initial target quit date. Dr. Gonzales presented a nice diagram showing that the number of patients achieving abstinence continued to increase across the first 12 weeks among those on Chantix or Zyban (although it increased faster among those on Chantix).

Colleagues have remarked that patients taking Chantix are less focused on the target quit day (typically day eight of taking Chantix) than we are used to. We think that’s because almost all of the patients we treated before Chantix were also using nicotine replacement therapy (sometimes combined with Zyban/bupropion). The NRT (patch, gum, etc.) is typically started on the target quit day and so patients are very aware of the importance of that day. We don’t typically combine Chantix with NRT (as the Chantix is supposed to block the nicotine receptors in the brain) and so on Chantix it’s easier to see the target quit date as less distinct from any other day and just continue reducing cigarette consumption rather than quitting completely.

The take-home message for patients is that it still makes sense to select a target quit-date (day eight) and to try to quit smoking completely on that day. However, if you don’t immediately “Get quit,” don’t give up on yourself or on the medicines. The evidence suggests that if you keep trying you will likely achieve abstinence, and that Chantix improves your chances, so long as you keep trying and keep taking the medicine. On the other hand, it’s important to be clear that the aim of the game is to quit completely, and it is better in the long run to throw away the cigarettes and get on with it.2

References
1. Foulds, Jonathan "Chantix: How Does This New Quit Smoking Medicine Work?" Healthline.com: Freedom From Smoking. 15 Apr. 2007 .
2. Foulds, Jonathan "Immediate and delayed quitting?" Healthline.com: Freedom From Smoking. 14 Oct. 2007 .
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