Smokefree and smiling: helping dental patients to quit tobacco

helping dental patients to quit tobacco Dh INFORMAtION READER bOx Partnership Working Document Purpose Best Practice Guidance Gateway Ref: 8177 Smoking cessation guidance for primary care dental teams Publication Date General Dental Practitioners Circulation List PCT CEs, Directors of PH Guidance to GDPs on the contribution that dental teams can make to smoking cessation Choosing Better Oral Health Gateway Ref: 4790 Helping Smokers who Want to Quit PCTs to be aware of contribution dentists can make to smoking cessation Jerry Read Dental and Eyecare Division 11th Floor New Kings Beam House 22 Upper Ground London SE1 9BW 020 7633 4132 For Recipient's Use Crown copyright 2007 First published May 2007 Produced by COI for Department of Health The text of this document may be reproduced without formal permission or charge for personal or in-house use.
Executive summary

Smoking and the use of smokeless tobacco have a major impact on both general and oral health 2 SMOKEFREE AND SMILING

Smoking cessation guidance for primary care dental teams Smoking and the use of smokeless tobacco have a major impact on both general and oral health. Choosing Better Oral Health (2005), the Government's Oral Health Plan for England, indicates that tobacco use, and especially smoking, increases the prevalence and severity of periodontal disease, and that smoking 20 cigarettes or more a day amplifies the risk of developing oral cancer sixfold. Chewing tobacco and using smokeless tobacco likewise heighten the risk of developing oral cancer.
Dental teams are well positioned to influence people who are tobacco users, particularly since their patients are often different from those that visit GP surgeries. They therefore have a very important role to play in increasing and supporting the number of people wishing to quit using tobacco. Most dental practices will make a major contribution by providing brief advice and by directing those who would like to quit towards the primary care trust (PCT) smoking cessation services. However, some dental practices may, in association with their PCT, wish to go a stage further – by having staff trained to provide more detailed advice and support. Whichever direction is considered the most appropriate for individual practices, the guidance contained in this booklet will help dental teams play a full and supportive part in encouraging people to stop using tobacco, and thereby to improve both their general and their oral health.
We would like to thank the team led by Professor Richard Watt for producing such an excellent guidance document.
Chief Dental Officer Programme Manager Department of Health Department of Health Tobacco Team SMOKEFREE AND SMILING 3 ExECUtIVE SUMMARY 1. Tobacco use remains a major public health problem in the UK, and is a significant cause of health inequalities. Smoking or chewing tobacco seriously affects general and oral health in a variety of ways. The most significant effects of smoking on the oral cavity are: oral cancers and pre-cancers; increased severity and extent of periodontal diseases; and poor wound healing. Nicotine from tobacco is highly addictive, and, although many smokers want to stop, few succeed unless they receive professional support.
2. Dental teams are ideally placed to become actively involved in tobacco cessation activity. With the establishment of a nationwide network of NHS Stop Smoking Services, a key priority is to ensure that dental teams refer smokers who are motivated to stop to their local NHS Stop Smoking Services, as cessation rates are substantially higher when smokers attend these specialist services. This guidance document seeks to outline ways of developing the active involvement of dental teams in smoking cessation, and of establishing systems of referral to local NHS Stop Smoking Services.
3. Key recommendations: Recommendation 1: All dental patients should have their smoking status (current, ex-, never
smoked) established and checked at regular intervals. This information should be recorded in
the patient's clinical notes.
Recommendation 2: All smokers and chewers of tobacco should be advised both of the value
of stopping, and of the health risks of continuing. The advice should be clear, firm and
personalised. It is essential that the message all smokers take away with them is that only
complete cessation will do.
Recommendation 3: All smokers should be advised of the value of attending their local NHS
Stop Smoking Services for specialised help in going smokefree. Smokers who are interested
and motivated to stop should be referred to these services.
Recommendation 4: In a small minority of cases, dental patients who are smokers and who
want to quit, but who do not wish to use the NHS Stop Smoking Services, should be offered
appropriate help in stopping by their dental team. Only dental team members who have received
accredited training in tobacco cessation should offer this assistance.
Recommendation 5: Primary care trusts (PCTs) are advised to take full account of the potential
that members of dental teams have to contribute to their NHS Stop Smoking Services. Dental
teams should be offered appropriate cessation training, and local systems of referral should
be established.
Recommendation 6: Dental schools are encouraged to develop smoking cessation training for
all members of dental teams.

1. Tobacco use remains a significant public health problem in the UK. Although rates of smoking have declined steadily since the 1970s, the latest figures indicate that 24% of the adult population smoke – approximately 12.5 million people (ONS, 2005). Smoking rates vary across the UK population, and are highest amongst socially disadvantaged groups, amongst men, and amongst young people. The use of smokeless tobacco and/or areca nut (pan) is also common amongst certain ethnic minority groups. 2. Smoking or chewing tobacco can seriously affect general and oral health in a wide variety of ways. At least 50 different diseases are caused by tobacco use, including 30% of all cancers, 90% of all lung disease, 30% of all ischaemic heart disease and strokes, and 70% of all chronic lung disease (Peto et al., 1996). Each year, smoking is responsible for approximately 89,000 premature deaths in England – that is more than 1,700 deaths per week, 244 a day or 10 every hour. The most significant effects of smoking on the oral cavity are: oral cancers and pre-cancers; increased severity and extent of periodontal diseases; and poor wound healing. (Allard et al., 1999).
Recent evidence has highlighted the fact that chewing tobacco causes both oral and pancreatic cancers (Cogliano et al., 2004).
3. The impact of tobacco use on health is alarming. But the benefits of stopping are substantial, particularly for people under 35 years of age: if they quit successfully, they will have a normal life expectancy. Many of the adverse effects of tobacco use on the oral tissues are reversible. This provides a useful means of motivating patients to stop. 4. Nicotine from tobacco, whether smoked or chewed, is highly addictive, and therefore stopping is a major challenge for most users. The majority of cigarette smokers report that they would like to stop, and they do make many attempts to quit. Over a 12-month period, nearly half of smokers will make a quit attempt, but only a very small number will successfully stop unassisted (West et al., 2006). Cessation rates are lowest amongst more dependent smokers.

5. Dental teams are ideally placed to get actively involved in tobacco cessation activity. Nearly 60% of the adult UK population visits a dentist for regular checkups. Dental teams are therefore in a unique position to provide opportunistic advice to a large number of ‘healthy' people who may be using tobacco and who need professional support to stop. Dental teams working in the primary care, salaried services and in hospitals also have a potentially important role to play in cessation. Surveys indicate that dental teams have an increasingly positive attitude towards tobacco cessation and are becoming more actively involved (John et al., 2003; Johnson et al., 2006). As health professionals, they have an ethical duty of care to provide their patients with evidence-based treatment and prevention, including tobacco cessation advice. However, many dental practitioners still do not routinely record information on tobacco use, or advise smokers to quit.
Jenny Godson (Consultant in Dental Public Health, Bradford and Airedale Teaching
Primary Care Trust)

Jenny has been active in the task of involving local dental teams in smoking cessation.
" In this area, we have several dental practices that are actively engaged in smoking cessation. In one particular practice, dentists and a hygienist have attended a smoking cessation training course and are currently rolling out a programme in a multi-surgery NHS practice. All the dentists in the practice are now routinely recording their patients' smoking status and assessing smokers' readiness to quit. A monitoring system is being established and real progress is being made." In the Bradford and Airedale area, good links have also been established between local dentists and the Stop Smoking Services.
" Many dentists in this area are providing brief advice to their patients and referring smokers who want help to quit to either the main Stop Smoking Services or cessation services run by local GPs. The signposting system seems to be working very well." 6 SMOKEFREE AND SMILING 6. Reducing tobacco use is a key priority for the NHS (Department of Health, 1999; Department of Health, 2004a), and is included as an important element in promoting better oral health (Department of Health, 2005). A major part of the Government's smoking strategy has been the establishment of a nationwide network of NHS Stop Smoking Services. Based within primary care trusts (PCTs), these services provide smokers with evidence-based treatment and support. Cessation rates amongst smokers who use these services are substantially higher than amongst those who receive advice from primary care professionals (West et al., 2000). A key priority is, therefore, to ensure that primary care professionals, such as members of a dental team, refer smokers who are motivated to stop to their local NHS Stop Smoking Services. The links between dental services and NHS Stop Smoking Services vary greatly across the country. In some areas, very good working relationships have been established, with dental practitioners frequently referring smokers to their local NHS Stop Smoking Services for specialist support and advice. In other areas, contact between the services is minimal.
7. A variety of guidelines has been published to encourage health professionals, including dental teams, to deliver effective cessation advice and support (Fiore et al., 2000; West et al., 2000; NICE, 2006; Beaglehole and Watt, 2004). The 2006 Dental Contract aims to provide an opportunity to enhance the scope and quality of preventive care offered by dental teams. This document aims to provide updated guidance for PCTs and dental teams on how they can contribute to the achievement of government targets for reducing tobacco use, and in particular to: further develop the active involvement of dental teams in tobacco cessation, and establish appropriate systems for referral to the local NHS Stop Smoking Services; encourage the delivery and uptake of tobacco cessation training opportunities for dental coordinate existing tobacco cessation resources and materials for dental teams.
8. Smoking cessation guidelines recommend that all health professionals, including dental
team members, should check the smoking status of their patients at least once a year, and
should advise all smokers to stop smoking (Fiore et al., 2000; West et al., 2000; NICE, 2006).
Smokers who want help in quitting should be referred to their local NHS Stop Smoking Services.
A tobacco cessation care pathway for dental practice is summarised in Figure 1 overleaf.

FIGURE 1: tObACCO CESSAtION CARE PAthWAY FOR DENtAL PRACtICE Establish and check Advise all tobacco Assess interest and at regular intervals users to stop.
motivation to quit.
patient's smoking/ tobacco use status.
their oral health " Are you interested " If you are interested complete cessation.
in stopping smoking, Highlight benefits there are services of quitting.
and treatments that can help you quit. Would you " You probably know be interested in smoking is harmful stopping smoking?" to your health but did you realise " The NHS provides Congratulate and free and effective stress benefit to oral health.
causes oral cancer? I strongly advise them quit. In fact, " Well done for not you to stop smoking with professional as soon as possible." help you are four may know, smoking times more likely " Let me show you to quit than trying to your general and by yourself. Are you affecting your gums " When did you quit?" interested in such and mouth. These changes can be reversed if you stop smoking. I advise you to stop smoking as soon as possible." Modified: Needleman et al.; 2006 8 SMOKEFREE AND SMILING

FIGURE 1: tObACCO CESSAtION CARE PAthWAY FOR DENtAL PRACtICE Stress value of receiving Provide information YES Congratulate and professional help with on how to contact visit, establish quitting. Emphasise treatment greatly Smoking Services increases chance of " Would you like me to refer you to the local NHS Stop Smoking YES Services, where there YES interested in quitting are people who are but does not wish trained to give you to attend NHS Stop expert advice and Smoking Services, offer brief advice:– set quit date " Are you interested in going to the local NHS Stop Smoking Services previous attempts for advice on quitting? The service is free and – discuss ways of dealing with withdrawal Emphasise benefits of quitting on oral health.
– highlight value of Provide leaflets how to access this about quitting and information on NHS – give details of Stop Smoking Services.
– provide leaflets – arrange follow-up Accept answer in non- judgemental manner.
Acknowledge decision and advise that you will ask again at future recall appointment.
Emphasise that you will always be available to discuss stopping smoking in the future.
SMOKEFREE AND SMILING 9 9. In the vast majority of cases, dental teams will only be involved in delivering brief advice to smokers. This should take less than five minutes of their time. The key elements in brief advice include: All patients should have their smoking status (current, ex-, never smoked) established and checked at regular intervals. This information should be recorded in the patient's clinical notes. The British Dental Association (BDA) medical history form includes suitable questions on tobacco use. Smokers should then be asked some simple questions, in order to assess their degree of interest in stopping smoking. All smokers and chewers of tobacco should be advised both of the value of stopping, and of the health risks of continuing. The advice should be clear, firm and personalised. It is essential that the message all smokers take away with them is that only complete cessation will do. Cutting down on the number of cigarettes smoked or changing to a lower-tar brand will not in itself yield a significant health benefit. Smokers compensate for the reduced number or type of cigarettes by smoking each cigarette more intensively (Benowitz et al., 1986). Although most people know of the risks of tobacco use in relation to cancers and heart disease, fewer are aware of the detrimental effects on the mouth. Dental teams thus have a unique opportunity to highlight the dangers of tobacco use. The early signs of tobacco use – such as tooth staining, changes to the soft tissues and halitosis – are easily identified and are reversible, and this provides a useful means of motivating smokers to stop.
All smokers should be advised of the value of attending their local NHS Stop Smoking Services for specialised help in stopping. Smokers who are interested and motivated to stop should be referred to these services (see paragraphs 11 and 12 below).
Lt Kay Birkin (Smoking Cessation Coordinator, Defence Dental Services)
Lt Kay Birkin became involved in setting up cessation services across the Defence Dental Services after an initiative linked to No Smoking Day three years ago. Lt Birkin explained that, because the armed services require their personnel to have an annual checkup, she and her staff are able to track the progress of smokers who are referred to cessation advisors through dental checkups.
" The Defence Dental Services have been involved for the past three years in a project with the Department of Health to improve smoking cessation services within the military, and as part of that we have been training the majority of our dental hygienists as smoking cessation advisors to deliver brief advice within our practices." Dental patients who are smokers are asked whether they would be interested in cessation help, and, if so, are referred to either a medical centre or the local cessation service.

10. In a small minority of cases, dental patients who are smokers and who want to quit, but who do not wish to use the NHS Stop Smoking Services, should be offered appropriate help in stopping by their dental team (see paragraph 16 below). Only dental team members who have received accredited training in tobacco cessation should offer this assistance.
11. In 2000, a national network of NHS Stop Smoking
Services was established to provide smokers with
specialist treatment and support. Each PCT now offers
both one-to-one treatment and group sessions, both
options delivered by trained advisors on a weekly basis,
normally over a 6–7-week period. The treatment is based on withdrawal-oriented therapy and
focuses on preventing relapse in the early stages of quitting, by providing intensive support and
supervised use of medication. In addition, specialist advisors are often employed to provide
support for priority groups, such as pregnant smokers, young people and certain ethnic minority
groups. Smokers can access the service either direct or through referral by a health professional.
To date, the majority of referrals have been through GPs and practice nurses. However, other
primary care professionals, such as dentists and pharmacists, are potentially very important
sources of suitable referrals to these services. Details of the local NHS Stop Smoking
Services can be obtained from the NHS Smoking Helpline (0800 169 0 169), by visiting
through the PCT Public Health department.
Val Mills (Manager, Buckinghamshire Stop Smoking Service)
Val has established very good links with local primary care dental teams and oral health promotion staff. " We have a good relationship with local dental teams. Placing items in the primary dental care newsletter and sending leaflets direct to dentists have helped us communicate with dental professionals locally." The Buckinghamshire Stop Smoking Service also has good links with the local oral health promotion team, who are very interested in this area of health improvement. Local dentists and the oral health promotion team now refer dental patients for smoking cessation support.
" The referral system is working well. The dentists and oral health promoters only refer people who want to quit." A range of training courses is offered to primary care professionals – from two-day Level 2 workshops to short courses on particular issues, such as NRT. Again, with the particular training courses on offer, the Buckinghamshire service has managed to engage with dental teams.
SMOKEFREE AND SMILING 11 12. The NHS Stop Smoking Services have helped many thousands of smokers stop successfully. Each year, approximately 330,000 smokers have quit by using these services. Indeed, smokers are four times more likely to stop successfully if they attend these services and use medication, rather than try to quit on their own without medication. As a result, policy guidance to health professionals now emphasises the importance of referring all smokers who wish to quit to their local NHS Stop Smoking Services for specialist assistance and support (NICE, 2006). 13. Dental teams and the local NHS Stop Smoking Services can work collaboratively in a variety of ways. As a first step, though, it is important that all members of a dental team are fully aware of the services offered locally and of how these are operated. Arranging a meeting with a representative of a local service could provide a useful opportunity for dental teams to learn about the service and the best ways of referring dental patients to it. Many NHS Stop Smoking Services have developed postcards and posters about their services for display in dental waiting rooms.
14. It is important, however, that smokers who are interested in making a quit attempt are referred for specialist support. Timing is crucially important: the smoker should be seen quickly by a local service, while they are still motivated and interested in making a quit attempt. Dental patients who are identified as smokers, and who express a desire to quit, should therefore be actively encouraged to visit their local NHS Stop Smoking Services to get specialist support. It may motivate a smoker to attend if practical information is provided about the type of support that is offered and about the appointments system, along with reassurance that the service is free. Some dental practices actually make an appointment; others merely provide encouragement.
Kerry Blake (dental patient and ex-smoker)
Kerry had smoked since she was 13 and had tried to stop before, but without any success. She explains that her relapse was not through lack of trying, but that she just didn't have the right motivation. She was referred to the hygienist at her local dentist, after expressing concern about her own oral and general health. Despite her earlier failed attempt to quit, Kerry was determined that, supported by her hygienist, she would go smokefree.
" Going to the sessions at my local dentist's gave me the motivation I needed to carry on and see the quit attempt through." Kerry was determined that this time she wasn't going to make excuses about stopping; she set a quit date and worked towards it with the help of her hygienist.
At her local practice, Kerry's hygienist got her to blow into a carbon monoxide monitor, and she was able to record the decreased levels of carbon monoxide as Kerry withdrew from cigarettes. Speaking about her hygienist, Kerry says:" Alison has always been a familiar face. She is fair but she is able to put her foot down when you make excuses. Now I am in control and smoking isn't! My biggest question now is why did no one ever tel me my breath smel ed so bad?! I was worn out and breathing was real y difficult. I am not going back." 12 SMOKEFREE AND SMILING 15. Depending on the availability of resources, in certain areas PCTs reimburse dentists for referring smokers to the NHS Stop Smoking Services. Although this is certainly an incentive, such an arrangement can only succeed in the longer term if there is good communication between the respective local services. However the referral is made, it is important that the patient's progress in stopping is assessed at a subsequent dental appointment and is recorded in their clinical notes. Stopping tobacco use is a difficult process and is associated with a range of unpleasant, short-term withdrawal symptoms, some of which, such as a dry mouth and ulcers, directly affect the oral cavity. Reassurance and advice from dental team members may help patients deal more effectively with these problems, thereby increasing their chances of quitting successfully. PROVIDING MORE DETAILED ADVICE WHEN
16. When smokers express a desire to stop, but are unwilling
to attend their local NHS Stop Smoking Services, advice
and support should be offered by their dental team. Most
smokers are, however, willing and keen to receive specialist
support, especially once they are informed about how the
service is offered and its success rates. Therefore, relatively
few dental patients should require assistance from their
dental team to quit. More detailed advice and support for
smokers should only be provided by dental staff that have
completed a recognised cessation training programme
(see paragraph 28 below), and in dental practices that have
the necessary resources available, e.g. carbon monoxide
monitors. The following guidelines could be used when
delivering brief interventions in a dental practice setting:
Ensure that the patient is ready to stop smoking and to stop for good.
Highlight the benefits of quitting and show the effects of tobacco use on the oral tissues.
Explain the importance of total cessation and stress the limitations of merely cutting down.
Assess the level of tobacco dependence.
Agree a quit date and recommend suitable preparation.
Explain the nature and duration of withdrawal symptoms.
Discuss the value of using medications that aid cessation (nicotine replacement therapy (NRT), bupropion and varenicline) and arrange a supply of the products selected in consultation with local Stop Smoking Services (see paragraphs 19 and 20 below).
Measure carbon monoxide levels before quitting and at subsequent review appointments. Provide information on the telephone helplines available. The NHS Smoking Helpline (0800 169 0 169) is open daily from 7am to 11pm. Help is also available on Asian-language helplines. Pregnant smokers should be directed to the NHS Pregnancy Smoking Helpline (0800 169 9 169), open daily from noon to 9pm. Other suitable leaflets can also be given.
SMOKEFREE AND SMILING 13 the health benefits of stopping smoking are substantial 14 SMOKEFREE AND SMILING Ideally, patients should be seen on a weekly basis for the first five weeks after their quit date, in order to assess progress and provide encouragement.
Monitoring and longer-term follow-up are essential. A patient's smoking status should be assessed at subsequent recall appointments. 17. The provision of tobacco cessation advice and support requires a team approach in the dental surgery. Good communication between team members is essential, as is the delegation of different roles and responsibilities. Dentists, for example, may be responsible for coordinating the team's activities, assessing the smoking status of patients, and referring motivated smokers for specialist support. Suitably trained dental care professionals may be more involved in providing information and support for smokers attending the dental surgery.
18. Several issues have emerged recently in the tobacco cessation field that have a direct
impact on oral health. These topics will now be reviewed to provide clarification.
19. Guidelines recommend that NRT should be offered to all smokers who want to stop, as use of NRT doubles a smoker's chances of quitting (Fiore et al., 2000; West et al., 2000; NICE, 2002). NRT is a safe means of helping smokers deal with withdrawal symptoms. Six different NRT products are currently available (gum, patch, nasal spray, inhaler, lozenge and sublingual tablet), all with similar success rates. These products are provided free of charge at NHS Stop Smoking Services, can be obtained on prescription from GPs or bought over the counter at pharmacies and other retail outlets. At present, dentists are not able to prescribe NRT, because NRT is not included in the Secretary of State's list for dental prescribing for NHS patients. This may be subject to review in the future.
20. Aside from NRT, the other effective pharmacotherapy used in tobacco cessation is bupropion (Zyban), an atypical antidepressant. This product is only available on GP prescription or through the NHS Stop Smoking Services. Due to its potential serious side effects and interaction with other medications, dentists cannot prescribe this drug, and this situation is highly unlikely to change. Another promising new pharmacotherapy, varenicline (Champix), became available as a prescription-only medicine in the UK in December 2006. There are no serious side effects or drug interactions associated with varenicline. While not presently available for NHS dental prescribing, this may also become subject to review. USE OF SMOKELESS TOBACCO
21. Amongst certain ethnic minority groups, chewing tobacco and/or areca nut (pan) is a common cultural practice. Evidence indicates that chewing tobacco and other products is associated with the development of oral cancers and other oral pathologies (Gupta and Warnakulasuriya, 2002; Cogliano et al., 2004). A recent Cochrane systematic review showed that advice delivered in dental surgeries is effective in helping patients who chew tobacco to stop (Carr and Ebbert, 2006). Current guidelines on the use of smokeless tobacco recommend that patients who chew tobacco should be supported to stop (West et al., 2004).
SMOKEFREE AND SMILING 15 22. A degree of controversy has, however, emerged over recommendations on ‘Snus', an oral, smokeless tobacco product that is illegal in the UK and most of the EU, but widely used in Sweden and Norway. Certain academics, anti-smoking groups and tobacco companies are calling for the restrictions on ‘Snus' to be relaxed, and indeed are advocating its use in tobacco cessation treatment, as a harm-minimisation measure. They argue that the use of ‘Snus' is relatively safe, and is much less harmful than smoking tobacco. Although the risks associated with smoking tobacco are undoubtedly higher overall, a reduced risk is not the same as no risk. Evidence clearly indicates that smokeless tobacco causes both oral and pancreatic cancers (Cogliano et al., 2004). It is therefore unethical for health professionals to recommend to smokers that they switch from smoking to using smokeless tobacco products. Indeed, there is only very limited evidence that using ‘Snus' is an effective way to quit smoking. Public health messages need to be consistent and evidence based in order to avoid confusion.
23. Some NHS Stop Smoking Services recommend glucose tablets as a means of dealing with nicotine cravings. The frequent consumption of sugar is the main cause of dental caries, and this needs to be considered in any recommendation to use glucose tablets. Glucose has been shown to reduce the urge to smoke and, in a small number of studies, to increase short-term abstinence rates (West, 2001). However, at present the use of glucose tablets is not a recommended element in tobacco cessation treatment (Fiore et al., 2000; West et al., 2000; NICE, 2006). In the absence of high-quality evidence that they help in cessation, and because of concerns that they may promote the development of dental caries, glucose tablets should not be recommended in tobacco cessation treatment.
24. PCTs are required to provide NHS Stop Smoking Services that meet minimum quality
standards covering the training of staff, the prescription of medication, the monitoring of
their activities and the recording of their results. Coordinators of Stop Smoking Services are
responsible for working with health providers – including family health service contractors and
other stakeholders, such as local authorities, community groups, local businesses, schools,
etc. – to ensure comprehensive service provision across the PCT area that adequately meets
the needs of clients. Furthermore, Standards for Better Health (Department of Health,
2004b) outlines the clinical governance requirements for PCTs to ensure that prevention
and health-promotion interventions exist to tackle smoking. In turn, the Clinical Governance
Framework for Primary Dental Care Services (Primary Care Contracting, 2006) emphasises the
contribution of primary dental care teams to tobacco use cessation.
25. PCTs are advised to take full account of the potential that members of dental teams have to contribute to their NHS Stop Smoking Services, and, in particular, to the regular access that staff working in NHS primary dental care settings have to patients who may not regularly attend any other part of the NHS. In commissioning services, PCTs could ensure that dental practices follow the guidelines outlined above (paragraph 16) – in particular to assess the smoking status of their patients, advise smokers of the benefits of quitting, and refer motivated smokers to the local NHS Stop Smoking Services. As a step towards monitoring these patient contacts, PCTs need to consider including dental practices in the monitoring and 16 SMOKEFREE AND SMILING information-gathering activities the PCTs are required to undertake in line with the Department of Health's Public Service Agreement on smoking. PCTs could also ensure that any training on smoking and tobacco use cessation that is provided to staff in direct contact with patients in primary or secondary care is also made available to members of their dental teams.
26. In recognition of the fact that, in a small minority of cases, smokers may opt to receive cessation support from their dental team, the PCT could ensure that the local Stop Smoking Services are able to support and advise dental practices in this activity. The Stop Smoking Services may choose to nominate selected dental teams to make a more formal contribution to smoking cessation by regularly supporting patients who have convenient access to the practices. Any dental practices that take on this role will need to abide by service protocols in terms of data collection and reporting procedures. There is an argument for funding this wider role from the smoking cessation budget, rather than from the budget for primary care dental services.
27. Pending any extension to the prescribing rights of dentists, PCTs could ensure that local Stop Smoking Services make arrangements for dental practices to refer patients for prescription of NRT.
Mary Drainer (Oral Health Advisor, Buckinghamshire PCT)
Mary believes it is very important to highlight the damage smoking does to patients' oral health.
" A smoker, especially a young smoker, hasn't always thought about the effect of smoking on the mouth." Mary is used to helping smokers of all ages quit, but she says that, with young smokers, it is important to" plant a seed; explaining the damage that smoking will do cosmetically can often be very effective." In Mary's experience, the way an oral health advisor or dentist uses language to help a smoker quit is very important. " Most smokers associate stopping smoking with an increase in stress, so the language you use is crucial. It is very important to use positive messages, coupled with questions like ‘have you considered stopping smoking?' rather than stigmatising the smoker." Another issue that smokers do not always realise is the effect tobacco use has on the success of their dental treatment. A smoker's soft tissues will take much longer to heal than a non-smoker's, and the risk of severe infection is increased.
" While someone remains a smoker, comprehensive dental treatment is a Mary is also concerned about oral cancer.
"It is important that we raise the profile of mouth cancer." She says that most smokers understand the dangers of other types of cancer, but have not considered the damage and facial disfiguration that oral cancer can cause.
28. As in any area of clinical and preventive
practice, appropriate training is essential to
enable dental teams to deliver tobacco cessation
support and advice. Undergraduate dental
students are taught in detail the oral pathology
associated with tobacco use and, to a more limited
extent, tobacco cessation (Health Development
Agency, 2005). During their basic training, other
members of the dental team may be exposed
to more teaching on tobacco cessation. A clear
need exists, however, to develop further the
competency of dental teams in tobacco cessation.
Revision of the General Dental Council's guidelines
on the dental undergraduate curriculum provides
an opportunity for greater emphasis to be placed on tobacco cessation as a core-learning
outcome. There is also a need for continuing education programmes covering tobacco cessation
and for input into postgraduate dental programmes. For example, placements at the local
Stop Smoking Services could be included in vocational training programmes, in order to enable
trainees to become more familiar with the treatments and support offered to smokers and the
best means of referring smokers to the services.
29. Based upon the Health Development Agency's (2003) Standard for Training in Smoking Cessation Treatments, NICE (2007) is soon to publish a training programme specifically designed for dental teams. The training resource has been developed to raise dental teams' awareness and knowledge of tobacco use cessation, and to develop the practical skills needed to deliver effective advice and support in a clinical dental setting. The programme consists of two parts: the first is a one-hour session designed for delivery at continuing professional development training events; the second element is a modular two-day programme that aims to develop dental teams' cessation skills and competencies. The training materials are designed to be delivered flexibly, by trainers from the local NHS Stop Smoking Services and oral health promotion staff. A variety of local training initiatives have also been developed across the country. It is important that any training delivered should conform to recognised published standards and be delivered by suitably trained personnel (Health Development Agency, 2003).
30. Choosing Better Oral Health: An Oral Health Plan for England. Department of Health, 2005.
Linked directly to the broader public health agenda, this document outlines approaches needed
to promote oral health and reduce inequalities across England. A key priority is the need for
dental teams to become more actively engaged in tobacco cessation activity.
18 SMOKEFREE AND SMILING 31. Brief Interventions and Referral for Smoking Cessation in Primary Care and Other Settings.
National Institute for Health and Clinical Excellence, 2006.
Based upon a comprehensive and detailed review of the available evidence, this document
outlines guidance on brief smoking cessation interventions and on referrals to specialist services.
32. An additional smoking cessation training resource for dental teams is planned for publication by the National Institute for Health and Clinical Excellence at the same time as this guidance (NICE, 2007). Based upon national cessation training guidelines, this flexible training resource has been produced to develop the knowledge of dental teams and, in particular, the practical skills they need to deliver effective tobacco cessation. 33. Helping Smokers Stop: A Guide for the Dental Team. Health Development Agency, 2004.
This is a joint publication by the Health Development Agency and the British Dental Association,
and it outlines practical ways in which a dental team can effectively help smokers quit successfully.
It includes practical case studies to illustrate ways of incorporating cessation activity into
routine clinical practice. Available at:
34. Proceedings of the 1st European Workshop on Tobacco Use, Prevention and Cessation for
Oral Health Professionals, published in Oral Health and Preventive Dentistry 2006; 4:1–77.
This is a detailed report on a workshop that reviewed all aspects of tobacco use and cessation
for oral health professionals. It includes papers on public health aspects of tobacco control, an
evaluation of tobacco cessation in the dental surgery, cessation in dental and dental hygiene
undergraduate education, and cessation in continuing education for dentists and hygienists.
A useful tobacco cessation care pathway is also presented.
35. Tobacco or Oral Health: An Advocacy Guide for Oral Health Professionals. FDI World Dental
Press, 2005.
This guide, developed jointly by the FDI World Dental Federation and the World Health
Organization, provides an overview of tobacco facts, discusses the role of the dental team in
tobacco control, examines the role of advocacy, and provides a number of recommendations on
ways of moving the tobacco control agenda forwards.
36. McEwen, A., McRobbie, H., West, R. and Hajek, P. Manual of Smoking Cessation: A Guide for
Counsellors and Practitioners.
Blackwell, 2006.
Written by leading experts in smoking cessation, this guide provides a detailed account of all
aspects of smoking cessation. An essential reference document.
37. Resources for use in dental surgeries include: Stop Smoking! Save your mouth…and your life – a smoking cessation leaflet for the dental
surgery. Produced by the BDA, Action on Smoking and Health (ASH) and GlaxoSmithKline Consumer Health, it is free to BDA members.
a website that includes information on local NHS Stop Smoking Services and other smoking cessation leaflets and resources.
Fiona Andrews, Regional Tobacco Policy Manager, NHS South West
John Beal, Consultant in Dental Public Health, Leeds PCT Amit Bose, Policy Manager, Department of Health Tom Dyer, GDP and Clinical Lecturer in Dental Public Health, University of Sheffield Claire Lowe, Senior Policy Officer, British Dental Association Tony Jenner, Deputy Chief Dental Officer, Department of Health Andy McEwen, Senior Research Nurse, University College London Lesley Owen, Analyst – Public Health, National Institute for Health and Clinical Excellence Jerry Read, Project Lead – Oral Health Promotion, Department of Health Mabel Slater, Director of Dental Care Professionals, King's College London Richard Watt (Chair), Professor of Dental Public Health, University College London Liana Zoitopoulos, Consultant in Community Special Care Dentistry, King's College London Allard, R., Johnson, N., Sardella, A. et al. Tobacco and oral diseases: Report of EU Working Group. Journal of the Irish Dental Association 1999; 46:12–23.
Beaglehole, R. H., Watt, R. G. Helping Smokers Stop: A Guide for the Dental Team. London: Health Development Agency, 2004.
Benowitz, N., Jacob, P., Kozlowski, L., Yu, L. Influence of smoking fewer cigarettes on exposure to tar, nicotine and carbon monoxide. New England Journal of Medicine 1986; 315:1310–13.
Carr, A. B., Ebbert, J. O. Interventions for tobacco cessation in the dental setting. Cochrane Database of Systematic Reviews 2006, Issue 1.
Cogliano, V., Straif, K., Baab, R., Grosse, Y., Secretan, B., Ghissassi, F. E. Smokeless tobacco and tobacco-related nitrosamines. The Lancet Oncology 2004; 5:708.
Department of Health. Smoking Kills – A White Paper on Tobacco. London: Stationery Office, 1999.
Department of Health. Choosing Health: Making Healthier Choices Easier. London: Stationery Office, 2004a.
Department of Health. Standards for Better Health. London: Stationery Office, 2004b.
Department of Health. Choosing Better Oral Health. London: Stationery Office, 2005. FDI/World Health Organization. Tobacco or Oral Health: An Advocacy Guide for Oral Health Professionals. Lowestoft: FDI World Dental Press, 2005.
20 SMOKEFREE AND SMILING Fiore, M. C., Bailey, W. C., Cohen, S. J. et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville: US Department of Health and Human Services, 2000.
Gupta, P. C., Warnakulasuriya, K. A. A. S. Global epidemiology of areca nut usage. Addiction Biology 2002; 7:77–83.
Health Development Agency. Standard for Training in Smoking Cessation Treatments. London: Health Development Agency, 2003.
Health Development Agency. Tobacco and Oral Health: A Survey of Dental Education and Training in Tobacco Issues. London: Health Development Agency, 2005. John, J. H., Thomas, D., Richards, D. Smoking cessation interventions in the Oxford region: Changes in dentists' attitudes and reported practices 1996–2001. British Dental Journal 2003; 195:270–75.
Johnson, N. W., Lowe, J. C., Warnakulasuriya, K. A. A. S. Tobacco cessation activities of UK dentists in primary care: Signs of improvement. British Dental Journal 2006; 200:85–89.
National Institute for Health and Clinical Excellence. Brief Interventions and Referral for Smoking Cessation in Primary Care and Other Settings. London: NICE, 2006.
National Institute for Health and Clinical Excellence. Guidance on the Use of Nicotine Replacement Therapy (NRT) and Bupropion for Smoking Cessation. London: NICE, 2002.
Needleman, I., Warnakulasuriya, K. A. A. S., Sutherland, G., Bornstein, M., Casals, E., Dietrich, T., Suvan, J. Evaluation of tobacco use cessation (TUC) counselling in the dental office. Oral Health and Preventive Dentistry 2006; 4:27–48.
Office for National Statistics (ONS). General Household Survey, 2003–2004. London: Office for National Statistics, 2005.
Peto, R., Lopez, A. D., Boreham, J. et al. Mortality from smoking worldwide. British Medical Bulletin 1996; 52:12–21.
Primary Care Contracting. Primary Care Dental Services Clinical Governance Framework. London: Stationery Office, 2006.
West, R. Glucose for smoking cessation: Does it have a role? CNS Drugs 2001; 15:261–65.
West, R., McEwen, A., Bates, C. Sex and Smoking: Comparisons between Male and Female Smokers: A Report for No Smoking Day. London: No Smoking Day, 2006.
West, R., McNeil, A., Raw, M. Smoking cessation guidelines for health professionals: An update. Thorax 2000; 55:987–99.
West, R., McNeil, A., Raw, M. Smokeless tobacco cessation guidelines for health professionals in England. British Dental Journal 2004; 196:611–17.
SMOKEFREE AND SMILING 21 Crown copyright 2007281637 1p 10k May 07 (ESP)Produced by COI for the Department of Health If you require further copies of this title quote 281637/Smokefree and Smiling: helping dental patients to quit tobacco and contact: DH Publications OrderlinePO Box 777, London SE1 6XH E-mail: Tel: 08701 555 455Fax: 01623 724 524Textphone: 08700 102 870 (8am to 6pm Monday to Friday)


Proteccionismo, filibusterismo, libre comercio: José Martí y los tratados comerciales José Luis Díaz Naranjo Director Académico, Campus Pérez Zeledón, Sede Regional Brunca, Universidad Nacional. Profesor de Economía. Correo electrónico:; Recibido: Febrero 2014 • Aceptado: Mayo 2014 Aun cuando los tratados de libre comercio se han constituido en los principales instrumentos de regulación en lo comercial, entre países, en los últimos 25 años, estos han sido un referente constante en los procesos bilaterales y multilaterales de negociación en esta materia. Como prác-tica se remonta al siglo XIX. En este sentido José Martí, héroe cubano, desarrolla un análisis del acuerdo comercial entre México y los Estados Unidos, propuesto en 1883, que mantiene vigencia, sobre la base de los preceptos en los que se fundamenta, el tráfico de mercancías y uso de recursos de todo tipo. Los acuerdos de esta naturaleza responden a estrategias propias del proceso de acumulación de capital, dentro del marco de la realización de la ganancia. Este artículo hace referencia al análisis martiano y su expresión en el proceso de globalización del signo actual, el referido a los tratados de libre comercio como medios de expansión y dominio político y económico.

Microsoft word - brey_2008_human-enhancement.doc

This is a preprint version of the following article: Brey, P. (2008). ‘Human Enhancement and Personal Identity', Ed. Berg Olsen, J., Selinger, E., Riis, S., New Waves in Philosophy of Technology. New Waves in Philosophy Series, New York: Palgrave Macmillan, 169-185. Human Enhancement and Personal Identity 1. Introduction Human enhancement, also called human augmentation, is an emerging field within