Cessation program expands

A $1.5 million grant from the Cancer Prevention and Research Institute of Texas will help more Texans kick the habit over the next three years.

The additional funding—awarded to Co-Principle Investigators Dr. Daniel Jones and Dr. Crystal Stinson—will allow Texas A&M College of Dentistry’s public health sciences department to expand its tobacco cessation program at nearby Agape Clinic and North Dallas Shared Ministries, says Katharine Miller Nimmons, who serves as program coordinator and evaluator for the CPRIT program.

These community clinics are staffed by public health sciences employees and offer dental health services at an affordable price to those who qualify. The Agape Clinic is sliding scale and donation based, while NDSM offers free services to clients in select ZIP codes. The clinics are a similar model to how UT Southwestern and Parkland Memorial Hospital offer medical services to the underserved in Dallas County, offering dental health care instead.

Before the grant became available this spring, clinic dental patients who expressed an interest in quitting had to make a separate appointment at the college to see the one-and-only certified tobacco cessation counselor.

“That’s a great program, but it’s not reaching as many patients as it could,” says Nimmons, manager of research projects administration in public health sciences. “This grant allows us to build on resources we already have, but increase capacity, then offer more locations and start offering cessation meds as well.”

With increased resources, the number of clients who can begin tobacco cessation treatment will essentially triple. Stinson was recently certified as an additional tobacco treatment specialist. Hiring a third counselor, who will be a native Spanish speaker, is in the works. Beyond that, funds will also help provide nicotine replacement therapy, such as patches, lozenges, gum and medication, Nimmons says.

When all program components are in place after the first year, a blueprint will be shared with the dental hygiene program at Texas Woman’s University in Denton County. The Texas A&M College of Dentistry program will emphasize continuing education, highlighting the link between tobacco cessation and overall oral health. In the third year, the dental hygiene program at Amarillo College will take the same road map and use it for patient care in Potter County.

“We targeted those areas because when we applied for the grant, there was not a big CPRIT tobacco cessation footprint. Texas is a statewide program, but they did not have many CPRIT programs in those counties,” Nimmons says.

All patients who come through the clinics are screened for tobacco use. Dental professionals use that opportunity to query their readiness to quit smoking. With the grant, the staff is able to offer free onsite cessation counseling and nicotine replacement therapy.

“Most people really do want to quit,” Stinson says. “In the general population, 70% to 80% of smokers want to quit and have tried.”

It usually takes multiple cessation attempts to quit before it sticks, varying by person, Nimmons says. In reporting their grant outcomes to the state, they’ll base their findings on clients who have been tobacco free for six and 12 months.

“The evidence does show that the most successful quit attempts are a combination of counseling and medication-assisted treatment,” Nimmons says.

Smokers are often surprised, Stinson says, to report that conquering a nicotine addiction is much harder than quitting heroin, cocaine, alcohol and even opioids.

“The remodeling that happens in your reward system because of nicotine makes it really hard for smokers to quit,” she says. “A lot of smokers are substance abuse users, too. They’ll say, ‘I quit what was supposed to be the worst thing in the world, but I can’t quit this.’ They want to and try over and over and can’t. But that’s the science of addiction, and that’s what the tobacco industry capitalized on.”

The CPRIT grant targets the most vulnerable populations and adjusts existing barriers to increase cessation, Stinson says.

According to Center for Disease Control and Prevention statistics, smoking is disproportionately concentrated in socioeconomically deprived populations, ethnic minorities and HIV-positive individuals, she says. Those who live in rural communities and the LBGT community, for instance, are more likely to smoke.

“It’s an accumulation of disadvantages that you have, and smoking causes health complications on top of it. It’s like a double whammy,” Nimmons says.

Tobacco smoke adds to complications for dental procedures. By adding carbon monoxide to the oral cavity, blood flood is decreased, which affects wound healing, Stinson says. Also, after an extraction, smoking can lead to dry sockets and lichen planus, an inflammatory condition that affects mucous membranes. Implants, too, are more likely to get infected. And, of course, related periodontal disease often leads to tooth loss.

Dental professionals are a frontline defense for traditional smokers and smokeless tobacco users because patients usually see their dentists more often than their primary care physicians, she says. Dental checkups include looking for signs of oral cancer.

“We screen the floor of the mouth and the lateral border of the tongue as high-risk sites for squamous cell carcinoma, a rapidly progressing type of cancer,” she says. “Even if patients are in a cessation program or not, we screen them every time we see them. We’re looking for any lesions, white or red, or anything that looks problematic in those high-risk sites.”

Tobacco use contributes to 19% of all cancers, which makes tobacco the leading cause of preventable cancer, according to the Texas Department of State Health Services. Lung cancer leads the list of tobacco smoke-related cancers, followed (in order) by bronchus and trachea, lip, oral cavity and pharynx, larynx, esophagus, kidney and renal pelvis, cervix, urinary bladder, pancreas, colon and rectum, stomach, liver and acute myeloid leukemia.

Preventable diseases—such as cancer, heart disease, stroke, lung disease, diabetes and chronic obstructive pulmonary disease—disability and even death can be attributed to tobacco use, according to the 2014 Surgeon General’s Report for the U.S. Department of Health and Human Services. Between 2006 and 2015, lung cancer had the highest fatality rate of all cancers for both men and women in Texas, according to Texas Cancer Registry statistics.