Smoking and behaviour change

smoking and changing behaviourAnna Middleton gives her perspective as an ex-smoker what it’s like to give up smoking and how dental teams can change patients’ behaviour.

Smoking is an excellent example of how knowledge does not equal action. Everybody knows that smoking is bad for you, yet so many people still choose to do it. The reasons behind smoking behaviours are far more complex than craving nicotine. Telling a smoker to stop smoking has the same effect as telling a depressed person to cheer up. How do I know? I am an ex-smoker.

Smoking is the biggest cause of preventable deaths in England, accounting for nearly 80,000 deaths each year. One in two smokers will die from a smoking-related disease. At the start of this year it was reported that around 350,000 people in the UK are expected to quit smoking in 2019, putting smoking rates at their lowest point ever. The study was carried out by the Oral Health Foundation and out of the 500 smokers surveyed, 66% of those planning to quit are doing so to improve their overall health. The other major motivating factor was financial gain. According to the NHS’s Smokefree initiative, most smokers stand to save approximately £250 per month by quitting.

Smoking leads to a whole host of health issues including an increased risk of tooth loss through periodontal disease, heart disease, lung disease and cancer. All factors which are pushing more people to stub out cigarettes once and for all.

‘No Smoking Day’ is an annual health awareness day to help smokers who want to quit smoking. The first ‘No Smoking Day’ was on Ash Wednesday in 1984, and it now takes place on the second Wednesday in March. What can we do to help our patients be finally free from cigarettes?

My story

Ask any smoker, and they would give anything to have never smoked that first cigarette. I was never a heavy smoker. I started when I was about 16 at school and smoked between five to 10 a day. I have never been proud of my smoking. I shamefully hid it for so long. Even when I became a dental nurse and then during my time studying as a hygienist I would still smoke from time to time. The truth? I was addicted to nicotine. There are no physical withdrawal pains or symptoms when nicotine leaves your body. You simply feel an empty feeling and something similar to being hungry. But there is a little voice in your head telling you that you want and need to smoke. And the only way to relieve that is by lighting up.

I tried nicotine patches, chew gum, lozenges, vaping and Champix (Varenincline), which is a prescription-only medicine. I really wanted to be a non-smoker and often managed to abstain from smoking for long periods of time. The whole time I wasn’t addressing the mental aspect of smoking and the question of ‘why did I still go back to smoking?’ Smokers see quitting as actually giving up something. They believe that somehow life won’t quite be as enjoyable without cigarettes. I can tell you now it’s quite the opposite. In the end reading Allen Carr – Easy Way to Stop Smoking worked for me. I gave up overnight and haven’t smoked since and never will again.

Behaviour change

What it really comes down to is behaviour change. This is a term that is spoken about a lot. It can apply to almost anything – eating healthier, exercising more, brushing twice a day, make sure you are on time for your dental appointments and finally giving up smoking. All of these require a change, and that change takes time.

If we look at the ‘Transtheoretical’ or ‘Stages of change’ model, there are five stages:

  1. Precontemplation
  2. Contemplation
  3. Preparation for action
  4. Action and
  5. Maintenance.

People may oscillate back and forth between the various steps for many months or years before achieving long-lasting change in their behaviour. If we apply this cycle to encouraging patients to giving up smoking – if we are lucky enough to even get them to contemplate the idea that it is something they need to do – they still need to actually set a stop date, quit smoking and then keep that new behaviour up by not smoking again. Even with the best intentions it is easy to see why people struggle.

Factors in successful behaviour change

What factors affect the decision to make behaviour change and how can we understand what may be the key to our patients? You can break down these factors into two categories: psychological and social.

Psychological factors

  • Time – we tend to value today over tomorrow. The threat of immediate loss, or the attraction of immediate gain, tend to be stronger than rewards or penalties in the future
  • Habits – much of our behaviour is habitual, and these habits tend to be prompted by the context in which they take place. That is why habits tend to be disrupted when the context changes (eg changing jobs, going on holiday)
  • Loss aversion – we put more effort into preventing loss than securing gain.

Social factors

  • Commitment – public commitments to change, especially if monitored by others can have a strong bearing on change
  • Messenger – demographic and behavioural similarities between the messenger and the audience can improve effectiveness
  • Ego – people want approval from others
  • Social norms – many studies show people are strongly influenced by social norms.

Obviously, this isn’t an exhaustive list, and not all apply equally to everyone. But being able to identify what factors apply to the patient in front of us may give us a higher chance of success.


As well as the things we are well versed in such as tailored approach, clear information provision and ability to access, direct and refer if needed. NICE touches on a few more interesting points, which indicate that there are better times than others to provide interventions, that not everything should be tackled at once and that monitoring is key, but also having back up plans. Not everything works first time. What happens if the engagement isn’t there, what do you do next?

  • Providers should recognise the times when people are more open to change, such as a new diagnosis, or when becoming a parent
  • Understand how motivated the individual is to change. If many behaviour changes are needed, which one- or ones- is the person most motivated to tackle?
  • Small, manageable changes to daily routine are most likely to be maintained
  • Individuals should receive monitoring and feedback at regular intervals to ensure maintenance of behaviour
  • Providers should have well versed ‘if-then’ plans to put into practice.

What can we do?

Screening – it is estimated that approximately 6,800 people are diagnosed with oral cancer in the United Kingdom annually. This accounts for 2% of all cancers diagnosed. According to the NHS, most cases of mouth cancer occur in older adults aged 50 to 74. However, it can still affect one in eight people under the age of 50. That’s why it’s imperative to receive regular oral cancer screenings from your dentist or hygienist and to pay close attention to the signs and symptoms.

Signs and symptoms – the best way to tackle oral cancers is through early intervention. If mouth cancer is picked up early, treatment is more likely to be successful. Here are three signs and symptoms not to ignore:

  1. Ulcers which do not heal in three weeks
  2. Red and white patches in the mouth
  3. Unusual lumps or swellings in the mouth or head and neck area.

Give patients ownership – it is their body and their responsibility. Approach each case by encouraging, educating and assisting.

Clear roles – we are responsible for educating the patient and having a standard message. Always document in the patient’s medical history about their smoking and if cessation was discussed and if it was accepted or declined.

Recommendations – think about what you can do for the patient and focus on what will benefit them. Have options in place such as referral to smoking counsellors, leaflets, pamphlets, online resources and information about nicotine replacement therapy.


Smoking has zero benefits and we can help our patients see how much better their lives will be without smoking the better. I embraced becoming a non-smoker as finally becoming free from the evil weed and celebrate my success with my patients. Ultimately when you truly take the plunge you don’t even need willpower. The bottom line is we will live longer, healthier lives without smoking. That is what I remind my patients of with a smile.

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