TOBACCO AND SMOKING CESSATION

introduction One of the most common preventable cause of death Accounting for about 20% of all cause –specific mortality(438,000 deaths per year) One in every five deaths Prevalence peaked 40% of adult in 1965. by 2006 had fallen to 20.9% 90% of smokers begin to smoke before the age of 20 The rates of tobacco use in men and women, once very different, are converging More closely linked to education than it is to age, race, occupation, or any other sociodemographic factors Smoking is a problem that is concentrated in lower socioeconomic groups

Introduction (cont.) Clinician often fail to assess smoking or offer intervention Among the barriers to intervention for tobacco use Inadequate knowledge of effective treatment strategies Uncertainty about the relative efficacy of treatment that currently available

Health consequences of tobacco use Increase overall mortality and morbidity rates Cardiovascular disease(MI, sudden death) Cerebrovascular disease Peripheral vascular disease COPD Cancers(lung, larynx, oral cavity, esophagus, bladder, kidney, pancreas, uterine cervix) Pregnancy complication( low birth weight, preterm delivery, miscarriage, stillbirth) Sudden infant death syndrome Cognitive deficits, developmental problems in childhood are linked to maternal smoking during pregnancy Osteoporosis, respiratory infection, peptic ulcer disease, cataracts, macular degeneration, sensorineural hearing loss, skin wrinkling

Health consequences of tobacco use(cont.) No safe level Reduced tar and nicotine content dose not protect against the health hazards Environmental tobacco smoke(ETS)

Health benefits of smoking cessation After age of 65 After the development of a smoking- related disease After 10-15 years of abstinence Pattern of risk redaction (1/2 excess risk of cardiovascular diseases after one year. 30-50% lung cancer still evident 10 years after quitting) Longer life expectancy Younger, fewer, free of smoking- related disease

Chronic disease model Tobacco use and dependence is a chronic, remitting, and relapsing condition Successful treatment will incorporate counseling and advice and along view of the therapeutic relationship clinician and patient

Addiction model Nicotine is the addictive substance in tobacco. the continued use of tobacco is due, in large part, to addiction to nicotine The major effect of nicotine an increase in midbrain dopamine level The positive reinforcement (relaxation, reduced stress, enhanced cognitive performance, and enhanced vigilance) and negative reinforcement (nicotine withdrawal syndrome) Each smoker associate certain behavior, situation, emotion, and activities with reinforcement effects of nicotine

Smoking behavior Attractiveness more than nicotine dependence A habit, integral part of daily life To Cope with stress and negative emotion

The addiction model, in keeping with the chronic disease model, indicates that combined behavioral and pharmacological treatment will be the most effective model

Smoking cessation 41% attempt to quit each year Fear of illness Awareness of health risks not sufficient 90% know that smoking is harmful Illness in family member Social unacceptability Only 5% of smokers who try to quit without assistant Succeed for 1 year Learning process

Behavioral support for smoking cessation Assessing tobacco use Assessing readiness to stop smoking Brief office counseling for smoking cessation Pharmacotherapy for smoking cessation

Assessing tobacco use Although nearly 70% of smokers report a desire to quite, few are offered assistance when visiting a clinician “ new vital sign”

Assessing readiness to stop smoking Are you planning to quit smoking in the next 6 months? If yes. are you planning to quit smoking in the next month?

Assessing readiness to stop smoking(contd.) Intervention Definition Stage of change Advise patient to quit; give brief motivational message Not seriously thinking of quitting in next 6 month precontemplation Advise patient to quit; give brief motivational message; discuss pharmacotherapy Seriously thinking of quitting in next 6 month Contemplation Set quit date; develop a quit plan; prescribe pharmacotherapy; provide behavioral therapy Desire to quite tobacco use in next 30 d and made a quite attempt of at least 24 h within last year Preparation Review pharmacotherapy; provide support; discuss relapse prevention Currently not smoking and abstinent <6 m Action discuss relapse prevention; provide encouragement Currently not smoking and abstinent ≥ 6 mo or more Maintenance

Assessing readiness to stop smoking(contd) Motivation can be stimulated by providing a consistent impact message such as “5 Rѕ” Relevance (personalized) Risk (immediate – long term) rewards(benefits) Roadblocks(barrier – overcome) repetition

smoking cessation counseling protocol for physician ASK- about smoking at every visit:”do you smoke?” ADVISE- every smoker to stop Make advice clear:”stopping smoking now is the most important action you can take to stay healthy” Tailor advice to the patient’s clinical situation(symptoms or family history). ASSESS-readiness to quit: “are you interested to quitting?”

smoking cessation counseling protocol for physician(contd.) ASSIST- the smoker in stopping smoking 1-For smokers ready to quit Ask smoker to set a “quit date.” Provide self help- material to take home. Offer pharmacotherapy. Consider referral to a formal program 2-for smoker not ready to quit Discuss advantages and barriers to cessation, from smoker’s viewpoint Provide motivational booklet to take home Advise smoker to avoid exposing family member to passive smoke Indicate willingness to help when the smoker is ready Ask again about smoking at the next visit

smoking cessation counseling protocol for physician(contd.) ARRANGE-follow up visit Make follow up appointment 1 week after quit date At follow up, ask about smoking status For smokers who have quit 1-congratulate! 2-ask smoker to identify future high risk situations 3-rehearse coping strategies for future high risk situations For smokers who have not quit: 1-ask:”what were you doing when you had that first cigarette?” 2- ask:”what did you learn from the experience?” 3- ask smoker to set a new “quit date.”

Relapse prevention High nicotine dependence (smoke >25 cigarettes/d – within 30 minutes of waking) No previous abstinence of 30 days or more History of major depression Current or past alcohol abuse or dependence Other smokers in the household

Relapse prevention(contd.) Triggering situation Inadequate coping response Comment: Planning for high–risk situation Avoidance of strong trigger Encouragement for successes Continued troubleshooting of problem areas Offering continued support and follow up Refer

Pharmacotherapy Not recommended Combination regimens Second - line First – line Anxiolytics Bupropion + nicotine patch Nortriptyline Nicotine replacement Mecamylamine Nicotine gum + nicotine patch clonidine Nicotine patch SSRI anti depressant Nicotine nasal spray+ nicotine patch Nicotine gum Silver acetate Nicotine nasal spray Naltrexone Nicotine inhaler lobeline Nicotine lozenge Nonicotine medication Buprropion SR

Nicotine replacement therapy Rationale: 1-blocking the negative reinforcement 2-reduction in the positive reinforcement of smoking

Nicotine replacement therapy(contd.) Transdermal nicotine patch 24 hour 21 mg/24h 8 weeks 14 mg/24h 7 mg/24h 16 hour 15 mg/16h 8 weeks Skin irritation, nervousness, vivid dreams, insomnia Lower starting dose for patients BW<100Ib (45.35 kg) or smoking fewer 10 cigarettes

Nicotine replacement therapy(contd.) Nicotine gum 2 mg 9-12 pieces/day(max 30) 2-3 month(max 6) chew as needed or one every 1-2 h while awake 4 mg 9-12 pieces/day(max 30) 2-3 month(max 6) Proper chewing technique is essential No liquid no acidic beverages 1-2 hours before gum nausea., dyspepsia, hiccup, dizziness, sore jaw. Mouth ulcer

Nicotine replacement therapy(contd.) Nicotine lozenge 2 mg & 4 mg as gum oral mucosa 7-9 pieces per day as needed for 3 month Nicotine inhaler 6 cartridges/ day 3-6 months Oral mucosa mimics the hands to mouth behavior Throat irritation cough Nicotine nasal spray 1-2 dose/h(max 8/day) 3-6 month Nose and throat irritation, watery eyes, sneezing and cough

Bupropion An antidepressant with dopaminergic and noradrenergic activity Sustained-release form Reduction the threshold for seizure (1/1000 or less) Insomnia, agitation, headache, and dry mouth 150-300 mg/day for 7-12 weeks 1 week before cessation

Contraindication for use of sustained-release bupropion due to risk of seizures Known seizure disorder idiopathic epilepsy Febrile childhood seizures Other seizures disorder (e.g. Alcohol withdrawal) History of serious brain injury Closed head trauma Stroke Brain surgery Drugs that lower seizure threshold (relative contraindication) Pheotiazines Alcohol Benzodiazepines Eating disorder Anorexia bulimia

Activity Applying motivational interviewing techniques: tobacco use intervention

Offer support and make patient-center Work together to create a patient- centered plan that matches the patient’s readiness to quit Encourage the patient to consider what could work, rather than focus on what could not Provide options (referral, nicotine replacement, patient education materials), but not direct advice Ask the patient to select next step Reinforce any movement toward making a change Follow-up on subsequent visits

Field work One smoker

Thanks