1. Update Smoking Cessation
Caglar Cuhadaroglu
Acibadem University
Respiratory Medicine

2. Guidelines and Exprience
CDC
ENSP
TURKISH THORACIC SOCIETY

3. BEFORE CLINIC AWARENESS
DOCTORS
HEALTHCARE PROFESSIONALS
ROLE MODELS
ALL POPULATION

4. DOCTORS
There are too many studies evaluated awareness and knowledge of medical students and doctors.
In UK, reporting rate 90% , providing support 59%
In Portugal, 9% of doctors educated for tobacco control.

5. BEFORE CLINIC AWARENESS
DOCTORS
HEALTHCARE PROFESSIONALS
Tobacco Control
Hazards ( second hand smoke)
Restrictions
Tobacco Clinics
Dependency
Cessation

6. 5 A
Ask
Advise
Assess
Assist
Arrange

8. Practical
It is easy
Need short time
Effective

9. Brief aproach ASK-ADVICE
3 minutes intervention succes rate is % 6.6
In many studies brief advice increase cessation rates 2.5%( absolute difference)
Repeat each visit . Be a good role model
Open and friendly.
Benefits, risks. Make a connection to a healthy baby

10. ASK-ADVICE
Assess

11. Assess No – Motivational Interviewing Technics
Are you willing to give quitting a try ?
Yes
Yes – for a special group ( pregnant, adolesent)
No – Motivational Interviewing Technics

12. Assist Behavioral therapies Pharmacogical Rx
100% effective technics( Advirtesiments)

13. Steps Education (face to face, groups)
Explain tobacco dependence disease
Explain the reasons for lighting up a cigarette
Explain the health consequences of smoking
Explain the benefits of quitting smoking
Explain tobacco cessation treatment
Explain chronic tobacco dependence management to prevent relapse

14. Tell Withdrawal Symptoms
Irritability
Anxiety
Headache
Restlessness
Coughing
Nausea
Insomnia
Dizziness
Depression
Difficulty concentrating

15. Tell Why ? 42 Nikotinik Reseptör a4 b2 Ana Mesaj
Nikotin beyinde sigara içmeyle bağlantılı ödül ve tatmin etkisine yol açtığı sanılan alanlarda dopamin salınmasını uyarır.
Arkaplan
İnhalasyondan sonra nikotin tercihli olarak birkaç saniye içinde beyinde mezolimbik-dopamin sisteminde yer alan nikotinik asetilkolinerjik (nACh) reseptörlerine bağlanır. Nikotin spesifik olarak Ventral Tegmental Alan’da (VTA) 4β2 nikotinik reseptörleri aktive eder ve Nukleus Akkumbens’te (nAcc) derhal dopamin salınmasını sağlar.1 Dopamin salınmasının sigara içmeyle bağlantılı ödül devrelerinin önemli bir bileşeni olduğu düşünülmektedir.1
Kaynak
1. Picciotto MR, Zoli M, Changeux J. Use of knock-out mice to determine the molecular basis for the actions of nicotine. Nicotine Tob Res. 1999; Suppl 2:S
1. Jarvis MJ. BMJ 2004; 328: Dani JA, Harris RA. Nature Neuroscience 2005; 8: Coe JW. J Med Chem 2005; 48:

17. Steps Set a date Tell friends, family
Find difficult times ( coffee, alchool, friends…)
Remove tobacco products, change your parfume...

18. Pharmacologic Treat.

19. Pharmacologic Treat.

20. Effectiveness and Abstinence Rates for Medications Compared With Placebo or Standard-Dose Nicotine Patch at 6-Months
Medication
Arms
Estimated abstinence rate (95% CI)
Estimated OR vs Placebo (95% CI)
Estimated OR vs Nicotine patch* (95% CI)
Monotherapies
Varenicline (2 mg/d) 5
33.2 ( )
3.1 ( )
1.6 ( )
Nicotine nasal spray 4
26.7 ( )
2.3 ( )
1.2 ( )
High-dose nicotine patch (>25 mg) (includes both standard or long-term duration)
26.5 ( )
Long-term nicotine gum (>14 weeks) 6
26.1 ( )
2.2 ( )
1.2 ( )
Varenicline (1 mg/d) 3
25.4 ( )
2.1 ( )
1.1 ( )
Nicotine inhaler
24.8 ( )
2.1 ( )
1.1 ( )
Bupropion SR 26
24.2 ( )
2.0 ( )
1.0 ( )
Nicotine patch (6-14 weeks) 32
23.4 ( )
1.9 ( )
1.0
Long-term nicotine patch (>14 weeks) 10
23.7 ( )
1.9 ( )
Nortriptyline
22.5 ( )
1.8 ( )
0.9 ( )
Nicotine gum (6-14 weeks) 15
19.0 ( )
1.5 ( )
0.8 ( )
*Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

21. Effectiveness and Abstinence Rates for Medication Combinations Compared With Placebo or Standard-Dose Nicotine Patch at 6-Months
Medication
Arms
Estimated abstinence rate (95% CI)
Estimated OR vs Placebo (95% CI)
Estimated OR vs Nicotine patch* (95% CI)
Combination Therapies
Patch (long-term; >14 weeks) + ad lib NRT (gum or spray) 3
36.5 ( )
3.6 ( )
1.9 ( )
Patch + bupropion SR
28.9 ( )
2.5 ( )
1.3 ( )
Patch + nortriptyline 2
27.3 ( )
2.3 ( )
0.9 ( )
Patch + inhaler
25.8 ( )
2.2 ( )
1.1 ( )
*Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

22. Combination Pharmacotherapy
Sustained release NRT (patch) + Immediate release NRT
Provides steady nicotine level
Allows patient to respond to urges
Medications with different targets
NRT + Bupropion SR
Varenicline + Bupropion SR?
Monotherapy with immediate release NRT should be used rarely

23. RCT of 1504 smokers in a research clinic
COMBINATION THERAPY
RCT of 1504 smokers in a research clinic
Received 1 of 6 treatments for 8 weeks
6 brief counseling sessions
7-day point prevalence abstinence at 8 wks and 6 months
Piper M, et al. Arch Gen Psychiat 2009;66:

24. Received 1 of 5 active treatments for 8 weeks
COMBINATION THERAPY
RCT of 1346 smokers recruited from 12 primary care clinics in Wisconsin
Received 1 of 5 active treatments for 8 weeks
Referred for counseling via telephone “quitline”
7-day point prevalence at 8 wks and 6 months
Smith SS, et al. Arch Intern Med 2009;169:

25. TRIPLE COMBINATION THERAPY Steinberg MB, et al
TRIPLE COMBINATION THERAPY Steinberg MB, et al. Annals Intern Med 2009; 150:
RCT of 127 smokers with known CVD, COPD, cancer, diabetes
Compared triple combination (nicotine patch + bupropion + nicotine inhaler) to patch alone
Triple therapy mean treatment duration 89 days
Patch alone mean treatment duration 35 days
At 6 months 7 day point prevalence abstinence:
Triple therapy 35%
Patch 19%
(OR 2.57, 95% CI 1.05 to 6.32, p-value 0.04)

26. Adherence to NRT Treatment Balmford J, et al
Adherence to NRT Treatment Balmford J, et al. Nicotine & Tobacco Research 2011;13:94-102
Only 28.6% of NRT users completed the recommended 8 weeks of treatment
Most quit prematurely because they believed the medication was not working, had unwanted side effects or believed that they no longer needed treatment.

27. Varenicline Maintenance of Abstinence Study
Wks 13–24
Wks 13–52
OR=2.47
p<0.0001
70.6
OR=
1.35 p=0.0126
44.0
N=602
Varenicline
N=604
Placebo
N=602
Varenicline
N=604
Placebo
Tonstad et al. JAMA 2006;296:64-71

28. In short
Brief behavioral treatment is effective for treating tobacco dependence
Pharmacotherapy is effective for treating tobacco dependence (NRT, bupropion, varenicline)
Behavioral treatment and pharmacotherapy together are best
Combination pharmacotherapy results in superior abstinence compared with single agent therapy for many smokers
Use combinations in smokers who have tried and relapsed with monotherapy AND in smokers with important comorbidity