1. Key Public Health issues of smoking Passive smoking in home, car, workplace, restaurants etc. Self- induced disease and cost of smoking related diseases on system Pollution of cigarette smoke, cigarette butts, fires caused by cigarettes thrown from cars etc. DALY and YLL Decreased productivity due to smoke breaks STATS For both men and women, smoking rates are higher among manual and factory workers than among office workers and professionals There is also a relationship with education - those who leave school early are more likely to smoke than those with higher levels of education. Smoking rates among indigenous Australian s are considerably higher than those for the non- indigenous community in every age group. In 2004-2005, the daily smoking rate among indigenous Australians was 50%. The highest rates of daily smoking among Australian men were in the 18-24 years age group (34%) ; for women in the 25-34 years age group (27%). In general education- dominated strategies are generally weak compared to policy/legislative approaches, environmental changes or fiscal instruments- because most risk behaviours do not occur because of a knowledge deficient

2. BARRIERS TO QUITTING — In the absence of nicotine, a smoker develops cravings for cigarettes and symptoms of the nicotine withdrawal syndrome. These include: Dysphoric or depressed mood Insomnia Irritability, frustration, or anger Anxiety Difficulty concentrating Restlessness Decreased heart rate Increased appetite or weight gain Additionally, smokers become conditioned to associate the pleasurable effects of tobacco use with environmental triggers such as their morning coffee, an alcoholic drink, or the end of a meal. These events become triggers to smoke and contribute to the difficulty smokers have in remaining abstinent from nicotine

3. Smoking Cessation Because tobacco use is both a physical addiction to nicotine (for The majority of smokers) and a learned behaviour, the counselling and pharmacotherapeutic approaches are synergistic, with combinations producing higher quit rates than either one alone BEHAVIORAL COUNSELLING — Clinical trials of smoking cessation counselling have generally tested intensive counselling strategies that consist of repeated visits or phone calls with a trained counsellor. This psychosocial counselling increases long-term smoking cessation rates and is effective when delivered in person, individually or in a group setting, or by telephone. Web and other computer-based counselling programs also appear to be effective.

4. The Doctors Role While more intense behavioural interventions are associated with higher rates of quitting, even brief interventions that can be delivered in medical practice are of benefit Clinician counselling Brief clinician advice to quit delivered routinely to all smokers seen in office practice increases the rates of smoking cessation. The 5 A's operationalise the elements of brief counselling for office practice. This system encourages clinicians to ask patients about their smoking status, advise smokers to quit, assess their readiness to quit, assist them with their smoking cessation effort, and to arrange for follow-up visits or contact

5. The role of Drugs Pharmacotherapy for smoking cessation aims: to relieve the symptoms of nicotine withdrawal and/or reduce the rewarding or reinforcing aspect of smoking, thereby making it easier for a smoker to stop the habitual use of cigarettes. Three categories of medications have demonstrated efficacy as aids to smoking cessation attempts: nicotine replacement therapy (NRT), bupronpion (Zyban) and varenicline (Champix). Current clinical practice guidelines recommend that smoking cessation pharmacotherapy be offered to all smokers making a quit attempt unless medically contraindicated.

6. Nicotine Replacement Therapy All (NRT) provides nicotine to a smoker without using tobacco, thereby relieving nicotine withdrawal symptoms as the smoker breaks the behaviour of cigarette smoking. NRT products differ in their method of delivering nicotine to the circulation. Eg. absorbed transdermally with a skin patch, through the nasal mucosa by the nasal spray, or through the oral mucosa with the nicotine chewing gum, nicotine lozenge, or nicotine inhaler. In randomized controlled clinical trials, all nicotine replacement products are superior to placebo, increasing quit rates about two- fold, but few trials have directly compared one product to another in the same study Nicotine replacement is safe to use even in outpatients with known cardiovascular disease the benefits of nicotine replacement outweigh potential risks in most smokers with acute coronary syndromes who are having nicotine withdrawal symptoms

7. Bupropion (Zyban) Originally used as an antidepressant (Dopamine-Reuptake Inhibitor) Mechanism of action is unclear… Bupropion may act by increasing dopamine activity in the nucleus accumbens. It is a weak blocker of dopamine and noradrenaline uptake, but it is not clear that this accounts for its efficacy in treating nicotine dependence. It is usually given as a slow-release formulation. (Rang and Dale) doubles the likelihood of smoking cessation (23% versus 12%). Safety — The most common side effects are insomnia, agitation, dry mouth, and headache. Neuropsychiatric effect: Serious neuropsychiatric events, including depression, suicidal thoughts, and suicide, have been reported with use; some cases may have been complicated by symptoms of nicotine withdrawal following smoking cessation. Another serious side effect is seizures, which can occur because bupropion reduces the seizure threshold. In clinical trials, the risk of seizure was 0.1 percent, and the drug is contraindicated in patients with a seizure disorder or predisposition to seizure.

8. Varenicline (Champix) Varenicline is hypothesized to aid smoking cessation in two ways. First, as a partial agonist, it binds to and produces partial stimulation of the alpha4beta2 nicotinic receptor, thereby reducing the symptoms of nicotine withdrawal. Second, because varenicline binds to the alpha4beta2 receptor subunit with high affinity, it blocks the nicotine in tobacco smoke from binding to the receptor, thereby reducing the rewarding aspects of cigarette smoking The efficacy has been demonstrated in at least seven double-blind randomized placebo-controlled trials Found to be superior to bupropion (44% versus 30% quit at 12weeks, 23 versus 16% at 52weeks) Safety Neuropsychiatric effect: Monitor for behavioral changes and psychiatric symptoms (eg, agitation, depression, suicidal behavior, suicidal ideation) rare reports of hypersensitivity reactions (eg, angioedema) and serious dermatologic reactions

9. Other methods HYPNOSIS AND ACUPUNCTURE — are included in some commercially available stop-smoking programs. However, a meta-analysis that assessed 22 studies comparing acupuncture to sham acupuncture or other methods of smoking cessation found no differences in outcome at any point in time. A similarly designed systematic review of hypnotherapy found insufficient data upon which to perform a meta-analysis. Smokers who are able to quit with these programs should be congratulated. For those unable, participation in programs supported by evidence should be encouraged

10. Summary As tobacco use is both a physical addiction to nicotine and a learned behaviour, counselling and pharmacotherapy in combination produces best results Counselling can be person-person, over the phone, group sessions and even web based 3 drugs at the moment –Nicotine Replacement Therapy –Bupropion (Zyban):atypical antidepressant, weak inhibitor of noradrenaline and dopamine reuptake –Vareniciline (Champix) :stimulates nicotine receptors to reduce ithdrawal symptoms and binds with high affinity to reduce rewarding affect of cigarettes

11. References Up-to-date Rang and Dale