1. Prepared by: Dr. Mohammad Shaikhani University of Sulaimani College of Medicine. Dept of Medicine.

2. Introduction:  Smoking is responsible for the death of 1/10 adults worldwide, or 5 million deaths /year.  50% will eventually die, mostly avoided by quiting.  The prevalence;18% - 30%, 50% in China& rising in developing countries.  Tobacco is one of the few causes of preventable death increasing globally.  In West, decreasing.  Although the gap is narrowing specially in adolescents, males more than females overall,

3. Determinants of tobacco use:  Tobacco dependence results from several closely interrelated factors:  Neurochemical  Environmental  Individual

4. Neurochemical determinants:  Nicotine is the critical reinforcing component.  Nicotinic Ach receptors have reinforcing effects.  Nicotine produces a sustained effect on dopamine release in the nucleus accumbens& induce motivational / reinforcing properties.  Medications that act on glutamate or GABA systems hold the promise of reducing drug cravings or avoiding relapse.

6. Enviromental determinants:  Availability.  Low cost.  Advertising specially to thee youth.  Friend, Peer pressure.

7. Individual determinants:  Individuals are not at equal risk of tobacco dependence.  Genetic component:  Psychiatric disorders *2- 3, more in schizophrenia, depression, drug addiction.  Tobacco may improve the psychiatric conditions or reduce the side effects of some psychiatric medications &mimic the effects of antidepressants,as tobacco smoke contains chemical substances that inhibit monoamine oxidase A/B.  This may explain the increased risk of depression for 6 months or longer following smoking cessation.

8. Management of tobacco dependence:  Adequate evaluation of the patient & environment.  Since 70% of smokers see a physician/year, physicians &health professionals have a substantial opportunity to influence smoking behaviour.  The essential features of smoking cessation treatment 5 As:  Ask about smoking at every opportunity  Advise all smokers to stop  Assess their willingness to stop  Assist the smoker to stop  Arrange follow-up  Success is often obtained only after several attempts& HCWs should adopt the same attitude as with other chronic disorders & should provide support over a long period.

9. Management: overall  2 approaches proven effective:  Pharmacotherapy  Nonpharmacologic interventions  Best results obtained when the 2 combined& pharmacotherapy increase chance of initiating / maintaining abstinence 23-fold& should be used more extensively.

13. Single-choice Qs: 1. The 1 st -line management pharmacological of tobacco dependence include all except: A. Tricyclic antidepressants. B. Benzodiazepines. C. Nicotine replacement. D.Buprpion. E.Varnecilin.

14. Single-choice Qs: 2. Nicotine replacement therapy is given in all these forms except: A. Gums. B.Inhaler. C.Lozenges. D. Patch. E.Suppositories.

15. Single-choice Qs: 3. The following are among non- pharmacological interventions to enhance smoking quitting except: A.Physian advice. B.Self-helpmterials. C. Social support. D.Hypnotherapy. E. Individual, group & telephone counseling.