10.tobacco cessation programme

complete description of tobacco cessation, NRT etc

1. TOBACCO CESSATION PROGRAMME 1 CHAITANYA.P II MDS Dept of Public Health Dentistry

2. PREVIOUS QUESTIONS Tobacco cessation Counselling. Apr2012, Oct 2013. 2

3. CONTENTS: Introduction to Tobacco. Tobacco production in India. Tobacco cessation clinics in I ndia. Global adult Tobacco survey(GATS). Behavioural counselling for cessation . Fagerstrome scale for smokers and non -smokers. Prochaska diclemente model. Nicotine replacement therapy Pharmacotherapy Studies related to success of tobacco cessation. References. 3

4. TOBACCO Plant: N icotiana Family: S olanaceae . Geographical origin: North America Ingredients: Nicotine. Species: N. tabacum 4

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6. 6 http:// www.mapsofworld.com/world-top-ten/tobacco-producing-countries.html Last accessed on 28/03/2016. 2012

7. 7 LIST OF COUNTRIES BY CIGARETTE CONSUMPTION PER CAPITA https:// en.wikipedia.org/wiki/List_of_countries_by_cigarette_consumption_per_capita Last accessed on 28/03/2016.

8. The Global Adult Tobacco Survey (GATS) is a nationally representative household survey that was launched in February 2007 16 low- and middle-income countries where more than half of the world’s smokers live and that bear the highest burden of tobacco use TOPICS FOCUSED: Tobacco use prevalence Second-hand tobacco smoke exposure and policies Cessation Knowledge, attitudes and perceptions Exposure to media Economics Bangladesh, Brazil, China, Egypt, India, Indonesia, Mexico, Pakistan, Philippines, Poland, Russian Federation, Thailand, Turkey, Ukraine, Uruguay and Viet Nam. 8

9. Global Adult Tobacco Survey (GATS) in 2010 revealed that 47.9% of males 20.3%of females, 34.6% of the adult used tobacco in one or the other form in India 9

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11. Source:- Global adult survey report 2010, Union M inistry of Human Health and Family Welfare INDIA 11

12. How people develop dependence to tobacco? 12

13. 13 On O ral cavity

14. 14 Oral Lesions and Conditions Related to Tobacco Use

15. 15 Potential Negative Impact on Periodontal Tissues from Smoked Tobacco Change in vasculature – reducing immune response. Suppression of hemorrhagic responsiveness(bleeding). Reduction of oxygen in the periodontal pocket – affecting composition of subgingival flora. Interference with cytokine production – inhibiting the immune response. Increase in proteolytic enzymes – leading to periodontal destruction. Compromised PDL attachment to root surface – poor healing following periodontal therapy. Decrease in lymphocyte production.

16. 16 http:// www.theguardian.com/news/datablog/2012/mar/23/tobacco-industry-atlas-smoking Last accessed on 28/3/2016

17. TOBACCO CESSATION CLINICS 2002 5 centers are established. Later it reached to 18 centers. 17

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19. Concept and operational plan was prepared by technical experts from three premier institutions. 19 Institute of Human Behaviour and Allied sciences, Delhi P ostgraduate institute of Medical Education and Research, Chandigarh National Institute of Mental health and Neurosciences, Bangalore

20. 20 Murthy P, Saddichha S; Tobacco cessation services in India: Recent developments and the need for expansion Indian Journal of Cancer, 2010, Volume 47,Suppl 1 .

21. 21 Three Components for Tobacco C essation

22. ARRANGE 5 A’S 22

23. Ask  - Identify and document tobacco use status for every patient at every visit. (You may wish to develop your own vital signs sticker, based on the sample below). Advise  - In a clear, strong, and personalized manner, urge every tobacco user to quit. Assess  - Is the tobacco user willing to make a quit attempt at this time? Assist  - For the patient willing to make a quit attempt, use counseling and pharmacotherapy to help him or her quit Arrange  - Schedule follow up contact, in person or by telephone, preferably within the first week after the quit date. 23

24. PATIENTS WHO ARE UNWILLING TO QUIT TOBACCO 5 R’S 24

25. FAGERSTROME SCALE 25

26. Fagerstrom scale for nicotine dependence - smoking 26

27. MAX SCORE = 10 27 How soon after you wake up do you smoke your first cigarette? 3-within 5 minutes 2- 6-30 minutes 1- 31-60 minutes 0- After 60 minutes 2. Do you find it difficult to refrain from smoking in places where it is forbidden (eg.in church, at the library, cinema etc.)? 1-Yes 0- No 3. Which cigarette would you hate to give up most? 1- The first one in the morning 0-All the others 4. How many cigarettes/day do you smoke? 0- 10 or less 1- 11-20 2- 21-30 3- 31 or more 5. Do you smoke more frequently during the first hour after waking than during the rest of the day? 1-Yes 0- No 6. Do you smoke if you are so ill you are in bed most of the day? 1- Yes 0-No Fagerstrom test for Nicotine Dependence(FTND) and Heaviness of Smoking(HIS)

28. Scores on Fagerstrom test Level of Dependence First line of Treatment Second Line of Treatment 0 to 2 Very low Dependence Psychological or Behavioral Intervention 3 to 5 Medium Dependence Psychological or Behavioral Intervention NRT(2mg) (Nutritional supplement) 6 to 7 High Dependence NRT(2mg) along with Psychological or Behavioral Intervention NRT(4mg) Above 8 Very High Dependence NRT(4mg) along with Psychological or Behavioral Intervention Pharmacological intervention 28

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30. MAX SCORE = 10 30 Fagerstrom test for Nicotine Dependence – S mokeless tobacco (FTND –ST) How soon after you wake up do you place your first dip? 3-within 5 minutes 2- 6-30 minutes 1- 31-60 minutes 0- After 60 minutes 2. How often do you intentionally swallow tobacco juice? 2-Always 1-Sometimes 0- Never 3. Which chew would you hate to give up most? 1- The first one in the morning 0-Any other 4. How many can/pouches per week do you use? 2- More than 3 1- 2-3 0- 1 5. Do you chew more frequently during the first hour after awakening than during the rest of the day? 1-Yes 0- No 6. Do you chew if you are so ill you are in bed most of the day? 1- Yes 0-No

31. 31 Scores on Fagerstrom test Level of Dependence First line of Treatment Second Line of Treatment 0 to 4 Very low Dependence Psychological or Behavioral Intervention 5 to 8 Medium Dependence Psychological or Behavioral Intervention NRT(2mg) (Nutritional supplement) 9 to 10 High Dependence NRT(2mg) along with Psychological or Behavioral Intervention NRT(4mg) Above 1 Very High Dependence NRT(4mg) along with Psychological or Behavioral Intervention Pharmacological intervention

32. Prochaska and Diclemente The Transtheoretical Model (TTM) (1983) 32

33. 33 http:// www.prochange.com/transtheoretical-model-of-behavior-change last accessed on 28/3/2016

34. 34 Stage of Readiness Patient Response to: “What are your thoughts and feelings about Quitting smoking?” Goal of intervention Typical Physician Intervention Precontemplation “I like to smoke” Introduce ambivalence “Your emphysema will improve after you quit smoking” Contemplation “I like to smoke, but I know I need to quit” Resolve ambivalence “How will your life be better after you’ve quit smoking?” Preparation “I’m ready to quit” Identify successful strategies “Choose a ‘quit day’ and let’s make plans for it” Action “I’m not smoking, but I still think about smoking from time to time” Provide solutions to specific relapse triggers “How can you deal with your desire to smoke in those situations?” Maintenance “I used to smoke” Solidify patient’s commitment to a smoke free life “This would be a good time to share your experience with other people” Summary of physician counselling based on the stages of change

35. NICOTINE REPLACEMENT THERAPY 35

36. NICOTINE REPLACEMENT THERAPY(NRT) 36

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38. 2 mg (< 25 cigarettes/day) 4 mg (≥ 25 cigarettes/day) User controls dose • Oral substitute for cigarettes • Available without prescription Disadvantages: Difficult for denture wearers to use side effects: Mouth irritation Stomach ache • Sore jaw • Nausea • Hiccups 38

39. urge to smoke Within 30 min after wake up Urge to smoke no sooner than 30 min 9–20 lozenges/day during first 6 weeks, then decrease dose gradually until treatment is stopped Advantages: Easy to use • Oral substitute for cigarettes • Available without prescription Adverse effects: Insomnia • Nausea • Hiccups • Coughing 39

40. Easy to use • Unobtrusive • Available without prescription. Disadvantages: User cannot adjust dose if craving occurs • Nicotine released more slowly than in other products Adverse effects: Skin irritation • Insomnia 40

41. User controls dose • Hand-to-mouth substitute for cigarettes Disadvantages; Frequent puffing needed • Device visible when used Adverse effects: Mouth and throat irritation Cough Rhinitis 41

42. dosage:1–2 doses/hr(1 mg total; 0.5 mg in each nostril) (maximum, 40 mg/day) User controls dose • Offers most rapid delivery of nicotine and highest nicotine levels of all nicotine replacement products. Adverse effects : Nasal irritation • Sneezing • Cough • Tearing 42

43. Pharmacotherapeutic approach 43

44. 44 Bupropion SR 1-2 wks before quit date 150mg/d for 3days, then 150mg bid for 7-12wks May continue use for 6mon after quit date

45. 45 Varenicline 1wk before quit date 0.5mg/d for 3d; then 0.5mg bid for 4d; then 1.0mg bid for 3mon May continue use for 6

46.   Recommended:-75–100 mg/day Treatment should be started 10–28 days before the quit date at a dose of 25 mg/day; the dose should be increased as tolerated. Side effects : Dry mouth • Sedation • Dizziness • Tremor Nortriptyline is a tricyclic anti‐depressant .It has a sedative effect which helps to improve sleep 46

47. Studies – success of tobacco cessation 47

48. A real-life study of the effectiveness of different pharmacological approaches to the treatment of smoking cessation: re-discussing the predictors of success S tudy place: University of Sao PauloMedical School , brazil. 836 – smokers. 25 cigarettes/day Fagerstrome Score - 6.6 . Result : tobacco cessation teaching in hospital has higher success rates. Nortriptyline + NRT Higher success rates(46.4%). 48 Gustavo Faibischew Prado, Elisa Maria Siqueira Lombardi, Marco Anto nio Bussacos , Frederico Leon Arrabal-Fernandes, Ma´rio Terra-Filho, Ubiratan de Paula Santos; A real-life study of the effectiveness of different pharmacological approaches to the treatment of smoking cessation: re-discussing the predictors of success; CLINICS 2011;66(1):65-71

49.   Settings   and   Design:  This is a community based tobacco cessation program of one year duration conducted among women in a low socioeconomic area of Mumbai, India.  Subjects   and   Methods:  It involved three interventions conducted at three months interval, comprised of health education, games and counseling sessions and a post intervention follow up. 49 Tobacco use among family members and in the community was primary reasons for initiation and addiction to tobacco was an important factor for continuation, whereas health education and counseling seemed to be largely responsible for quitting. The quit rate at the end of the programme was 33.5%. GA Mishra, SV Kulkani , Majumdar PV, SD Gupta, SS Shastri ; Community-based tobacco cessation program among women in Mumbai, Indian Journal of Cancer, Dec 2014, Volume 51, supplement 1

50. AIMS: To assess the tobacco quit rates among employees, through self report history, and validate it with rapid urine cotinine test; compare post-intervention KAP regarding tobacco consumption with the pre-intervention responses and assess the tobacco consumption pattern among contract employees and provide assistance to encourage quitting. SETTINGS AND DESIGN: This is a cohort study implemented in a chemical industry in rural Maharashtra, India. MATERIALS AND METHODS: All employees (104) were interviewed and screened for oral neoplasia . Active intervention in the form of awareness lectures, focus group discussions and if needed, pharmacotherapy was offered. Medical staff from the industrial medical unit and from a local referral hospital was trained. Awareness programs were arranged for the family members and contract employees. RESULTS: Forty eight per cent employees consumed tobacco. The tobacco quit rates increased with each follow-up intervention session and reached 40% at the end of one year. There was 96% agreement between self report tobacco history and results of rapid urine cotinine test. The post-intervention KAP showed considerable improvement over the pre-intervention KAP. 56% of contract employees used tobacco and 55% among them had oral pre-cancerous lesions. CONCLUSIONS: A positive atmosphere towards tobacco quitting and positive peer pressure assisting each other in tobacco cessation was remarkably noted on the entire industrial campus. A comprehensive model workplace tobacco cessation program has been established, which can be replicated elsewhere. 50 GA Mishra, SV Kulkani , Majumdar PV, SD Gupta, SS Shastri ; Workplace tobacco cessation program in India: A success story. Indian Journal of Occupational and Environmental Medicine; December 2009, Volume 13, Issue 3.

51. World No Tobacco Day 2016: Get ready for plain packaging packaging of tobacco products is an important demand reduction measure . It reduces the attractiveness of tobacco products, restricts use of tobacco packaging as a form of advertising, limits misleading packaging and labelling, and increases the effectiveness of health warnings. For World No Tobacco Day, 31 May 2016, WHO and the Secretariat of the WHO Framework Convention on Tobacco Control are calling on countries to get ready for plain ( standardized) packaging of tobacco products. http://www.who.int/campaigns/no-tobacco-day/2016/en/ . Last accessed on 28/03/2016. 51

52. Barriers of tobacco cessation The lack of training and sensitization of health professionals limits the assessment and intervention of tobacco use. 52

53. Lack of trained health professionals to provide quitting support 53

54. Lack of knowledge of ill effects of tobacco. 54

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56. References Daly & bachelor,Richard Watt – Essential Dental Public Health . Esther v Wilkins – clinical practice for dental hygienist .   Prochaska JO, DiClemente CC. Toward a comprehensive model of change. In: Miller WR, Heather N, eds. Treating addictive behaviors: processes of change. New York: Plenum, 1986:3–27. Clinical practice. Treatment of tobacco use and dependence. N Engl J Med 2002;346:506-512. Murthy P, Saddichha S; Tobacco cessation services in India: Recent developments and the need for expansion;Indian Journal of Cancer, 2010;Volume 47 ; Suppl 1 WHO – GLOBAL ADULT TOBACCO SURVEY (GATS)-2007. 56

57. GA Mishra, SV Kulkani , Majumdar PV, SD Gupta, SS Shastri ; Community-based tobacco cessation program among women in Mumbai, Indian Journal of Cancer, Dec 2014, Volume 51, supplement 1 GA Mishra, SV Kulkani , Majumdar PV, SD Gupta, SS Shastri ; Workplace  tobacco cessation program in India: A success  story. Indian Journal of Occupational and Environmental Medicine; December 2009, Volume 13, Issue 3. Cherian Varghesea ; Initiating tobacco cessation services in India: challenges and opportunities; WHO South-East Asia Journal of Public Health 2012;1(2):159-168 . Krishna M. Palipudi , Prakash C. Gupta, Dhirendra N. Sinha, Linda J. Andes, Samira Asma , Tim McAfee, on behalf of the GATS Collaborative Group; Social Determinants of Health and Tobacco Use in Thirteen Low and Middle Income Countries: Evidence from Global Adult Tobacco Survey; Plos one; March 2012, Volume 7, Issue 3,e33466 57

58. 11 . http://www.who.int/campaigns/no-tobacco-day/2016/en / . Last accessed on 28/03/2016. 12. Brian A King, Sara A Mirza , Stephen D Babb, and for the GATS Collaborating Group; A cross-country comparison of second hand smoke exposure among adults: findings from the Global Adult Tobacco Survey ( GATS); Tob Control . 2013 July ; 22(4): e5. 13. Gustavo Faibischew Prado, Elisa Maria Siqueira Lombardi, Marco Anto nio Bussacos , Frederico Leon Arrabal-Fernandes, Ma´rio Terra-Filho, Ubiratan de Paula Santos; A real-life study of the effectiveness of different pharmacological approaches to the treatment of smoking cessation: re-discussing the predictors of success; CLINICS 2011;66(1): 65-71. 58

59. 59 14. http :// www.mapsofworld.com/world-top-ten/tobacco-producing countrieshtml . Last accessed on 28/03/2016 . 15. https ://en.wikipedia.org/wiki/List_of_countries_by_cigarette_consumption _ per_capita Last accessed on 28/03/2016. 16. Norman O. Harris; Primary Preventive Dentistry, 7 th Edition, 2009, Julie Levin Alexander publishers. 17. h t tp :// www.theguardian.com/news/datablog/2012/mar/23/tobacco-industry-atlas-smoking Last accessed on 28/3/2016

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