smoking cessation

The presentation cover evidences about smoking cessation and the NRT along with other modalities.

1. SMOKING CESSATION Laila Mahzari Sara Alajmi Bushra Alenazi Weam Nasser Fatimah Alduheem

2. Objectives Introduction . Chemical components in cigarettes. The negative effects of smoking. Benefits of Smoking Cessation. Electronic Cigarettes: Human Health Effects. Enhanced Motivational Interviewing Versus Brief Advice For Adolescent Smoking Cessation: Results From A Randomized Clinical Trial. Nicotine Replacement Therapy. A Randomized Trial of Nicotine-Replacement Therapy Patches in Pregnancy. Zyban for smoking cessation in a general: the response to an invitation to make a quit attempt. Perceived barriers to smoking cessation in selected vulnerable groups: a systematic review of the qualitative and quantitative literature. Barriers and motivators to gaining access to smoking cessation services amongst deprived smokers. Conclusion

3. introduction Laila Mahzari

4. Introduction Cigarette smoking is one of the major preventable causes of morbidity and mortality all over the world. According to World Health Organization (WHO, 2008 ) Tobacco is the second major cause of death. It is currently responsible for the death of 1 in 10 adults.

5. Cont. In 2005, tobacco caused 5.4 million deaths which was 1 in every 6 seconds . It is the major risk factor for the development of chronic obstructive pulmonary disease (COPD), lung cancer and contributes to risk for heart disease and many other conditions.

6. Cont. There are more than 15 billion cigarettes smoked a day around the world .(World Health Organization; U.S. Centers for Disease Control and Prevention; Action on Smoking and Health (ASH)). Smoking is the main cause of behind the death of 13,544 in Saudi Arabia, according to statistics published by the Saudi Charitable Society to Combat Smoking on its website ( Ghafour , 2008).

7. Cont. The cigarette imports in the country were SR1.7 billion in 2005 and the economic losses caused by smoking were SR25 billion in the five years from 2005 to 2010. The majority of Saudi smokers who took part in a recent survey said they started practicing the damaging habit as a result of the influence of friends. Some participants (8.4 percent) said it was the family impression that made them smokers while 5.9 percent blamed work pressure for smoking.

8. Cont. The total population of the Kingdom is 26.5 million according to a July 2012 estimate by Central Intelligence Agency (CIA), US. It is estimated that about a quarter of Saudi Arabia's residents smoke. Smokers in Saudi Arabia spend more than SR5 billion to buy some 40,000 tons of tobacco yearly, not to mention other losses related to the high cost of the treatment of serious diseases associated with smoking (Fakeeh, 2011).

9. Chemical components in cigarettes Because the nicotine in tobacco is addictive, quitting smoking can be challenging.

10. The negative effects of tobacco and smoking are : Eyes Macular degeneration Hair Hair loss Skin Aging, wrinkles, wound infection Brain Stroke Mouth and pharynx Cancer, gum disease Lungs Cancer, chronic obstructive pulmonary disease (emphysema and chronic bronchitis), pneumonia, asthma Heart Coronary artery disease, raised blood pressure

11. Cont. Stomach Cancer, ulcer Pancreas Cancer, increase blood glucose levels and less control over blood glucose levels Bladder Cancer Women Cervical cancer, early menopause, irregular and painful periods, infertility Men Impotence Arteries Peripheral vascular disease Bone Osteoporosis

12. Cont. Smoking during pregnancy Increased risk of: miscarriage premature birth low birth weight infant Effect of tobacco smoke on children Increases the risk of: respiratory infections middle ear infections meningococcal infections asthma .

13. Health benefits of quitting 12 hours Blood levels of carbon monoxide are significantly decreased 5 days Improvements in the sense of taste and smell 6 weeks Risk of wound infection after surgery substantially reduced 3 months Lung function is improving as cilia recover 1 year Risk of coronary heart disease is halved after one year compared to continuing smokers 10 years Risk of lung cancer is halved and continues to decline 15 years All cause mortality falls to the same level as for those who have never smoked

14. Electronic Cigarettes: Human Health Effects May 2014 Sara Alajmi

15. Methods: Systematic literature searches were conducted through September 2013 to identify research related to e-cigarettes and health effects. Five reference databases (Web of Knowledge, PubMed, SciFinder , Embase and EBSCOhost )  e-cigarette components.

16. Physiological effects observed in clinical studies: mouth and throat irritation and dry cough at initial use. no change in heart rate, carbon monoxide (CO) level, or plasma nicotine level. increase respiratory flow resistance similar to cigarette use. no change in complete blood count (CBC) indices.

17. Exposure risks for non-users: react with ambient nitrous acid to produce TSNAs, leading to inhalation, ingestion, or dermal exposure to carcinogens. Potential for reduced harm or cigarette smoking cessation. Marketing information frequently includes a stated or implied claim that using e-cigarettes will help smokers quit or reduce cigarette use. Supporting data, however, are quite limited. small studies have demonstrated short-term reduction in cigarette smoking while using e-cigarettes.

18. These 81 respondents included 72 daily users of ecigarettes, one non-daily user and eight former users .

19. Conclusions e-cigarettes have potential advantages over traditional cigarettes, there are many deficiencies in the available data. There are not adequate data to support the safety of long-term use of electronic cigarettes at this time. No e-cigarette has been approved by FDA as a cessation aid.

20. Enhanced Motivational Interviewing Versus Brief Advice For Adolescent Smoking Cessation: Results From A Randomized Clinical Trial Published in 2012 

21. Methods Adolescent cigarette smokers 14–18 years old ( n  = 162) 85 males 77 females smoke at least once per week for the past month. MI = 79 BA= 83 Patients with recent traumatic injury (in medical settings) were excluded

22. MI therapeutic style:  1) establishing rapport 2) exploring pros and cons of smoking and quitting. 3) delivery of computer-generated personalized assessment feedback. 4) imagining the future with and without smoking. 5) reviewing a menu of change options and .developing a change plan. 6) enhancing self-efficacy for change.

23. Telephone boosters. discussion was designed to reinforce progress toward goals in MI ,  In BA, the 5-minute discussion reiterated strong directive advice to quit smoking and maintain abstinence . Parent intervention: in MI focused on increasing parent support for the adolescent’s goals for changing smoking Parents in both conditions were mailed informational materials on helping adolescents quit smoking.

24. Finally There is a need for efficacious interventions for adolescent smokers. In this trial, MI modestly reduced smoking rates (average cigarettes per day) in the short-term compared to BA. MI may provide an efficacious first step toward smoking cessation. An important direction for future intervention development research is how best to capitalize on these proximal effects to lead to longer-term abstinence for adolescent smokers.

25. Nicotine Replacement T herapy Bushra Alenazi

26. How It Works? It helps to reduce nicotine withdrawal and craving (by supplying the body with nicotine). It contains about one-third to one-half the amount of nicotine found in most cigarettes. Nicotine replacement therapy is safe when used properly. Nicotine by itself is not nearly as harmful as smoking. Tars, carbon monoxide , and other toxic chemicals in tobacco cause harmful effects, not the nicotine

27. Types of NRT The US Food and Drug Administration (FDA) has approved 5 forms of nicotine replacement therapy :

28. Studies

29. Adverse events associated with nicotine replacement therapy (NRT) for smoking cessation. A systematic review and meta-analysis of one hundred and twenty studies involving 177,390 individuals Edward J Mills1*, Ping Wu2, Ian Lockhart3, Kumanan Wilson4, Jon O Ebbert5 Published in 2010

30. METHOD 10 electronic databases from inception to November 2009 Ninety-two RCTs involving 32,185 participants 28 observational studies involving 145, 205 participants were identified.

31. RESULT pooled RCT evidence of varying NRT formulations found : increased risk of: heart palpitations and chest pains nausea and vomiting gastrointestinal complaints insomnia

32. Cont: Result Pooled evidence specific to the NRT: patch found an increase in skin irritations Orally administered NRT was associated with mouth and throat soreness , mouth ulcers ; hiccoughs and coughing

33. Cont: Result There was no statistically significant increase in anxiety or depressive symptoms associated with NRT use.

34. Discussion Although NRT was associated with an increased risk of heart palpitations, the review did not observe an increased incident of heart attack or death . The most serious adverse event reported in both RCTs and observational studies were heart palpitations and chest pains. Psychological adverse events, particularly suicidal ideation, are a major concern in patients initiating smoking cessation. They found only one large retrospective observational study that discussed this topic and reported no significant difference in fatal and non-fatal self-harm associated with NRT compared to other frequently used pharmacotherapies, bupropion or varenicline.

35. conclusion This review demonstrates that NRT is associated with adverse effects that may be discomforting for the patient but are not life-threatening . Clinicians should inform patients of potential side effects which are associated with the use of NRT for the treatment of tobacco dependence.

36. Second study A Randomized Trial of Nicotine-Replacement Therapy Patches in Pregnancy march 1, 2012

37. METHODS They took participants from 7 hospitals in England who where: 16 to 50 years of age with pregnancies of 12 to 24 weeks’ gestation smoked 5 or more cigarettes per day. Participants received: 1- behavioral cessation support 2- and they randomly assigned to 8 weeks of treatment : With active nicotine patches (15 mg per 16 hours) or matched placebo patches.

38. Cont: METHOD Abstinence from the date of smoking cessation until delivery: Validated by measurement of exhaled carbon monoxide or salivary cotinine. Safety was assessed by monitoring for adverse pregnancy and birth outcomes.

39. Result Of 1050 participants, 521 were randomly assigned to nicotine-replacement therapy and 529 to placebo:

40. There was No significant difference in the rate of abstinence from the quit date until delivery between the nicotine-replacement and placebo groups.

41. conclusion Adding a nicotine patch (15 mg per 16 hours) to behavioral cessation support for women who smoked during pregnancy did not significantly increase the rate of abstinence from smoking until delivery or the risk of adverse pregnancy or birth outcomes.

42. Weam Nasser

43. The objective of this study to assess the feasibility and success of Zyban as part of smoking cessation programme within UK general practice. Sample: smokers Never used Zyban Had participated in previous NRT trial (PATCH 2 study in 2000 ) N= 479

44. Continuing smokers from the Patch 2 study, who had never used Zyban (n=479) Excluded (n=240) Previous use of Zyban -risk of seizures -clinical contra-indications Other medications Light or x-smokers Moved away Died Refused contact Other INVITED (n=239) Refused (n=65) No Reply (n=40) Accepted (n=134) Failed to contact their GP Made and kept GP appointment (n=79) Eligible to enter the study (n=74) Met the nurse and set quitdate (n-63) Made a quit attempt (n=54) Figure 1. Flow diagram of Participation.

45. Fagerstrom test

46. Hospital Anxiety and Depression Scale (HADS)

47. the Eysenck Personality questionnaire.

48. 3 × 10 marked difference between men and women P<0.05

49. successful quitters at six and twelve months in PATCH 3 showed a trend to lower mean nicotine dependency score (11.8 and 12.2 respectively) than those who made an unsuccessful quit attempt (14.4). The most notable positive finding was that women fared less well than men , which is a not uncommon finding and suggests that additional ways to help female smokers overcome the problems they face may be warranted. Too few subjects!!

50. Weam Nasser

51. between July 2011 and July 2013 Randomized double blinded, placebo control trial Done @ 61 center In 10 countries (Australia, Canada, Czech Republic, Egypt, Germany, Japan, Mexico, Taiwan, United Kingdom, and United States) Participants were recruited through advertising. 24 weeks: 12 weeks reduction 12 weeks of abstinence 28 weeks: follow-up

52. Eligibility - Age >=18 - Smoke around >=10 cigarettes/day - No abstinence period >3months/past year - Exhaled CO > 10ppm - Not willing or able to quit smoking the next month, But willing to reduce smoking the next 3 months Exclusion: history of a suicide attempt or suicidal behaviour major depressive Psychosis panic disorder posttraumatic stress disorder or schizophrenia severe chronic obstructive pulmonary disease alcohol or substance abuse significant cardiovascular or cerebrovascular disease pregnancy, lactating Of 1747 potentially eligible participants screened, 1510 (86%) was accepted

53. Method Counselling training was provided -Advices on reduction techniques -focus on problem solving - skills training - highlight successes.

54. continuous abstinence rate (CAR) during the last 10 weeks of treatment (weeks 15-24) CARs during weeks 21 through 24 during weeks 21 through 52.

55. Enrollment

56. Results

57. Time Vareneciline placebo 4 Weeks 50% 47.1% 31.1% 8 Weeks 75% 26.3% 15.1%

58. Conclusion Among cigarette smokers not willing or able to quit within the next month, but willing to reduce cigarette consumption and make a quit attempt at 3 months , use of Vareneciline for 24 weeks compared with placebo significantly : increased smoking cessation rates at the end of treatment

59. Perceived barriers to smoking cessation in selected vulnerable groups: a systematic review of the qualitative and quantitative literature Received 25 August 2014 Accepted 20 November 2014 Published 22 December 2014 Fatimah Alduheem

60. Design A systematic review was carried out to identify the perceived barriers to smoking cessation within six vulnerable groups.

61. Objectives To identify barriers that are common and unique to six selected vulnerable groups: low socioeconomic status; Indigenous; mental illness and substance abuse; homeless; prisoners; and at-risk youth.

62. Aims Identify barriers that are common across all vulnerable groups included in the review. Identify barriers that may be unique to specific groups. The results of the review will be used to develop a practical model to help understand the barriers to quitting among vulnerable groups and to aid smoking cessation intervention development.

63. Methods Study design. Databases and search. Inclusion and exclusion criteria. Risk of bias in individual studies.

64. Results 65 eligible papers were identified: 24 with low socioeconomic groups, 16 with Indigenous groups, 18 involving people with a mental illness, 3 with homeless groups, 2 involving prisoners and 1 involving at-risk youth. One study identified was carried out with participants who were homeless and addicted to alcohol and/or other drugs. Barriers common to all vulnerable groups included: smoking for stress management, lack of support from health and other service providers, and the high prevalence and acceptability of smoking in vulnerable communities. Unique barriers were identified for people with a mental illness (eg, maintenance of mental health), Indigenous groups (eg, cultural and historical norms), prisoners (eg, living conditions), people who are homeless (eg, competing priorities) and at-risk youth (eg, high accessibility of tobacco).

65. Discussion Main barriers identified across all vulnerable groups : Stress management. Lack of support to quit from health professionals and other service providers. High prevalence and acceptability of smoking.

66. Barriers specific to certain groups Indigenous groups : Indigenous groups identified unique stressors linked to smoking including racism and historical factors; cultural practices including ceremonial use of tobacco and cultural values that promote sharing. Prisoners : Prisoners identified unique stressors within their living conditions that contributed to their smoking including social isolation, anxiety regarding legal matters and transfers to other prisons. People with a mental illness : Low motivation to quit smoking.

67. Conclusion Vulnerable groups experience common barriers to smoking cessation, in addition to barriers that are unique to specific vulnerable groups. Individual-level, community-level and social network-level interventions are priority areas for future smoking cessation interventions within vulnerable groups.

68. Barriers and motivators to gaining access to smoking cessation services amongst deprived smokers qualitative study Received: 2 August 2006 Accepted: 6 November 2006 Published: 6 November 2006

69. Background Smoking is strongly associated with disadvantage and is an important contributor to inequalities in health. Smoking cessation services have been implemented in the UK targeting disadvantaged smokers, but there is little evidence available on how to design services to attract this priority group.

70. Methods We conducted focus groups with 39 smokers aged 21–75 from the most socio-economically deprived areas of Nottingham UK who had made an unsuccessful attempt to quit within the last year without using smoking cessation services, to identify specific barriers or motivators to gaining access to these services.

71. Discussion The participants in this study were smokers who had previously attempted to quit smoking without formal support, and who lived in extremely deprived areas. Although motivated to quit smoking, they felt that their smoking was intractable and were torn between thinking that only intensive measures would help them to stop but also that all that was really required was willpower. They felt increasingly marginalised by society and government and felt that their addiction was not taken as seriously as addiction to heroin or alcohol. They knew little about the services available to help them, but perceived them to be ineffective and expensive despite evidence to the contrary. Participants stated the need for a wide variety of cessation group timings and locations without being aware that these services already existed.

72. Results Barriers to use of existing services related to fear of being judged, fear of failure, a perceived lack of knowledge about existing services, a perception that available interventions – particularly Nicotine Replacement Therapy – are expensive and ineffective, and negative media publicity about bupropion. Participants expressed a preference for a personalised , non-judgemental approach combining counselling with affordable, accessible and effective pharmacological therapies; convenient and flexible timing of service delivery, and the possibility of subsidised complementary therapies.

73. Conclusion We conclude that smokers from these deprived areas generally had low awareness of the services available to help them, and misconceptions about their availability and effectiveness. A more personalized approach to promoting services that are non-judgmental, and with free pharmacotherapy and flexible support may encourage more deprived smokers to quit smoking.

74. Conclusion

75. Summary Cigarette smoking is one of the major preventable causes of morbidity and mortality all over the world . The earlier smoking is stopped, the greater the health gain . No e-cigarette has been approved by FDA as a cessation aid There is a need for efficacious interventions for adolescent smokers This review demonstrates that NRT is associated with adverse effects that may be discomforting for the patient but are not life-threatening.

76. Cont. Adding a nicotine patch during pregnancy did not significantly increase the rate of abstinence from smoking until delivery or the risk of adverse pregnancy or birth outcomes. Zyban can reduce the nicotine dependency score within a 12 months course. Gender and genotype may play a role in smoke cessation, but further studies are needed to ensure that. Vareneciline helped in smoke cessation for smokers whose unable to stop within 3 months. There are many barriers to quit smoking but with the strong motivation they can quit smoking.