Smoking cessation

Cigarette smoking is one of the major preventable causes
of morbidity and mortality all over the world.
• According to World Health Organization (WHO, 2018)
Tobacco is the second major cause of death. It is currently
responsible for the death of 1 in 10 adults.

1. SMOKING CESSATION Dr Kamal Bharathi. S Department of Pulmonary Medicine Sri Manakula Vinayagar Medical college and Hospital

2. Tobacco The plant is part of the genus  Nicotiana and of the  Solanaceae  family. While more than 70 species of tobacco are known, the chief commercial crop is N. tabacum . Nicotiana tabacum  is a native of tropical and sub-tropical America but it is now commercially cultivated worldwide.

3. Mayans usage of tobacco The phrase " y- otoot 'u-may ," written on the vessel, translates as 'the house of his/her tobacco. Used as: Making powerful alcohol drink Making bug and snake repellent Snort and snuff Proved with Mass Spectroscopy the traces of nicotine.

4. History of tobacco First smoked all over the Americas by Red Indians in shamanistic rituals. The pipe was called Peace pipe. In 1492 Christopher Columbus arrived at ‘San Salvador’ where the natives thought that he and his men were divine beings sent by the Gods. They presented Columbus with gifts including wooden spears, wild fruits and dried leaves. He did not smoke; indeed he threw the leaves away!!

5. Rodrigo de Jerez  was one of the  Spanish  crewmen who sailed with Columbus . He is credited with being the first European  smoker . Jerez picked up the tobacco smoking habit to Spain. Later he was arrested and spent 7 years in prison. Smoking tobacco had caught on.

6. Tobacco Invasion in I ndia Cannabis smoking in India has been known since at least 2000 BC and is first mentioned in the Atharvaveda, which dates back a few hundred years BC. During Mughal rule, Hookah smoking was popular among local people. Men of the same caste or sub- caste gathered around in the evenings to share a common hookah. The cultivation of tobacco started in southern Gujarat in the late 17th century after the British colonized. Because the hookah was tedious to carry around, a cheaper and portable form of the hookah was developed, called the chillum. Bidis were developed soon after. During the severe drought of 1899 in Gujarat, which compelled many families to migrate in search of a livelihood, that the bidi became a small-scale industry. The father of the modern bidi and the industry is possibly Mohanlal Patel of Gomtipur District, Ahmedabad,

7. Tobacco Invasion in India It’s mentioned that, tobacco had been cultivated in Andhra Pradesh during the region of Krishna Deva Raya. The cultivation of the tobacco dates back to 17th century when it started in Gujarat. A few soon later, some bidi rollers of this region had settled down into the parts of the country During drought it became as a small-scale industry. Because of the rapid expansion of the railway network between in 1912 to 1918, the bidis were also spread out to all parts of the country. Now, India is the world’s 2 nd  largest producer of tobacco with an estimated annual production of 800 million kgs . And Andhra Pradesh is the largest producer of tobacco in India.

8. The integrated approach to successful smoking cessation

9. Is smoking a life style choice? Smoking a cigarette for a beginner is a symbolic act of rebellion Smoking is not a life style choice Creates a dependent state Nicotine addiction is a complex process Quitting smoking leads to decrements in attention and cognition Impaired concentration, thinking, and performance associated with nicotine deprivation are strong motivating factors to smoke

10. Nicotine actions

11. Mechanism of Action of Nicotine in the Central Nervous System Nicotine binds preferentially to nicotinic acetylcholinergic (nACh) receptors in the central nervous system; the primary is the  4  2 nicotinic receptor in the Ventral Tegmental Area (VTA) After nicotine binds to the  4  2 nicotinic receptor in the VTA, it results in a release of dopamine in the Nucleus Accumbens (nAcc) which is believed to be linked to reward   2  2 4  2  4  4  2 N i c o t i n i c R e c e p t o r

12. Why do Smokers smoke? No n - Phys io lo g ic al Re as o ns Peer pressure Mass media Pleasure and relaxation Nature of work Improved thinking and performance Relief from negative moods (anxiety, stress, anger, irritability and depressed mood) Weight control Phys io logic al Re as o ns Physical dependence on nicotine Relief from withdrawal symptoms

13. Nicotine Dependence

14. Effects of Nicotine Withdrawal When nicotine levels drop, most smokers report physiological withdrawal symptoms such as : Anxiety Irritability Restlessness Difficulty in concentrating GI disturbance Craving Drowsiness

15. SMOKING CESSATION 5As (Ask ,Advise, Assess, Assist ,Arrange for follow up) 5 Stages of change (Precontemplation , Contemplation ,Determination , Action, Maintenance) 5 Rs (Relevance, Risks, Rewards, Roadblocks, Repetition)

16. 5 A 1. Ask about smoking . 2. Advise every smoker to stop smoking . 3. Assess readiness to quit . 4. Assist the smoker in stopping smoking . 5. Arrange for follow up and monitor the progress of the smoker

17. “1” A SK : The smoking history • Since how long you became a smoker ? • What type of smoke you are using ? • Why you are smoking ? • How many cigarette per day ? • What is frequency of smoking ? • What is the preferred times for smoking ? • What are the behaviors associated with smoking ? • How long you take after walkup in the morning to smoke?

18. Non Smoker • Congratulate him . • Encourage him to continue as non-smoker . • Advice to avoid indirect smoking ( second – hand smoker ) . • Encourage him to participate in smoking cessation .

19. • Any attempt to stop before ? ( take details about this attempt). • Do you have any medical problem due to smoking? • Is there any smoker around you ( home , work ) ? • Is there any family member or friend who had any medical problem due to smoking ? • Are you married ? Do you have children ? • Are you convinced about the risk of smoking? • Are you willing to quit ?

20. A smoker’s dependence on nicotine can be estimated from: 1. The duration of smoking history . 2. The number of cigarettes smoked daily . 3. How soon after waking up the smoker has his or her first morning cigarette. More dependent smokers have: 1. Smoked for many years . 2. Smoke more cigarettes daily . 3. Smoke within the first 30 minutes of awakening .

21. ADVICE Advice should be: 1. Clear - I think it is important for you to quit smoking now and I can help you." "Cutting down while you are ill is not enough. 2. Strong - As your clinician, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. The clinic staff and I will help you. 3. Personalized - Tie tobacco use to current health/illness, and/or its social and economic costs, motivation level/readiness to quit, and/or the impact of tobacco use on children and others in the household.

22. ASSESS • Determine the patient's willingness to quit smoking within the next 30 days: - If the patient is willing to make a quit attempt at this time, provide assistance. - If the patient will participate in an intensive treatment, deliver such a treatment or refer to an intensive intervention. - If the patient clearly states he or she is unwilling to make a quit attempt at this time, provide a motivational intervention. - If the patient is a member of a special population (e.g., adolescent, pregnant smoker), provide additional information specific to that population.

23. “2” Assess: measurements of smoking intensity CO measure is useful for reinforcing patient’s motivation to quit (Modified) Fagerstr̈om Test for Nicotine Dependence Biochemical serum, urine or salivary cotinine exhaled carbon monoxide

24. ASSIST Meta-analyses of clinical trials to study the Effectiveness of the 5-As Tobacco Cessation Treatments. It showed smoking cessation was twice as likely when smokers • Attended classes, • Received counselling, or • Used pharmacotherapies

25. 5 Stages of change 1. Precontemplation : The patient states he/she is not ready to quit. The patient's motivation status should be documented and monitored at every subsequent visit. 2. Contemplation: The patient is considering smoking cessation at some point in the future. 3. Determination: The patient is actively considering cessation soon and is engaging in some quit-oriented behavior. 4. Action: The patient is actively involved in a quit attempt and has quit smoking within the last six months. 5. Maintenance: The patient has quit for at least six months.

26. 5R The model of " 5 Rs " Relevance, Risks, Rewards, Roadblocks, Repetition is helpful to motivate smokers who are not ready to quit

27. RELEVANCE Motivational information has the greatest impact if it is relevant to a patient's disease status or risk, family or social situation (e.g., having children in the home), health concerns, age, gender, and other important patient characteristics (e.g., prior quitting experience, personal barriers to cessation).

28. RISKS Ask the patient to identify potential negative consequences of tobacco use. • The clinician may suggest and highlight those that seem most relevant to the patient. Examples of risks are: -Acute risks - Shortness of breath, exacerbation of asthma, harm to pregnancy, impotence, infertility, and increased serum carbon monoxide.

29. • Long-term risks - Heart attacks and strokes, lung and other cancers (larynx, oral cavity, pharynx, esophagus, pancreas, bladder, cervix), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), long-term disability, and need for extended care. • Environmental risks - Increased risk of lung cancer and heart disease in spouses; higher rates of smoking in children of tobacco users; increased risk for low birth weight, Sudden Infant Death Syndrome, asthma, middle ear disease, and respiratory infections in children of smokers.

30. REWARDS Ask the patient to identify potential benefits of stopping tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. Examples of rewards include: – Improved health – Food will taste better – Improved sense of smell – Feel better about yourself – Home, car, clothing, breath will smell better – Not worry about exposing others to smoke – Feel better physically and perform better in physical activities – Reduced wrinkling/aging of skin

31. ROADLOCKS • Ask the patient to identify barriers to quitting and note elements of treatment that could address barriers. • Typical barriers might include: – Withdrawal symptoms – Fear of failure – Weight gain – Lack of support – Depression – Enjoyment of tobacco

32. REPETITION • The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting. • Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.

33. DETERMINATION 1. Set a quit date. Ideally, the quit date should be within 2 weeks. He can select a special date in his life or in the year. 2. Write this date in the patient file . 3. Tell family, friends, and coworkers about quitting and request understanding and support. 4. Anticipate challenges /triggers to planned quit attempt, particularly during the critical first few weeks. These include nicotine withdrawal symptoms. 5. Prior to quitting , avoid smoking in places where you spend a lot of time (e.g., work, home, car)

34. 6. Remove tobacco products and smell from your environment the day before quitting . 7. Total abstinence is essential. "Not even a single puff after the quit date.“ 8. Review past quit attempts including identification of what helped during the quit attempt and what factors contributed to relapse. 9. Alcohol can cause relapse, the patient should consider limiting/abstaining from alcohol while quitting. 10. Quitting is more difficult when there is another smoker in the household. Patients should encourage housemates or his colleagues to quit with them or not smoke in their presence.

35. 11. Provide a supportive clinical environment while encouraging the patient in his or her quit attempt. "My office staff and I are available to assist you.“ 12. Help the patient develop social support for his or her quit attempt in his or her environments outside of treatment. "Ask your spouse/partner, friends, and coworkers to support you in your quit attempt.“ 13. Assess behaviors associated with smoking ( you can use smoker diary ) to concentrate on them in the quitting process.

36. 14. Recommend the use of pharmacotherapies found to be effective. Give him the options ,details and what is suitable for his condition 15. Explain how these medications increase smoking cessation success and reduce withdrawal symptoms . 16. Always remind him about quitting rewards and keep encouraging him . 17. Tell him that relapse can happen . So, he can know the weaknesses and try again and again until he succeed . 18. Determination and the will are the cornerstone in the quitting process.

37. Inte rve ntio n S trate g ie s Non-pharmacological Self-help Behavioural Group support Hypnosis Pharmacological Nicotine Replacement Bupropion Verinicline

38. Non-pharmacological S e lf - he lp Pro g ramme s: Smoking Cessation Clinics Counselling support Behavioural programmes If the above programmes are inadequate, then pharmacological therapies are sought

39. Behavioural Programmes Self-management strategies Aversion conditioning techniques Relapse-prevention methods Nicotine fading

40. S e lf - Manag e me nt Strategies Most commonly used Make smokers more aware of their smoking patterns and cues Self-monitoring Record when, where, and why they smoke Promote a behavioural change and design a treatment plan Stimulus control (Cue extinction) Done before quitting to reduce the strength of the smoking cue Avoiding dominant cues (talking on the phone, finishing a meal

41. Aversion Conditioning Techniques Should only be administered by trained smoking cessation specialists Used to decrease a smoker’s urge to smoke before quit dates or upon relapse Techniques include rapid smoking and satiation Rapid smoking : Smokers puff cigarettes every 6 to 8 seconds until the cigarette is gone or nausea occurs Satiation : Smokers double or triple their daily cigarette consumption for brief periods of time

42. Relapse -Prevention Methods Designed to prevent smokers from returning to smoking behaviour Avoidance : Minimising exposure to temptations, e.g. stress, other smokers Coping Strategies : Techniques such as deep breathing or use of relaxation tapes, to deal with withdrawal symptoms Contingency management : Rewards and punishments

43. Nicotine Fading Gradual reduction of nicotine intake : Tapering the number of cigarettes smoked Switching to brands containing less nicotine Disadvantage : Smokers can compensate by inhaling more deeply and longer Further reinforce each episode of smoking Results are inconsistent and thus not recommended for routine use

44. PHARMACOLOGICAL THERAPIES Nicotine Replacement Therapies Combination Therapy

45. Nicotine Replacement Therapies Gum Transdermal patches Nasal Spray Oral Inhaler Lozenges

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47. Nicotine Gum Administered on an as-desired basis Most people chew 8 to 15 pieces a day; Each piece is chewed for 20 to 30 mins Approximately 50% of nicotine is released Providing 8 to 15mg of nicotine per day from the 2- mg form and 16 to 30mg from 4-mg form Approx. one-third or one-half of the usual daily intake of a person who smokes 30 cigarettes daily Recommended use for 4 to 6 months and patients should be encouraged to wean from nicotine gum, but the optimal duration of use is unknown .

48. Efficacy of Nicotine Gum: Successful only accompanied by intensive behavioural programmes Acidic drinks, such as coffee or soda, decrease acidity of saliva and may interfere with the effects of nicotine gum One should never smoke and chew

49. Nic o tine Patc he s Delivering a steady amount of nicotine to the body right through the skin (usually on an arm, abdomen) Easy to use Once a day (changing the location each time)

50. Safety and Adverse Effects of Nicotine Patches: Skin irritation at the patch site Insomnia Headache Cold and flu-like symptoms Nausea Myalgia Dizziness Less common : Sleep disturbance, GI side effects - diarrhoea, upset stomach

51. Nicotine Lozenge Use: Allow to dissolve (Don’t Chew but Suck like a hard candy.) Pros: Flexible dosing (Up to 20 lozenges/ day) More discreet than gum; Keep mouth busy; OTC; Cons : Need to use correctly (don’t chew, suck) May cause insomnia, some nausea, hiccups, heartburn, coughing Dosing: Based on Time To First Cigarette (TTFC) 4 mg ≤ if 30 mins TTFC 2mg > if 30 mins TTFC Length of T r e a tm e nt: 12 weeks

52. Nicotine Nasal Spray Dosing: 1-2 doses per hour 1 does = 2 spays (1 spray/nostril) Use enough to control withdrawal symptoms Length of Treatment: 3-6 months

53. Nicotine Nasal Spray Use: Spray (don’t sniff, swallow, or inhale) PRN or fixed-schedule (1-2 doses/hour) Pros: Rapid delivery though nasal mucosa Flexible dosing (up to 40 doses) Cons: Nasal irritation, rhinitis, coughing, & watering eyes. Some dependence liability Rx needed

54. S afe ty of Re plac e me nt The rapie s NRTs should be used with extra caution in patients with cardiovascular disease Smoking while using patch or gum therapy may increase the risk of cardiovascular and toxic effects of nicotine Patients should stop smoking completely when starting treatment In addition, many smokers see such therapy as simply prolonging their dependence or fear becoming dependent on the replacement itself

55. COMBINATION THERAPY

56. Bupropion Works on the biology of nicotine addiction By enhancing dopamine levels in the reward pathway Affect noradrenergic neurons in the locus ceruleus to reduce craving and withdrawal symptoms

57. Do s ag e & Adminis tratio n fo r Bupro pio n Start with 150mg/day for the first 3 days Follow by a dose increase to 300mg/day given as 150mg b.d. (at 8-hourly interval) Maximum dose : 300 mg/day Doses above 300mg/day should not be used due to dose-dependent risk of seizures

58. Patients should start taking bupropion BEFORE they quit smoking They should set a “target quit date” during the 2nd week of treatment with bupropion as it takes about 1 week to reach steady-state blood levels Treatment with bupropion should be continued for 7-12 weeks Dose tapering is not necessary when discontinuing bupropion Important that patients continue to receive counselling and support throughout treatment with bupropion, and for a period of time thereafter

59. Individualization of Therapy Need for education/counseling/support Discontinue if patient has not made significant progress toward abstinence by the seventh week of therapy If unsuccessful, re-evaluate later for retrial of therapy Bupropion should be used as a part of a comprehensive smoking cessation treatment program

60. Bupropion in Clinical Practice Bupropion is indicated for the treatment of nicotine dependence as an aid to smoking cessation in subjects aged 18 years and over. Adult smokers who are motivated to stop could benefit from treatment with bupropion. For the majority of patients, the recommended dosage is 150mg once daily for 3 days, increasing to 150mg twice daily.

61. Varenicline Tartrate Indicated for smoking cessation in adults Oral administration (tablet) Non-nicotine a partial agonist selective for the α4β2 nicotinic acetylcholine receptor Dual action with dual benefits Partial agonist activity: Reduces craving and withdrawal symptoms Antagonist activity: Produces a reduction of the rewarding and reinforcing effects of smoking

62. Varenicline: Dosage Treatment period is 12 weeks An additional course of 12 weeks of treatment may be considered for patients who have successfully quit at end of 12 weeks Varenicline is supplied for oral administration in 2 strengths: 0.5 and 1.0 mg; titration is as below:

63. Pharmacokinetics of Varenicline Half-life ~24 hours max within 3 to 4 hours Steady state reached within 4 days Oral bioavailability unaffected by food 92% of drug is excreted unchanged No inhibition of cytochrome P450 enzymes No clinically meaningful drug interactions identified No dose restrictions in patients with hepatic insufficiency Dose adjustment required for severe renal impairment, may be considered for moderate renal impairment. No dosage adjustment is necessary for elderly patients absent renal impairment

64. Adverse Effects During clinical trials, approximately 4000 individuals were exposed to varenicline Most frequently reported AEs (≥10%) associated with varenicline 1 mg vs placebo were: Nausea Abnormal dreams Insomnia Headache The percentage of participants who discontinued treatment due to adverse events receiving varenicline treatment was comparable; 11.4% vs 9.7%

65. Contraindications & Interactions Contraindications: hypersensitivity to the active substance or to any of the excipients No clinically meaningful drug interactions have been identified with varenicline

66. Precautions There are no adequate data from the use of varenicline in pregnant women Varenicline should not be used during pregnancy Varenicline may have minor or moderate influence on the ability to drive and use machines Patients are advised not to engage in potentially hazardous activities until it is known whether their ability to perform these activities is affected

67. Second Line Drugs

68. New Medications in the Pipeline Rimonabant Cannabinoid receptor inhibitor Blocks reinforcing effects of nicotine Also suppresses appetite In phase III trials Not approved for smoking cessation by FDA Nicotine Vaccine Produces antibodies to nicotine Reduces nicotine levels in animals CYP246 Inhibitors CYP246 is a hepatic enzyme that metabolizes nicotine Higher blood nicotine levels per cigarette smoked Could also increase potency of NRT Eg Methoxsalen , Tranylcypromine

69. THANK YOU…!!!