Smoking cessation complete guideline .ppt

A lifelong smoker has about a one in three chance of dying prematurely from a complication of smoking.

1. SMOKING
CESSATION
Dr. MehulThakkar

2. Introduction
Portuguese introduced tobacco to India 400 years
ago. Ever since, Indians have used tobacco in
various forms.
According to a report from the Indian Council of
Medical Research (ICMR), there are 184 million
tobacco users in India, which include 40 million
cigarette smokers, 80 million bidismokers and 60
million using chewable forms of tobacco.
65 % of all men and 33% of all women use tobacco
in some form.

3. By 2020 it is predicted that tobacco will account
for 13% of all deaths in India.
A lifelong smoker has about a one in three
chance of dying prematurely from a
complication of smoking.

4. Tobacco
Tobacco smoke is an aerosol of droplets (particulates) containing
water, nicotine and other alkaloids, and tar.
The particulate phase of tobacco include nicotine, benzo(a)pyrene
and other polycyclic hydrocarbons, N'-nitrosonornicotine, beta-
naphthylamine, polonium-210, nickel, cadmium, arsenic, and lead.
The gaseous phase contains carbon monoxide, acetaldehyde,
acetone, methanol, nitrogen oxides, hydrogen cyanide, acrolein,
ammonia, benzene, formaldehyde, nitrosamines, and vinyl chloride.
Tobacco smoke may produce illness by way of systemic absorption
of toxins and/or cause local pulmonary injury by oxidant chemicals.

5. MOA
The mechanisms by which smoking increases risk are multifactorial–
structural and
immunologic alterations.
Structural changes –
peribronchiolarinflammation and fibrosis,
increased mucosal permeability,
impairment of mucociliaryclearance,
changes in pathogen adherence, and disruption of the respiratory epithelium.
Acrolein, acetaldehyde, formaldehyde, free radicals produced from chemical
reactions in the cigarette smoke, and nitric oxide, may contribute to the
observed structural alterations in airway epithelial cells.

6. MOA (contd..)
Immunologic mechanisms include alterations in cellular and
humoralimmune system function.
Decreased level of circulating immunoglobulins,
A depression of antibody response to certain antigens,
A decrease in CD4+ lymphocyte counts,
An increase in CD8+ lymphocyte counts,
Depressed phagocyte activity, and
Decreased release of pro-inflammatory cytokines.
Many of the immunologic disturbances in smokers resolve
within 6 weeks after smoking cessation, supporting the idea that
smoking cessation is highly effective in a relatively short period
of time in the prevention of infection.

7. Health Hazards of Tobacco Use (Risks Increased
by Smoking)
Cancer-
Cigarette Smoking and Cancer Risk
Cancer Site Average Relative Risk
Lung 15.0–30.0
Urinary tract 3.0
Oral cavity 4.0–5.0
Oropharynx and hypopharynx4.0–5.0
Esophagus 1.5–5.0
Larynx 10.0
Pancreas 2.0–4.0
Nasal cavity, sinuses, nasopharynx1.5–2.5
Stomach 1.5–2.0
Liver 1.5–2.5
Kidney 1.5–2.0
Uterine cervix 1.5–2.5
Myeloid leukemia 1.5–2.0

8. Cardiovascular Disease-
Sudden death
Acute myocardial infarction
Unstable angina
Stroke
Peripheral arterial occlusive disease (including thromboangiitisobliterans)
Aortic aneurysm
Pulmonary Disease-
Lung cancer
Chronic bronchitis
Emphysema
Asthma
Increased susceptibility to pneumonia and pulmonary tuberculosis
Increased susceptibility to desquamativeinterstitial pneumonitis
Increased morbidity from viral respiratory infection

9. Gastrointestinal Disease-
Peptic ulcer
Esophageal reflux
Reproductive Disturbances-
Reduced fertility
Premature birth
Lower birth weight
Spontaneous abortion
Abruptio placentae
Premature rupture of membranes
Increased perinatal mortality
Oral Disease (Smokeless Tobacco)-
Oral cancer
Leukoplakia
Gingivitis
Gingival recession
Tooth staining

10. Other
Non-insulin-dependent diabetes mellitus
Earlier menopause
Osteoporosis
Cataract
Tobacco amblyopia (loss of vision)
Age-related macular degeneration
Premature skin wrinkling
Aggravation of hypothyroidism
Altered drug metabolism or effects
Delayed wound healing

11. Why do people smoke?
Pleasure, arousal, enhanced vigilance, improved
performance, relief of anxiety or depression,
reduced hunger, control of body weight, peer
pressure, advertising and smoking in movies.

12. Neurochemical effects of nicotine.

13. WHO Statement on Smoking Cessation
Smoking cessation is a critical step toward
substantially reducing the health risks run by smokers,
thereby improving world health.
Tobacco has been shown to cause about 25 life-
threatening diseases, many of which can be
prevented, delayed, or mitigated by smoking
cessation.
As life expectancy increases in developing countries,
the morbidity and mortality burden of chronic diseases
will increase still further.
This projected tobacco-related disease burden can be
lightened by intensive efforts at smoking cessation.

14. WHO Statement on Smoking Cessation –
contd…
Studies have shown that 75-80% of smokers want to
quit, while one-third have made at least three serious
attempts.
If only small portions of today’s 1.1 billion smokers
were able to stop, the long-term health and economic
benefits would be immense.
Governments, communities, organizations, schools,
families and individuals are called upon to help current
smokers stop their addictive and damaging habit.

15. Physiological effects of cessation
The forced expiratory volume in 1 second (FEV1) has
been used as the primary measure of pulmonary function
in several studies.
Among all persons over the age of 45 years, the FEV1
declines at a rate of approximately 20 mL/yr as a natural
consequence of aging.
In the Lung Health Study, patients with chronic
obstructive pulmonary disease (COPD) who continued to
smoke showed a steeper rate of decline in FEV1 of about
62 mL/yr.
Patients who were able to quit successfully reduced their
rate of decline to that of nonsmokers.

16. Benefits of smoking cessation
Short-term –
1. The excess risk of premature coronary heart disease falls
by one-half within 1 year of abstinence.
2. Some of the toxic effects of cigarette smoking that may
lead to cardiac events, such as increased platelet
activation, elevated carbon monoxide levels, and coronary
artery spasm, are immediately reversible with cessation.
3. Pregnant women who stop during the first 3-4 months of
pregnancy eliminate their excess risk of having a low-
birth-weight baby.

17. Benefits (contd.)
Long-term-
1. Men who stop smoking before age 50 cut their age-
specific mortality rate in half and extend their life by
6 years compared to continuing smokers.
2. Men who quit smoking by age 30 have a similar life
expectancy to those who never smoked, which is 10
years longer than that of continuing smokers.

18. Weight gain
Several studies on the effects of smoking on weight
have shown that ex-smokers gain more weight over
time than non-smokers or active smokers.
The typical weight gain associated with smoking
cessation ranges from 2.5-4.5 kg (5-10 lb).
Women tend to gain slightly more weight than men.
Genetic predisposition, younger age, and reduced
physical activity may increase the risk for weight
gain.

19. Levels of intervention
Individual approach
Mass approach

20. Counseling
Assess the level of dependence
Quantify the amount of exposure
Strategies -
1.Individualized counseling
2.Group counseling
3.Telephonic counseling

21. Counseling (contd…)
Counselling delivered by physicians and other health
professionals significantly increases quit rates over self-
initiated strategies.
Even a brief (3-minute) period of counselling to urge a
smoker to quit results in smoking cessation rates of 5-10%.
At the very least, this should be done for every smoker at
every health care provider visit.
Education in how to offer optimal smoking cessation advice
and support should be a mandatory element of curricula for
health professionals.
There is a strong dose-response relationship between
counselling intensity and cessation success.
Ways to intensify treatment include increasing the length of
the treatment session, the number of treatment sessions, and
the number of weeks over which the treatment is delivered.

22. Contd…
Sustained quit rates of 10.9% at 6 months have been
achieved when clinician tutorials and feedback are linked
to counselling sessions.
With more complex interventions (for example,
controlled clinical trials that include skills training,
problem solving, and psychosocial support), quit rates can
reach 20-30%.
In a multicenter controlled clinical trial, a combination of
physician advice, group support, skills training, and
nicotine replacement therapy achieved a quit rate of 35%
at 1 year and a sustained quit rate of 22% at 5 years.

23. Brief strategies to help a patient quit (the "5
A's") which can be implemented in as little as 3
minutes, increase cessation rates significantly.
1.Ask
2.Advise
3.Assess
4.Assist
5.Arrange

24. An algorithm for treating tobacco use. (Adapted from The Tobacco Use and Dependence Clinical
Practice Guideline Panel, Staff, and Consortium Representatives: A clinical practice guideline for treating
tobacco use and dependence: A US Public Health Service Report. JAMA 283:3244–3254, 2000.)

25. Problems encountered
Patient doesn’t make an attempt
Withdrawal symptoms
Relapse

26. Withdrawal symptoms
Anxiety, irritability, difficulty in concentrating,
restlessness, hunger, craving for tobacco,
disturbed sleep, and in some people depression.
The symptoms begin quickly, as soon as several
hours after the last cigarette. They generally peak
within the first few days and are usually minimal
by 30 days. Some smokers, however, complain
of tobacco cravings for months or even years
after quitting.

27. Pharmacotherapy
The U.S. Public Health Service recommends
that all persons who are ready to make a quit
attempt, in the absence of contraindications,
should be offered NRT when trying to quit
smoking.

28. Types
1
st
line-
1.Nicotine gum
2.Nicotine inhaler
3.Nicotine nasal spray
4.Nicotine patch
5.Sustained-release Bupropion hydrochloride
2
nd
line-
1.Clonidine
2.Nortriptyline

29. Newer drugs-
1.Rimonabant
2.Varenicline
Miscellaneous –
1.Herbal remedies-
Burdock root
Echinacea
Hyssop
Valerian root
2.Laser therapy

30. Pharmacotherapy
Precautions/Contraindicati
ons
Adverse Effects Dosage Duration
First-line Drugs
Sustained-release bupropion
hydrochloride
History of seizure Insomnia
150 mg every morning for 3
days then 150 mg twice daily
(begin treatment 1–2 weeks
prequit)
7–12 weeks maintenance
up to 6 months
History of eating disordersDry mouth
Nicotine gum
Temporomandibular joint
disorder
Mouth soreness
1–24 cigarettes/day; 2 mg
gum (up to 24 pieces/day) ≥25
cigarettes/day; 4 mg gum (up
to 24 pieces/day)
Up to 12 weeks
Dyspepsia
Nicotine inhaler
Local irritation of mouth and
throat
6–16 cartridges/day Up to 6 months
Nicotine nasal spray
Chronic nasal disorders,
including rhinitis, polyps, and
sinusitis
Nasal irritation 8–40 doses/day 3–6 months
Throat burning
Nicotine patch
Skin diseases, such as
atopic or eczematous
dermatitis
Local skin reaction 21 mg/24 hr 4 weeks, then
14 mg/24 hr 2 weeks, then
Insomnia 7 mg/24 hr 2 weeks
15 mg/16 hr 8 weeks

31. Second-line Drugs
Pharmacotherapy
Precautions/Contraindicati
ons
Adverse Effects Dosage Duration
Clonidine Rebound hypertension Dry mouth 0.15–0.75 mg/day 3–10 weeks
Drowsiness
Dizziness
Sedation
Nortriptyline Risk of arrhythmias Sedation Dry mouth 75-100 mg/day 12 weeks

32. Nicotine replacement therapy
A smoker should be instructed to quit smoking
entirely before beginning nicotine replacement
therapies.
Nicotine medications seem to be safe in patients with
cardiovascular disease and should be offered to
cardiovascular patients.
Although smoking cessation medications are
recommended by the manufacturer for relatively
short-term use (generally 3–6 months), the use of
these medications for 6 months or longer is safe and
may be helpful in smokers who fear relapse without
medication.

33. Nicotine gum
Optimal use of nicotine gum includes
instructions to chew slowly, to chew 8 to 10
pieces per day for 20 to 30 minutes each, and to
continue for an adequate period for the smoker
to learn a lifestyle without cigarettes, usually 3
months or longer.
Side effects of nicotine gum are primarily local
and include jaw fatigue, sore mouth and throat,
upset stomach, and hiccups.

34. Nicotine patch
Patches are applied in the morning and removed
either the next morning or at bedtime,
depending on the patch.
Patches intended for 24-hour use can also be
removed at bedtime if the patient is experiencing
insomnia or disturbing dreams.
Full-dose patches are recommended for most
smokers for the first 1 to 3 months, followed by
one or two tapering doses for 2 to 4 weeks each.

35. Nicotine nasal spray and inhaler
Nicotine nasal spray, one spray into each nostril,
delivers about 0.5 mg nicotine systemically and can
be used every 30 to 60 minutes. Local irritation of
the nose commonly produces burning, sneezing,
and watery eyes during initial treatment, but
tolerance develops to these effects in 1 to 2 days.
The nicotine inhaler actually delivers nicotine to the
throat and upper airway, from where it is absorbed
similarly to nicotine from gum. It is marketed as a
cigarette-like plastic device and can be used ad
libitum.

36. Nicotine lozenges
Nicotine lozenges have been marketed over the counter.
The lozenges are available in 2 mg and 4 mg strengths
and are to be placed in the buccal cavity where they are
slowly absorbed over 30 minutes.
Smokers are instructed to choose their dose according to
how long after awakening in the morning they smoke
their first cigarette (a measure of the level of
dependence).
Those who smoke within 30 minutes are advised to use
the 4 mg lozenge, whereas those who smoke their first
cigarette at 30 minutes or more are advised to use the 2
mg lozenges. Use is recommended every 1 to 2 hours.

37. Contraindications to nicotine
therapy
Although package inserts recommend caution in using
nicotine products in patients with cardiovascular disease,
studies of patch use show no association between NRT
and acute cardiovascular events, even in patients who
smoke intermittently while using the patch.
The nicotine nasal spray should not be used in persons
with severe reactive airway disease.
Pregnant and breast-feeding smokers should be urged to
quit first without any pharmacologic therapy.
NRT should be offered only if the potential benefits of the
increased chance of abstinence afforded by these products
outweigh their risks.

38. Bupropion
Sustained-release Bupropion (Zyban) is a
dopamine-norepinephrinereuptake inhibitor
originally marketed and still widely used as an
antidepressant.
Bupropion was found to aid smoking cessation
independent of whether a smoker is depressed.
Bupropion is dosed at 150 mg (sustained release)
per day for 7 days prior to stopping smoking, then
at 300 mg (two 150 mg sustained-release doses) per
day for the next 6 to 12 weeks.

39. Contraindications to Bupropion
Bupropion SR should not be prescribed to patients
who have a seizure disorder, who have a current or
former diagnosis of bulimia or anorexia nervosa, or
who have used a monoamine oxidase(MAO)
inhibitor within the previous 2 weeks.
As with use of nicotine replacement therapy,
bupropion SR should be used only after a pregnant
woman has failed to quit without pharmacotherapy
and the benefits of an increased chance of smoking
cessation outweigh the risks of using it.

40. Combination Therapy
1.Nicotine patch with nicotine gum or nasal
spray:
A meta-analysis of three studies found that combination nicotine therapy
is almost twice as effective as monotherapy. While the patient is
receiving a relatively constant amount of nicotine through the
patch, he or she can adjust the dose on an acute basis using a
second agent. Combination therapy is recommended only when
monotherapy has failed.
2.2. Nicotine patch and bupropion SR:
One randomized, controlled trial comparing the nicotine patch alone,
bupropion SR alone, and a combination of bupropion SR and the
patch found that the combination is safe and significantly increases
quit rates compared to the patch alone but not compared to
bupropion SR alone.

41. Newer drugs
Varenicline -
A recent drug -now said to be one of the best smoking
cessation drugs.
Available with the brand name “Chantix” manufactured by
'Pfizer'.
This was developed by an ex-smoker whose father died of
cancer caused by smoking.

42. MOA of Varenicline
The drug works by partially blocking the alpha4-beta2
nicotinic receptor in the brain andproduces effects similar to
nicotine, while blocking nicotine itself from the receptors.
Within 10 to 19 seconds of a single puff from a cigarette,
nicotine attaches to this receptor. The receptor, in turn,
triggers large increases in dopamine, which rewards the
smoker with a pleasurable sensation.
This approach is designed to prevent withdrawal symptoms
while it blocking the nicotine from cigarettes for smokers who
relapse.

43. University of Oslo reported that smokers taking Varenicline
(Chantix) were more likely to be smoke-free at 12 weeks than
patients taking Buproprionor placebo. But by one year, only
one in five patients treated with Chantixwere still smoke free,
which led a number of researchers to raise questions about the
drug's staying power.
The FDA said the approved course of Chantixtreatment is 12
weeks(1 mg/bid.). Patients who successfully quit smoking
during treatment may continue with an additional 12 weeks to
increase the likelihood of long-term smoking cessation.

44. Rimonabant –
Rimonabant is the first of a new class of drugs that
block the cannabinoid receptor 1 (CB1).
In a study, 36% of patients who stayed on the drug
for 10 weeks had complete smoking abstinence
during the final 4 weeks of the study.
Other effects –weight loss, increasing HDL
cholesterol.

45. Mass approach
Health education-mass-media tobacco education
and counter advertising campaigns.
Increased tobacco taxes.
Business and workplace indoor smoking bans.
Restricted youth access to tobacco.
Phone "quit lines" and internet-based counselling
resources for patients and healthcare providers.
Prominent health warnings on tobacco product
packing.

46. Summary
Cigarette smoking is the most important
preventable cause of respiratory disease.
Most smokers would like to quit smoking but
have difficulty doing so because of nicotine
addiction.
Both behavioural counselling and
pharmacotherapy enhance quit rates, and the
effects of these interventions are generally
additive.

47. Thank you