Smoking cessation complete guideline .ppt
- 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 bidi smokers 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 – peribronchiolar inflammation and fibrosis, increased mucosal permeability, impairment of mucociliary clearance, 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 humoral immune 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 hypopharynx 4.0–5.0 Esophagus 1.5–5.0 Larynx 10.0 Pancreas 2.0–4.0 Nasal cavity, sinuses, nasopharynx 1.5–2.5 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 thromboangiitis obliterans) Aortic aneurysm Pulmonary Disease- Lung cancer Chronic bronchitis Emphysema Asthma Increased susceptibility to pneumonia and pulmonary tuberculosis Increased susceptibility to desquamative interstitial 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 1st line- 1. Nicotine gum 2. Nicotine inhaler 3. Nicotine nasal spray 4. Nicotine patch 5. Sustained-release Bupropion hydrochloride 2nd 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 disorders Dry 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-norepinephrine reuptake 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 and produces 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 Buproprion or placebo. But by one year, only one in five patients treated with Chantix were 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 Chantix treatment 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