Tobacco Cessation-Opportunities & Obstacles : Tobacco Cessation-Opportunities & Obstacles Prof AKM Mosharraf Hossain
MBBS FCCP FCPS PhD
Prof of Respiratory Medicine
Bangabandhu Sheikh Mujib Medical University
[email protected]
Tobacco Dependance : Tobacco Dependance Tobacco dependence is recognised as a disease in the WHO’s International Classification of Diseases (ICD-10) and the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV).
Definition of Tobacco Dependence : Definition of Tobacco Dependence A chronic medical disorder involving multiple central nervous system abnormalities at the cellular and sub-cellular
Multiple CNS circuits and cell-membrane receptors play a role
Chronic up-regulation and reduced sensitivity of specific CNS receptors, such as the alpha-4 beta-2 nicotinic acetylcholine receptor, leads to acute episodes of reversible nicotine withdrawal symptoms ACCP Tobacco-Dependence Treatment Tool Kit, 3rd Edition 3 §6.1_ACCP TD TK Slide Set.stages_ASK_2009-04-01-revDPLS-2009/07/09 & 11/14 & 11/15
Tobacco Use in Different countries of the world: Global Adult Tobacco Survey 2009 : Tobacco Use in Different countries of the world: Global Adult Tobacco Survey 2009
Global Burden : Global Burden There are 1 billion 100 million smokers in the world
1/3 of the population over the age of 15 smokes In developed states 42% of men and 24% of women smoke
Smoking causes about 90,000 deaths per year
Smoking tobacco causes 85-90% of lung cancers
The WHO: EPIDEMIC “Tobacco epidemic death toll”(WHO Mpower report 2008) : The WHO: EPIDEMIC “Tobacco epidemic death toll”(WHO Mpower report 2008) 100 million deaths in the 20th century
5.4 million deaths per year
Without urgent action, it is predicted that there will be more than 8 million deaths a year by 2030
Of these more than 80% will be in developing countries
1 billion deaths are predicted for the 21st century
One Approximately Every Two Minutes : One Approximately Every Two Minutes Http://phil.cdc.gov/Phil/default.asp >430,000 (1178/day)
Sir Richard Doll : Sir Richard Doll Died in June at age 92
1950 study linking smoking to lung cancer
1954: Doll and Hill published “The Mortality of Doctors and Their Smoking Habits” in BMJ (lead to most M.D. giving up smoking)
Follow-up study in 2004
½ - 2/3 of all individuals who begin smoking in youth will die because of it
It Isn’t Breast Cancer? : It Isn’t Breast Cancer?
:
Why consuming this poison? : Why consuming this poison? Smoking usually starts as symbolic act of rebellion or maturity or social pressure
Nicotine from cigarettes are highly addictive- because they are delivered rapidly to brain
In new user it act as psychomotor stimulant in brain. Tolerance develop over time
Smoking cigarettes feels good mainly because it reverses the nicotine withdrawal symptoms
Smoking is a chronic relapsing addictive disease
Tobacco Dependance : Tobacco Dependance
Two Forms of Nicotine : Two Forms of Nicotine Bound to tobacco leaf
Free (altered by pH of the smoke)
Results when ammonia is added
Immediate impact
More satisfaction
http://tobaccodocuments.org/product_design/00044522-4523.html
pH
Cigarette: 5.5 – 6.0 (filter & carbon actually increases pH, verified by tobacco documents)
Spit: up to 8.3 (Source: CDC)
Cigar: 6.2 – 8.2
http://cancercontrol.cancer.gov/tcrb/monographs/9/m9_6.PDF
Absorption of Nicotine : Absorption of Nicotine Rate of Absorption
Cigarette : fastest route
Cigar : slower than cigarettes
Spit : slowest rate
http://cancercontrol.cancer.gov/tcrb/monographs/9/m9_6.PDF
STRATEGIES FOR SMOKING CESSATION : STRATEGIES FOR SMOKING CESSATION EHLE progect: Enpowering Health Learning in the Elderly
Evolution of Smoking Cessation : Evolution of Smoking Cessation 1950-Five-Day Plan
1960-Behavior modification
1970- Emphasis on cognitive treatment
1980- Relapse prevention
1980- Stages of change
1980-Nicotine gum approved in U.S.
STRATEGIES PROPOSED BY THE WHO TO COMBAT THE SMOKING EPIDEMIC: (WHO Policy Recommendations for Smoking Cessation and Treatment of Tobacco Dependence) MPOWER : STRATEGIES PROPOSED BY THE WHO TO COMBAT THE SMOKING EPIDEMIC: (WHO Policy Recommendations for Smoking Cessation and Treatment of Tobacco Dependence) MPOWER Monitor tobacco use and prevention policies
Protect people from tobacco smoke
Offer help to quit tobacco use
Warn about the dangers of tobacco
Enforce bans on tobacco advertising,
promotion and sponsorship, and
Raise taxes on tobacco
Algorithm for Treating Tobacco Use : Algorithm for Treating Tobacco Use Does patient now use tobacco? Is patient now willing to quit? Did patient once use tobacco? Provide appropriate tobacco dependence treatments
The 5A’s Promote motivation to quit
The 5R’s Prevent relapse No intervention required – encourage continued abstinence YES NO YES NO YES NO
THE BENEFITS(www.sfuma.it) : THE BENEFITS(www.sfuma.it) Less than 30 minutes- blood pressure and the temperature of hands and feet return to normal.
After 8 hours levels of oxygen in the blood return to normal and levels of carbon monoxide are reduced.
After 48 hours senses of taste and smell are increased
After 72 hours breathing becomes easier
After 1 week the risk of a heart attack is reduced,
Between 2 weeks and 3 months lung capacity increases by 300% and circulation improves, walking becomes easier, and you feel more energetic.
THE BENEFITS(www.sfuma.it) : THE BENEFITS(www.sfuma.it) Between 1 and 9 months a third of those who gained weight when quitting have regained their original weight, risk of infections is drastically reduced; colds, coughs, tiredness and shortness of breath are also reduced.
After 1 year the risk of a heart attack is halved
After 5 years the risk of lung cancer is reduced by 50%
After 10 years the likelihood of dying from lung cancer is equal to that of a non-smoker and the risk of other cancers is reduced
Nicotine withdrawal symptoms : Nicotine withdrawal symptoms
BRIEF STRATEGIES: Helping the Patient willing to Quit : BRIEF STRATEGIES: Helping the Patient willing to Quit The 5A’s ASK
ADVISE
ASSESS
ASSIST
ARRANGE
1. ASK : 1. ASK systematically identify all tobacco users at every visit
implement a system that ensures that, every patient at every clinic visit, tobacco use status is queried and documented.
Slide 29: expand the vital signs to include tobacco use
VS: BP= Pulse=
RR= Weight=
Temp= Tobacco use
[ ]current
[ ]former
[ ]never
2. ADVISE : 2. ADVISE Strongly urge all tobacco users to quit
advise should be
clear
strong
personalized
* Encourage all staff to reinforce the cessation message and support the patients quit attempt
3. ASSESS : 3. ASSESS determine willingness to make a quit attempt
assess patient’s willingness to quit:
Willing to quit
intensive treatment
unwilling to quit (5 R’s)
special population (adolescent, pregnant smoker)
4. ASSIST : 4. ASSIST aid the patient in quitting
help the patient with a quit plan
patient’s preparation for quitting (STAR)
S – set a quit date (2 weeks)
T – tell family, friends and co-workers
A – anticipate challenges (withdrawal symptoms)
R – remove tobacco products from the environment
Slide 33: provide practical counseling (problem solving/skills training)
Abstinence
Past quit experience
Anticipate triggers or challenges in upcoming attempt
Alcohol
Other smokers in the household
Slide 34: Provide intratreatment social support
Help patient obtain extratreatment social support
Recommend the use of approved pharmacotherapy
Provide supplementary materials
5. ARRANGE : 5. ARRANGE schedule follow-up contact (in person or via telephone)
timing
actions during follow-up contact
For patients unwilling to quit: The 5 R’s : For patients unwilling to quit: The 5 R’s Relevance
Risks
a. acute risk
b. long-term risk
c. environmental risk
Rewards
Roadblock
Repetition
Relevance : Relevance Encourage the patient to indicate why quitting is personally relevant, being as specific as possible. 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).
Risks : Risks Acute risks: Shortness of breath, exacerbation of asthma, increased risk of respiratory infections, harm to pregnancy, impotence, infertility.
Long-term risks: Heart attacks and strokes, lung and other cancers (e.g., larynx, oral cavity, pharynx, esophagus, pancreas, stomach, kidney, bladder, cervix, and acute myelocytic leukemia), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), osteoporosis, long-term disability, and need for extended care.
Environmental risks: Increased risk of lung cancer and heart disease in spouses; increased risk for low birth-weight, sudden infant death syndrome (SIDS), asthma, middle ear disease, and respiratory infections in children of smokers.
Rewards : Rewards Improved health
Food will taste better Improved sense of smell
Saving money
Feeling better about oneself
Home, car, clothing, breath will smell better
Setting a good example for children and decreasing the likelihood that they will smoke
Having healthier babies and children
Feeling better physically
Performing better in physical activities
Improved appearance, including reduced wrinkling/aging of skin
Roadblocks : Roadblocks Withdrawal symptoms
Fear of failure
Weight gain
Lack of support
Depression
Enjoyment of tobacco
Being around other tobacco users
Limited knowledge of effective treatment options
Repetition : 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.
Components of Relapse Prevention : Components of Relapse Prevention PROBLEMS
Lack of support for
cessation
Negative Mood or
Depression
Strong or prolonged
Withrawal Symptoms RESPONSES
Schedule follow up visits or
phone calls; help pt identify
sources of support w/in his
or her environment
Refer patient for counselling
or support
Provide counselling
Prescribe appropriate meds
Refer patient to a specialist
Extend the use of pharmacotx
add/combine pharmacologic
meds
Components of Relapse Prevention : Components of Relapse Prevention Weight Gain Start / increase physical
activity
Discourage strict dieting
Reassure patient
Healthy diet/fruits and
vegetables
Maintain Pharmacotx
to delay weight gain
Refer to a specialist
/program
Components of Relapse Prevention : Components of Relapse Prevention Flagging Motivation/
feeling depressed Reassure patient that these feelings are common
Recommend rewqrding activities
Ensure patient is not
engaged in periodic
tobacco use
Emphasize that
beginning to smoke
(even a puff) will
increase urge and make
quitting difficult
CARBON MONOXIDE (CO) : CARBON MONOXIDE (CO) poisonous gas
no color, no smell
by-product of combustion
car exhaust fumes, tobacco smoke
binds to Hb in RBC 200x as readily as oxygen
reduce release of oxygen
smokers can have 2-20% of their normal blood oxygen taken up by CO
Nicotine Replacement Therapy (NRT) : Nicotine Replacement Therapy (NRT) Most effective when used in combination with behavioral counseling
Available in various forms
Contraindicated in acute vascular event but can be used in stable CHD
Need to be used 6-8 weeks in two weeks blocks
Non-nicotine therapy for smoking cessation : Non-nicotine therapy for smoking cessation Bupoprion (Zyban)
Can be used in patients with IHD
Caution with diabetes Varinicline (Champix)
What is Spit (Smokeless) Tobacco? : What is Spit (Smokeless) Tobacco? Snuff is finely ground or shredded tobacco. Typically, the user places a pinch or dip between the cheek and gum
Chewing tobacco is available in loose leaf and plug with the user putting a wad of tobacco inside the cheek
Smokeless is not harmless!
What is in Spit Tobacco? : What is in Spit Tobacco? contains 28 carcinogens
The most harmful are the tobacco-specific nitrosamines (TSNAs) that are formed during the growing, curing, fermenting, and aging of tobacco.
cancer-causing substances include N-nitrosamine acids, volatile N-nitrosamines, benzo(a)pyrene, volatile aldehydes, formaldehyde, acetaldehyde, crotonaldehyde, hydrazine, arsenic, nickel, cadmium, benzopyrene, and polonium–210. (NCI-2003)
Smokeless Tobacco : Smokeless Tobacco One can of smokeless tobacco has the same nicotine as over 5 packs of cigarettes (Skoal, Copenhagen & Kodiak have the highest rates of freebase nicotine on the market).
The cancer causing chemicals in tobacco are 100x stronger than in cigarettes.
There are 100x the level of nitrosamines in dip, than is allowed by law in food.
One can of smokeless tobacco contains a lethal dose of tobacco if a child or animal eats it.
Health Effects : Health Effects Spit Tobacco users are 50 times more likely to get oral cancer than non-users
Spit tobacco use may cause cancer of the esophagus, larynx, stomach and pancreas and can form within five years of regular use
Leukoplakia is a white, leathery patch which forms in the mouth and is considered a pre-cancerous lesion
(S.T.O.P Guide, 1997; Hatsukami, D.& Seversen, Nicotine and Tobacco Research, 1999)
Obstacles in Developing countriesThorax 2004;59:623–630. : Obstacles in Developing countriesThorax 2004;59:623–630. Economic factors;
Lack of awareness by policy makers
Consequences and costs of tobacco;
Low perception of risks among the public;
Lack of policies that promote cessation;
Smoking behaviour of service providers
Poor healthcare systems;
Lack of infrastructure and industry action.
The cost effectiveness of pharmacological smoking cessationtherapies in developing countries: a case study in the Seychelles Tobacco Control 2004;13:190–195. : The cost effectiveness of pharmacological smoking cessationtherapies in developing countries: a case study in the Seychelles Tobacco Control 2004;13:190–195. Pharmacological cessation therapy can be highly cost effective as compared to other common medical interventions in low mortality, middle income countries, particularly if medications can be procured at low prices.
Conclusion : Conclusion Cessation is vital to any tobacco control programme.
We need to develop some tobacco cessation clinic at least at divisional levels.
Smoking cessation is not included in the educational curriculum of medical education
Brief counselling (5 A’s) be integrated in all healthcare services
Anti-smoking pharmacotherapy should be available
Have a Good Day : Have a Good Day