Smoking cessation

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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