Smoking Cessation Program

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SMOKING CESSATION PROGRAMME AMANY ABOU ZEID, MSc., MD, MRCP, FCCS CHEST MEDICINE CAIRO UNIVERSITY HOSPITAL

History:

History The first paper rolled cigarettes were made by Egyptian soldiers in 1832 R J Reynolds introduces Camel (the first ‘modern’ cigarette) in 1913 The Surgeon General released the first U.S. report linking cigarettes to lung cancer in 1964 http://www.jti.com/english/tobacco_corner/tobacco_history/1601.aspx

Alarming Facts:

Alarming Facts Only 2 to 3% individuals succeed long term with smoking cessation Relapse even occurs in 50% after lung resection for carcinoma 40% after larngectomy 30% after MI 15 to 20 % after CABG

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WHO prefers Tobacco and not Nicotine Tobacco contains many pharmacologically active substances No addiction in history purely to nicotine Is It Addiction to Nicotine or Tobacco?

Smoking:

Smoking PLEASURE ? PROBLEM ??

Smoking and Health:

Smoking and Health Short-term effects : Psychoactive: memory, energy, emotions, attention, behavior, sleep disorders Increased heart rate and arterial pressure Peripheral vasoconstriction Increased respiratory rhythm Long-term effects : Respiratory diseases Cardiovascular diseases Ophthalmologic, digestive, oral, urinary and osteoarticular disease Various cancers Reduced immunity Negative effects on fertility, pregnancy and foetus

Is Cigar a Better Option?:

Is Cigar a Better Option? Similar spectrum of disease, with certain particularities Lung cancer risk : compared to non smokers 1.9 times higher in pipe smokers 3 times higher in cigar smokers 16 times higher in cigarette smokers (Higgris et al ,1988) Advantages: Occasional smokers Rarely inhale smoke deeply in lower airways

What About Pipe Smoking?:

What About Pipe Smoking? Oral and tongue cancers Advantages : Less dependence on nicotine Costs Easier to quit (less withdrawal symptoms)

Narguile/Shisha - A New Trend?:

Narguile/Shisha - A New Trend? Advantages: Washing tobacco process removes a lot of toxic compounds Less nicotine and lower dependency Disadvantages: Dangerous carbon monoxide levels Risk of “mouth to mouth” contamination Higher risk of COPD

How Difficult Is It To Quit?:

How Difficult Is It To Quit? Total Smokers ~2–3% Succeed in quitting ~ 70% Want to quit ~ 30% Trying to quit 1. Bridgwood et al, General Household Survey 1998. 2. West, Getting serious about stopping smoking 1997. 3. Arnsten, Prim Psychiatry 1996

The Process of Stopping Smoking:

The Process of Stopping Smoking Raw et al, Thorax 1998. Consensus Statement JAMA 2000 Ask Establish smoking status on an ongoing basis Advise Patients to set ‘stop date’ Arrange Help the smoker to stop: support and pharmacotherapy shown to be most effective strategy Follow-up Offer support and check ongoing smoking status A A Inform patient of specific risks of smoking in relation to their overall health status Assist A A

The Process of Stopping Smoking:

The Process of Stopping Smoking ASK Identify the smokers record at a regular base

The Process of Stopping Smoking:

The Process of Stopping Smoking ASK Identify the smokers ADVISE Health risks and benefits of smoking cessation in a personalized manner

Quit Smoking Why? Are here any benefits???:

Time After Stopping 20 minutes BP, HR & peripheral circulation improve 8 hours Nicotine & CO levels Fall by 50%. PaO 2 - N 24 hours All Nicotine eliminated Taste & smell improved 48 hours CO normal, mucociliary clearance, risk of MI falls 72 hours Breathing easier, bronchospasm relaxes. Energy improves 2-12 wks Circulation improves 3-9 mths Cough & wheeze improve 1 year Risk of MI reduced by 50% 10 years Risk of lung cancer reduced by 50%. Risk of MI back to normal 15years Risk of stroke back to normal Quit Smoking Why? Are here any benefits???

The Process of Stopping Smoking:

The Process of Stopping Smoking ASK Identify the smokers ADVISE Heath risks and benefits of smoking cessation in a personalized manner ASSESS Motivation to quit

Assess the Motivation to Quit:

Assess the Motivation to Quit Does the patient want to stop smoking? Would the smoker be prepared to stop in the next two weeks?

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Different Types of Smokers

The Process of Stopping Smoking:

The Process of Stopping Smoking ASK Identify the smokers ADVISE Heath risks and benefits of smoking cessation in a personalized manner ASSESS Motivation to quit ASSIST Aid smoker in quitting

ASSIST: Plan to Quit :

ASS I S T : Plan to Q uit Set a quit date (ideally in 2 weeks ) Describe possible nicotine withdrawal symptoms Review past quitting experiences Inform smokers´ family and friends in order to provide support Explain therapeutic treatment

The Process of Stopping Smoking:

ASK Identify the smokers ADVISE Heath risks and benefits of smoking cessation in a personalized manner ASSESS Motivation to quit ASSIST Aid smoker in quitting ARRANGE Follow-up contacts !!! The Process of Stopping Smoking

Smoking: A Chronic Disease:

Smoking: A Chronic Disease Smoking Ce ssation Interventions Counseling Pharmacotherapy Behavioural interventions The nicotine dependence can be treated

What to do in a Smoking Cessation Clinic:

Assessment of Motivation Smoking dependence (Fagerstrom) Health problems Select a treatment protocol Follow-up visits regularly (up to 12 m) What to do in a Smoking Cessation Clinic

First Visit:

First Visit Medical history Physical examination (BP , HR , Body Weight) Spirometry Chest x-ray / laboratory tests Expired C Ο Dependence and Questionnaires Fagerstrom test The smoking cessation clinical practice guideline JAMA 1996;275:1270-1280

Pharmacotherapy for Smoking Cessation:

Pharmacotherapy for Smoking Cessation First line therapy Nicotine Replacement (NRTs) Bupropion SR Second line therapy Clonidine Nortriptyline Consensus Statement JAMA 2000

Pharmacotherapy Efficacy:

Pharmacotherapy Efficacy Bupropion and Nicotine replacement therapy (NRT) double the chance of long-term abstinence Benefits of quitting greatly exceed any risks of treatment Combination of counselling and pharmacotherapy even better

How Often Does the Patient Visit the Clinic?:

How Often Does the Patient Visit the Clinic? Guidelines Once a week the first month of treatment Then at 3, 6, and 12 months later

Treatment Plan:

Treatment Plan Bupropion Continuing therapy 1pill/day 8-19 weeks Bupropion Continuing therapy 2pills/day x7weeks Bupropion 150 mg 2pills/day Day 7 Smoking Cessation Continuing Smoking Days 1-6 Bupropion 150 mg 1 pill /day 0, 1, 2, 3, 4, 7, 10, 13, 16, 19 weeks F O LL OW - U P Quit day (10-14 days) 2-7 weeks

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Nicotine Replacement Products Patch 16 and 24 hours 15 and 21 mg Gum 2 and 4 mg Lozenge 1, 2, 4 mg Sublingual tablet 2 mg Oral Inhaler 10 mg Nasal spray 1 mg

Other Methods:

Other Methods

Clonidine:

Clonidine Alpha 2 -partial agonist effect (central) Tablets or Patches (0.1-0.75 mg/day) Success rates Cochrane meta-analysis (5 studies) Placebo Clonidine_____ 13.9 % 25.6 % (range 17.7-33.6%)

Mecamylamine:

Mecamylamine Mecamylamine is a nicotine antagonist Efficacy assessed in 1 study (n=48) Abstinence rate at one year: Mecamylamine Nicotine + nicotine patch patch 37.5% 4.2%

Hypnosis:

Hypnosis 9 studies Equivalent to no intervention

Acupuncture:

Acupuncture 22 studies No evidence that acupuncture is useful

New: Varinicline:

New: Varinicline Direct nicotine receptor antagonist/partial agonist On-going phase 2 studies

New: Rimonabant:

New: Rimonabant A Cannabinoid-receptor antagonist Effective for short term smoking cessation Also prevents the weight gain associated with smoking cessation

New: Nicotine Vaccination:

New: Nicotine Vaccination Antibodies against nicotine Less nicotine reaches the brain Phase 1 and 2 studies

Conclusion:

Conclusion Bupropion is first line drug therapy Clonidine second line drug therapy Mecamylamine requires additional testing Therapies under investigation Varinicline Rimonabant Nicotine vaccination

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Do You Still Want to Smoke?

Thank You:

Thank You