Smoking cessation pt1 Mohammad AbuAssi

EPIDIMIOLOGY Cigarette smoking remains a leading cause of preventable disease and premature death in the United States and other countries. 15.5 % of people aged 18 years or older in the United States considered themselves smokers 2016. On average, 435,000 people in the United States die prematurely from smoking-related diseases each year; overall, smoking causes 1 in 5 deaths. 1 one in five American adults still smokes regularly (22 percent of men, 17.5 percent of women) Smoking cessation is difficult, with the average smoker attempting to quit five times before permanent success

Smoking is a risk factor for …. Except …. In addition smoking has a strong association with fire-related and trauma-related injuries.

Smoking-caused disease is a consequence of exposure to toxins in tobacco smoke. Although nicotine plays a minor role, if any, in causing smoking-induced diseases, addiction to nicotine is the proximate cause of these diseases Nicotine addiction and tolerance E-cig

NICOTINE AND NEUROTRANSMITTER RELEASE Stimulation of nicotinic cholinergic receptors releases a variety of neurotransmitters in the brain, One of them, dopamine, signals a pleasurable experience and is critical for the reinforcing effects (effects that promote self-administration) of nicotine and other drugs of abuse, as well as for compelling drives such as eating.

NEUROADAPTATION With repeated exposure to nicotine, neuroadaptation (tolerance) to some of the effects of nicotine develops. As neuroadaptation develops, the number of binding sites on the nicotinic cholinergic receptors in the brain increases, probably in response to nicotinemediated desensitization of receptors Desensitization — ligand-induced closure and unresponsiveness of the receptor — is believed to play a role in tolerance and dependence

What happens when you quit smoking ? One year after your last cigarette The lungs will have experienced dramatic health improvements in terms of capacity and functioning. You’ll notice how much easier you breathe on exertion less coughing compared to when you smoked. you’ll have saved a dramatic amount of money. Three years after your last cigarette your risk of a heart attack has decreased to that of a nonsmoker. Five years after your last cigarette your risk of death from lung cancer has dropped by half compared to when you smoked. 15 years after your last cigarette At the 15-year mark, your risk for heart attack and stroke has decreased to equal that of a person who’s never smoked before.

Primary care physicians have many opportunities to counsel patients about smoking cessation

Five A’s Counseling Strategy Physicians should address smoking cessation with all patients who use tobacco. The five A’s framework (ask, advise, assess, assist, arrange) has been developed to allow physicians to incorporate smoking cessation counseling into busy clinical

Ask “Have you ever been a smoker or used other tobacco products Ask “Have you ever been a smoker or used other tobacco products? Do you use tobacco now? How much?” Calculater: Back.Year Advice “I think quitting smoking is very important for you because of your asthma. I want you to come back to the office next week so we can talk about this more Assess Patients’ motivation to quit smoking should be assessed at every visit. Willingness to quit and barriers to quitting should be assessed, “Have you ever tried to cut back on or quit smoking? Are you willing to quit smoking now? What keeps you from quitting? How soon after getting up in the morning do you smoke?”

ASSESS-2-Readiness rulers Assess how ready the patient currently is to quit tobacco use. (i.e., “On a scale of 1 to 10, where 10 is very ready, how ready are you to quit smoking?”)

Stages of change in smoking cessation Precontemplation: Current smokers who are NOT planning on quitting within the next 6 months. Contemplation: Current smokers who are considering quitting within the next 6 months and have not made an attempt in the last year. Preparation: Current smokers who have made quit attempts in the last year and are planning to quit within the next 30 days. Action: Individuals who are not currently smoking and stopped within the past 6 months (recently quit). Maintenance: Individuals who are not currently smoking and stopped smoking for longer than 6 months but less than 5 years (former smokers).

Five R’s Strategy for Motivating Patients to Quit Smoking Relevance: Encourage the patient to identify reasons to stop smoking that are personally relevant. i.e.: Pregnancy, personal or family risk of disease, person in the household with asthma Risks: Advise the patient of the harmful effects of continued smoking, both to the patient and to others, incorporating aspects of the personal and family history whenever possible. i.e. :Effects on the patient and the patient’s family, friends, and coworkers; measuring “lung age”* through spirometry can help personalize risk Rewards: Ask the patient to identify the benefits of smoking cessation. i.e.: Improved health, financial savings from not buying cigarettes, decreased cigarette odor Roadblocks: Explore the barriers to cessation that the patient may encounter. i.e.: Presence of other smokers in the home or workplace, history of failed quit attempts or severe withdrawal symptoms, stress, psychiatric comorbidity, low motivation, weight gain, enjoyment of smoking Repeat: Include aspects of the five R’s in each clinical contact with unmotivated smokers

ASSIST Withdrawal: Common nicotine withdrawal symptoms (e.g., irritability, anxiety, restlessness) peak within the first week of abstinence and last two to four weeks; NRTs can be helpful because they gradually decrease nicotine dependence; smokers should also be advised to decrease caffeine intake Depression: Smokers are more likely than nonsmokers to have a depressive episode, and smokers with depression are less likely to successfully quit, smoking cessation may trigger depression in those with a history of depression; physicians should consider monitoring the mood of smokers during quit attempts and screen for depression in those who have repeatedly been unable to quit; bupropion (Zyban) may be an appropriate cessation aid for smokers at risk of depressive relapse Weight gain: Although most smokers gain fewer than 10 lb (4.5 kg) after quitting, weight gain can vary (10 percent will gain 30 lb [13.5 kg]; although this weight gain poses less health risk than smoking, concern about weight gain may interfere with the quit attempt; sustained-release bupropion or an NRT (particularly gum or lozenges) may be helpful in these patients because they delay weight gain while in use; it may be easier to monitor and adjust food intake/exercise balance after immediate tobacco cravings are no longer as prominent

Behavioral tips 1 Find Your Reason 2 Give Yourself a Break by finding another way to relax 3 Lean On Your Loved Ones 4 Clean House Once you’ve smoked your last cigarette, toss all of your ashtrays and lighters. Clean your closet and your car from the cig smell 5 Avoid Alcohol and Other Triggers like coffee 6 Eat Fruits and Veggies Don’t try to diet while you give up cigarettes. Too much deprivation can easily backfire. Instead, keep things simple and try to eat more fruits, vegetables, whole grains, and lean protein. These are good for your whole body. 7 Choose Your Reward (MONEYYY)