1. Smoking Cessation Medication
Gholamreza Heydari MD, MPH, PhD
Director
Tobacco Prevention and Control Research center
Shahid Beheshti Medical University

2. Smokers die early
Pirie et al Lancet Jan 12;381(9861):133-41

3. Quitting Works

5. Nicotine

6. Mesolimbic dopamine pathway
Binds to
nACh receptors
Increase in
dopamine
nicotine
positive reinforcement

7. Tobacco withdrawal syndrome
Signs & symptoms
Duration
Prevalence
Irritability
< 4 weeks
50%
Depression
60%
Restlessness
Poor concentration
< 2 weeks
Increased appetite
> 10 weeks
70%
Sleep disturbance
< 1 week
25%
Urges to smoke
> 2 weeks
Mouth Ulcers
> 4 weeks
40%
Constipation
>4 weeks
17%

8. Individual and Environment
The quitting process
Individual and Environment
Smoking
Quit Attempt
Abstinence
Tobacco Control Policies
Brief Interventions (e.g. AB+offer of C)
Smoking Cessation Treatments
Adapted from: Hughes Drug and alcohol dependence (2011):

9. Remaining Quit Treatment Behavioural support Pharmacotherapy
Supportive environment

10. Healthcare Professionals Role
Health care professionals can increase a patient’s odds of quitting with brief advice, medication, and behavioural support 1
Tasks
Identifying people who smoke
Motivating a quit attempt
Refer for treatment and support
Supporting ongoing abstinence
This slide provides some basic reasons why education and training of HCPs is necessary. For example:
Dangers of smoking
Effectiveness of HCP intervention on increasing quit odds
Common barriers to TDT
AVEYARD P. & WEST R (2007) Managing smoking cessation, BMJ, 335,

11. Advice from a Health Professional is the major external trigger
Source: - Smoking Toolkit Study

12. Pharmacological Interventions for Smoking Cessation

13. Nicotine replacement therapy
Binds to
nACh receptors
Increase in
dopamine
Nicotine +++
Nicotine +

14. Nicotine Delivery
Source: Royal College of Physicians

15. NRT: Long-term (>6 month) quit rates vs. placebo
Pooled 150 studies
RR=1.60 (95% CI: )
Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 11. Art. No.: CD DOI: / CD pub4.

16. NRT - safety and side-effects
There are no ‘real’ contraindications to NRT
Some individual product differences e.g. gum not good for people with dentures
No drug interactions
The most common side effects are localised e.g.
Taste of oral products
Hiccups with the mouth spray
Skin irritation with patch
Facilitator: Hayden

17. Types of NRT
Gum
Lozenge
Microtab
Patch
Inhaler
Spry

18. Bupropion
Atypical antidepressant which acts on dopamine and noradrenaline pathways and possibly as a nicotinic antagonist, designed to reduce motivation to smoke by
reducing cravings and withdrawal symptoms
reducing the rewarding effect of smoking
What to say to your patients?
Works by alleviating craving and other withdrawal symptoms
It’s not a magic cure, but it will make quitting easier

19. Bupropion: Long-term (>6 month) quit rates vs. placebo
Pooled 36 studies
RR=1.69 (95% CI: )
Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD DOI: / CD pub3.

20. Safety and side-effects
Nausea (30%) – mostly well tolerated
Seizure
Facilitator: Hayden

21. Varenicline Varenicline = partial agonist of the 42 nAchR
What to say to patients
Varenicline works by reducing craving for cigarettes making quitting smoking a little easier and increases the chances of stopping for good.
However it’s no magic cure and effort is still required.

22. Varenicline: Long-term (>6 month) quit rates vs. placebo
Pooled 14 studies
RR=2.27 (95% CI )
Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD DOI: / CD pub6.

23. Safety and side-effects
Nausea (30%) – mostly well tolerated
Strange dreams and insomnia
Facilitator: Hayden

24. Long-term outcomes
Source: New Zealand Guidelines for Helping People Stop Smoking

25. National study on smoking cessation, Iran 2014

26. Conclusion Pharmacotherapy is effective but it is not magic
It must use with other supports
First line
Champix, NRT, Zyban
Facilitator: Hayden

27. Thank you Visit our site: www.tpcrc.sbmu.ac.ir Quit line: 27122050-1
Thank you