1. TOBACCO AND SMOKING CESSATION

2. introduction One of the most common preventable cause of death
Accounting for about 20% of all cause –specific mortality(438,000 deaths per year)
One in every five deaths
Prevalence peaked 40% of adult in by 2006 had fallen to 20.9%
90% of smokers begin to smoke before the age of 20
The rates of tobacco use in men and women, once very different, are converging
More closely linked to education than it is to age, race, occupation, or any other sociodemographic factors
Smoking is a problem that is concentrated in lower socioeconomic groups

3. Introduction (cont.)
Clinician often fail to assess smoking or offer intervention
Among the barriers to intervention for tobacco use
Inadequate knowledge of effective treatment strategies
Uncertainty about the relative efficacy of treatment that currently available

4. Health consequences of tobacco use
Increase overall mortality and morbidity rates
Cardiovascular disease(MI, sudden death)
Cerebrovascular disease
Peripheral vascular disease
COPD
Cancers(lung, larynx, oral cavity, esophagus, bladder, kidney, pancreas, uterine cervix)
Pregnancy complication( low birth weight, preterm delivery, miscarriage, stillbirth)
Sudden infant death syndrome
Cognitive deficits, developmental problems in childhood are linked to maternal smoking during pregnancy
Osteoporosis, respiratory infection, peptic ulcer disease, cataracts, macular degeneration, sensorineural hearing loss, skin wrinkling

5. Health consequences of tobacco use(cont.)
No safe level
Reduced tar and nicotine content dose not protect against the health hazards
Environmental tobacco smoke(ETS)

6. Health benefits of smoking cessation
After age of 65
After the development of a smoking- related disease
After years of abstinence
Pattern of risk redaction (1/2 excess risk of cardiovascular diseases after one year % lung cancer still evident 10 years after quitting)
Longer life expectancy
Younger, fewer, free of smoking- related disease

7. Chronic disease model
Tobacco use and dependence is a chronic, remitting, and relapsing condition
Successful treatment will incorporate counseling and advice and along view of the therapeutic relationship clinician and patient

8. Addiction model
Nicotine is the addictive substance in tobacco. the continued use of tobacco is due, in large part, to addiction to nicotine
The major effect of nicotine an increase in midbrain dopamine level
The positive reinforcement (relaxation, reduced stress, enhanced cognitive performance, and enhanced vigilance) and negative reinforcement (nicotine withdrawal syndrome)
Each smoker associate certain behavior, situation, emotion, and activities with reinforcement effects of nicotine

9. Smoking behavior Attractiveness more than nicotine dependence
A habit, integral part of daily life
To Cope with stress and negative emotion

10. The addiction model, in keeping with the chronic disease model, indicates that combined behavioral and pharmacological treatment will be the most effective model

11. Smoking cessation 41% attempt to quit each year Fear of illness
Awareness of health risks not sufficient
90% know that smoking is harmful
Illness in family member
Social unacceptability
Only 5% of smokers who try to quit without assistant
Succeed for 1 year
Learning process

12. Behavioral support for smoking cessation
Assessing tobacco use
Assessing readiness to stop smoking
Brief office counseling for smoking cessation
Pharmacotherapy for smoking cessation

13. Assessing tobacco use
Although nearly 70% of smokers report a desire to quite, few are offered assistance when visiting a clinician “ new vital sign”

14. Assessing readiness to stop smoking
Are you planning to quit smoking in the next 6 months?
If yes. are you planning to quit smoking in the next month?

15. Assessing readiness to stop smoking(contd.)
Intervention
Definition
Stage of change
Advise patient to quit; give brief motivational message
Not seriously thinking of quitting in next 6 month
precontemplation
Advise patient to quit; give brief motivational message; discuss pharmacotherapy
Seriously thinking of quitting in next 6 month
Contemplation
Set quit date; develop a quit plan; prescribe pharmacotherapy; provide behavioral therapy
Desire to quite tobacco use in next 30 d and made a quite attempt of at least 24 h within last year
Preparation
Review pharmacotherapy; provide support; discuss relapse prevention
Currently not smoking and abstinent <6 m
Action
discuss relapse prevention; provide encouragement
Currently not smoking and abstinent ≥ 6 mo or more
Maintenance

16. Assessing readiness to stop smoking(contd)
Motivation can be stimulated by providing a consistent impact message such as “5 Rѕ”
Relevance (personalized)
Risk (immediate – long term)
rewards(benefits)
Roadblocks(barrier – overcome)
repetition

17. smoking cessation counseling protocol for physician
ASK- about smoking at every visit:”do you smoke?”
ADVISE- every smoker to stop
Make advice clear:”stopping smoking now is the most important action you can take to stay healthy”
Tailor advice to the patient’s clinical situation(symptoms or family history).
ASSESS-readiness to quit: “are you interested to quitting?”

18. smoking cessation counseling protocol for physician(contd.)
ASSIST- the smoker in stopping smoking
1-For smokers ready to quit
Ask smoker to set a “quit date.”
Provide self help- material to take home.
Offer pharmacotherapy.
Consider referral to a formal program
2-for smoker not ready to quit
Discuss advantages and barriers to cessation, from smoker’s viewpoint
Provide motivational booklet to take home
Advise smoker to avoid exposing family member to passive smoke
Indicate willingness to help when the smoker is ready
Ask again about smoking at the next visit

19. smoking cessation counseling protocol for physician(contd.)
ARRANGE-follow up visit
Make follow up appointment 1 week after quit date
At follow up, ask about smoking status
For smokers who have quit
1-congratulate!
2-ask smoker to identify future high risk situations
3-rehearse coping strategies for future high risk situations
For smokers who have not quit:
1-ask:”what were you doing when you had that first cigarette?”
2- ask:”what did you learn from the experience?”
3- ask smoker to set a new “quit date.”

20. Relapse prevention
High nicotine dependence (smoke >25 cigarettes/d – within 30 minutes of waking)
No previous abstinence of 30 days or more
History of major depression
Current or past alcohol abuse or dependence
Other smokers in the household

21. Relapse prevention(contd.)
Triggering situation
Inadequate coping response
Comment:
Planning for high–risk situation
Avoidance of strong trigger
Encouragement for successes
Continued troubleshooting of problem areas
Offering continued support and follow up
Refer

22. Pharmacotherapy Not recommended Combination regimens Second - line
First – line
Anxiolytics
Bupropion + nicotine patch
Nortriptyline
Nicotine replacement
Mecamylamine
Nicotine gum + nicotine patch
clonidine
Nicotine patch
SSRI anti depressant
Nicotine nasal spray+ nicotine patch
Nicotine gum
Silver acetate
Nicotine nasal spray
Naltrexone
Nicotine inhaler
lobeline
Nicotine lozenge
Nonicotine medication
Buprropion SR

23. Nicotine replacement therapy
Rationale:
1-blocking the negative reinforcement
2-reduction in the positive reinforcement of smoking

24. Nicotine replacement therapy(contd.)
Transdermal nicotine patch
24 hour mg/24h weeks
14 mg/24h
7 mg/24h
16 hour mg/16h weeks
Skin irritation, nervousness, vivid dreams, insomnia
Lower starting dose for patients BW<100Ib (45.35 kg) or smoking fewer 10 cigarettes

25. Nicotine replacement therapy(contd.)
Nicotine gum
2 mg pieces/day(max 30) month(max 6)
chew as needed or one every 1-2 h while awake
4 mg pieces/day(max 30) month(max 6)
Proper chewing technique is essential
No liquid
no acidic beverages 1-2 hours before gum
nausea., dyspepsia, hiccup, dizziness, sore jaw. Mouth ulcer

26. Nicotine replacement therapy(contd.)
Nicotine lozenge
2 mg & 4 mg as gum oral mucosa pieces per day as needed for 3 month
Nicotine inhaler
6 cartridges/ day months
Oral mucosa mimics the hands to mouth behavior
Throat irritation cough
Nicotine nasal spray
1-2 dose/h(max 8/day) month
Nose and throat irritation, watery eyes, sneezing and cough

27. Bupropion
An antidepressant with dopaminergic and noradrenergic activity
Sustained-release form
Reduction the threshold for seizure (1/1000 or less)
Insomnia, agitation, headache, and dry mouth
mg/day for 7-12 weeks
1 week before cessation

28. Contraindication for use of sustained-release bupropion due to risk of seizures
Known seizure disorder
idiopathic epilepsy
Febrile childhood seizures
Other seizures disorder (e.g. Alcohol withdrawal)
History of serious brain injury
Closed head trauma
Stroke
Brain surgery
Drugs that lower seizure threshold (relative contraindication)
Pheotiazines
Alcohol
Benzodiazepines
Eating disorder
Anorexia
bulimia

29. Activity
Applying motivational interviewing techniques: tobacco use intervention

30. Offer support and make patient-center
Work together to create a patient- centered plan that matches the patient’s readiness to quit
Encourage the patient to consider what could work, rather than focus on what could not
Provide options (referral, nicotine replacement, patient education materials), but not direct advice
Ask the patient to select next step
Reinforce any movement toward making a change
Follow-up on subsequent visits

31. Field work
One smoker

32. Thanks