1. An important health problem
Tobacco SMOKING
An important health problem

2. Learning Objectives At the end of the sessions, students will be able to….
Recall the epidemiology of smoking pattern
Recognize the hazards of smoking
Identify the health benefits of smoking cessation
Explain why tobacco dependence is a chronic disease
Assist users attempting to quit smoking
Identify special consideration in smoking cessation

3. EPIDEMIOLOGY

4. Tobacco-based products:
Cigarettes
pipes
cigars
hookahs ((shisha/ narghile/ argileh/ hubble bubble and goza))
chewing tobacco etc.

5. What’s in a Cigarette? Tobacco Carbon monoxide Hydrogen cyanide
Nitrogen oxide
Ammonia
Nicotine, phenol, polyaromatic HC
Tar total particulate matter (nicotine and water)
Filter with titanium oxide accelerant
Flavours
Liquid vapour
Benzene
Formaldehyde
Acrolein
N-nitrosamines
Non-particulate matter

6. What is a cigarette does in the body?
Delivers nicotine to the lungs and brain within 7 sec
Frequent, small-dose stimulation makes smoking highly addictive
Most cigarettes contain ≥ 10 mg of nicotine
Cigarettes release carbon monoxide which adheres to red blood cells faster than oxygen, decreases O2
increased heart rate
Polycythemia

7. The smoking epidemiology……
1.1 billion smokers above 15 year, globally.
5 million people die every year due to smoking
By 2030, if continue, smoking will kill one in 6 people.
Smoking represents the most readily preventable risk factor for morbidity and mortality.
Tobacco control can save billions of dollars and millions of lives
Increased tax of US$ 0.80 per pack: decrease 9%, 66 million fewer smokers
( World Health Organization.10, Jan 2017.

8. Prevalence of Smoking in Saudi Arabia
% (median = 17.5%)
School students % (median = 16.5%),
University students % (median = %),
Adults % (median = 22.6%).
Elderly people 25%.
Males 13-38% (median = 26.5%)
Females 1-16% (median = 9%).
Most smokers began smoking before age 18
Many people start smoking at an age when they are easily influenced by peers and advertising
Young adults (between the ages 20 – 24 years)
Highest smoking rate (27%)
Relatively brief smoking history
Often identify themselves as “social smokers”
Social smokers are at risk of becoming regular smokers (Gilpin, White & Pierce, 2005

9. Prevalence of Smoking in Saudi Arabia
17% of primary health care physicians in Riyadh city were current smokers, 20% ex-smoker.
Al- shahri M, Al Almaie S. promotion of non-smoking: The role of primary health care physicians. Ann Saudi Med 1997;17:515-17

10. The smoking epidemic
75% of smokers want to quit
<2% of smokers quit each year

11. HAZARDS

12. Smoking Health Risks (Short Term)
Shortness of breath
Worsening asthma or bronchitis
Increased risk of respiratory infection
Harm to pregnancy
Impotence
Infertility

13. Smoking Health Risks (Long-term)
Heart attack and stroke
Lung and other cancers
Chronic obstructive pulmonary disease (COPD)
Osteoporosis
Disability (chronic bronchitis and emphysema)
Need for extended care
larynx
oral cavity
pharynx
esophagus
pancreas
stomach
kidney
bladder
cervix
acute myelocytic leukemia

14. Benefits of Queting

15. Benefits of Quitting (Short term)
20 mins:
8 hours:
24 hours:
48 hours:
72 hours:
BP & pulse rate return to normal
Blood nicotine & CO halved, O2 back to normal
CO eliminated; lungs start to clear mucus etc.
Nicotine eliminated; senses of taste, smell much improved.
Breathing easier; bronchial tubes begin to relax; energy levels increase

16. Benefits of Quitting 2-12 weeks: 3-9 months: 5 years: 10 years:
Circulation improves Lung function increased by 10%, coughs, wheezing decrease Risk of heart attack halved Risk of lung cancer halved compared to continued smoking Risk of heart attack equal to never-smoker’s

17. Simple; Just stop
DEPEDENCY

18. Why do people continue to smoke?
Addiction to nicotine
Perceived benefits (relaxation, stress relief, weight loss)
Social context
Mental health issues

19. Smoking Cessation Barriers
Withdrawal symptoms
Fear of failure
Weight gain
Lack of support
Depression
Enjoyment of tobacco
Being around other users
Limited knowledge of effective treatment options

20. Physician Barriers to Helping Patients Stop Smoking
Time constraints of practice
Lack of office systems
Low expectation of success
Lack of knowledge of what to do
Frustration with smokers

21. Tobacco Dependence as a chronic disease

22. What is Nicotine Dependence?
The following characteristics:
Substance abuse
Continues self-administer substance despite perceived negative effects
High tolerance towards the substance
Manifests withdrawal symptoms when trying to stop use
In assessing a smoker’s degree of dependence, look for the presence of these four characteristics. Craving and withdrawal are indicators of compulsion. Loss of control means the smoker uses more tobacco than he/she wishes to or plans. The degree of difficulty in quitting and the amount smoked are other markers of dependence, as are denying the serious health risks.

23. Effects of Nicotine Slows circulation Affects appetite Increase BMR
changes brain activity - improving reaction times, ability to pay attention and brings on euphoria Addiction
Increases dopamine levels Creates a feeling of pleasure
affects appetite – possibly due to inhibiting insulin release, leading to hyperglycemia.
BMR: The body is always using energy for essential functions such as building new cells, keeping the heart beating, and breathing, sending messages through the nerves and for warmth).

24. The addiction pathways
‘Reward’ pathway (mesolimbic dopamine system)
‘Withdrawal’ pathway (locus coeruleus)
This slide illustrates two pathways in the brain that are important in nicotine addiction—the ‘reward’ pathway consisting of a network of dopaminergic neurons in the mesolimibic system; and the ‘withdrawal’ pathway, which involves noradrenergic neurons in the locus coeruleus.1
Reward pathway
Like other addictive drugs, nicotine activates the mesolimbic system resulting in release of dopamine in the nucleus accumbens.2,3
This dopamine surge is believe to induce feelings of pleasure or elation that become associated with nicotine intake.2,3
The rapid action of inhaled nicotine on these pathways provide immediate ‘positive reinforcement’.4
The smoker is motivated to repeat the behaviour, leading to compulsive use of the drug.
Chronic nicotine administration produces tolerance so that smokers need to smoke more to achieve the same effect.5
Withdrawal pathway
A second factor involved in the development of nicotine addiction is the occurrence of withdrawal symptoms on deprivation of nicotine.
These are believed to develop as a result of adaptive changes in the brain during chronic nicotine use and to be mediated by noradrenergic activity in the locus coeruleus.1,6
1. Leshner AI. Hosp Pract 1996; Oct 15:
2. Nisell M, Nomikos GG, Svensson TH. Pharmacol Toxicol 1995; 76:
3. Pontieri FE, Tanda G, Orzi F, Di Chiasa G. Nature 1996; 382:
4. Thompson GH, Hunter DA. Ann Pharmacother 1998; 32:
5. Benowitz NL. Prim Care Clin Office Practice 1999; 26:
6. Svensson TH, Engberg G. Acta Physiol Scand 1980; (Suppl 479):

25. “Reward” Pathway
Mesolimbic dopamine system has been characterized as a “reward "pathway
Nicotine produces a dopamine surge in the nucleus accumbens
Smoking cessation is followed by pathophysiologic withdrawal and craving

26. Withdrawal
Chronic drug use affects brainstem structures
(locus ceruleus)
Noradrenergic cells become more excitable
When a person abstains, the firing rates become abnormally high – a possible basis of withdrawal symptoms

27. Nicotine withdrawal syndrome
acute/uncontrollable need to smoke (craving)
irritability
restlessness, anger, anxiety feelings
tiredness
increased appetite, especially for sweets and resultant weight gain
trouble to concentrate and focus memory
depression
headaches
insomnia
dizziness
Nicotine withdrawal symptoms are caused by suddenly stopping nicotine supply. Nicotine withdrawal can manifest itself in the first 4-12 hours after stopping smoking. manifestations are temporary, reaching maximum intensity in the first 24 to 72 hours and decreasing in the ensuing 3-4 weeks.

28. TRETMENT

29. Treatment of Nicotine Addiction
Combination of counseling and pharmacotherapy is more effective than either option alone
The more intense the intervention, the better the outcome of abstinence

30. Pharmacologic Options
Two categories of pharmaceutical options:
Nicotine replacement therapy (NRT)
Non-nicotine replacement therapy

31. Nicotine Replacement Therapy (NRT)
Nicotine Patch
Nicotine Lozenges
Nicotine Gum
Nicotine Inhalers
Provide nicotine to reduce withdrawal symptoms
Take between 1-4 hours to reach maximum blood levels (unlike cigarettes, 7 seconds)
Non-prescription  available over-the-counter

32. Non-nicotine Therapy Bupropion Hydrochloride (Zyban)
Also marketed as the anti-depressant medication Wellbutrin
Presumed to alleviate cravings associated with nicotine withdrawal affecting noradrenaline and dopamine
Varenicline Tartrate (Champix)
Targets nicotinic acetylcholine receptors to decrease cravings and withdrawal
Clonidine & Nortriptyline
Second-line medications used in smoking cessation

33. Other options of treatment
Hypnosis
Herbal remedies
Acupuncture
Laser treatment
No clinical evidence to verify results from these treatments
Some clients/patients report that they are beneficial (Fiore, et al., 2008)

34. Counselling Intensive intervention that last a minimum of 10 minutes
Commonly conducted by nurses in various health-care settings
Motivational Interviewing
Directive and client-centred standard counselling techniques
Stages of Change theory

35. Stages of Change PRECOMTEMPLATION CONTEMPLATION PREPARATION ACTION
Unaware or unwilling to change
CONTEMPLATION
Ambivalent, but thinking about changing
PREPARATION
Decided to change and taking steps
ACTION
Started to do things differently
MAINTENANCE
Changed for sometime and integrating the change into their routine
Prochaska and DiClemente

36. Not thinking of quitting in the next six months Contemplation
Precontemplation
Not thinking of quitting in the next six months
Contemplation
Thinking of quitting in the next six months
Preparation
Planning to quit in the next month
Relapse
There is a broad range of research supporting a “stages-of-change” model for smoking cessation. These five stages include: precontemplation, contemplation, preparation, action and maintenance - with relapse as an element that can throw the smoker back to the beginning of the entire process. Most people begin in the precontemplation stage, as the small arrows leading to the circle imply, and the exit point for the successful smoker is from the maintenance stage. As we all know, this is a cyclical process and most smokers need several attempts to successfully manoeuvre through this process.
Briefly, the stages are outlined as follows:
Precontemplation - not thinking about change in the next six months;
Contemplation - seriously thinking about changing smoking behaviour;
Preparation - planning to stop smoking within the next 30 days and having made a 24-hour quit attempt in the last 12 months;
Action - having quit smoking and actively applying cessation and maintenance skills;
Maintenance - having not smoked for more than six months.
A 1994 study by Rohren and Croghan concluded that there is potential clinical application of the stages-of-change model, as it showed the action stage to be the best predictor of smoking cessation at six months after quitting. Individuals in the action stage had twice the six-month cessation rate as those in the contemplation stage (see references).
A stage-matched approach will likely be more effective, as patients in precontemplation and contemplation are more likely to move ahead to the next stage after receiving a stage-matched intervention. Also, using stage-appropriate interventions enables the physician to focus on achievable outcomes.
Maintenance
Quit for more
than six months
Action
Quit in the last
six months 2

37. How to begin? (5As) ASK- about smoking – understand your patient
ASSESS - what is the next step?
ADVISE - why cessation is important
ASSIST - offer to help
ARRANGE- follow-up process
The following slides give a range of issues to bear in mind when you counsel patients to quit

38. aren’t willing to quit, and recently quit.
The 5 As apply to
Those who (three categories):
are willing to quit,
aren’t willing to quit, and
recently quit.

39. Smoking Cessation: Willing to Quit
ASK Identify and document tobacco use status of every patient at every visit.
Example: When recording vital signs, include an area to note tobacco use.

40. Smoking Cessation: Willing to Quit
ADVISE In a clear, strong, and personalized manner advise every tobacco smoker to quit.

41. Smoking Cessation: Willing to Quit
Advise examples:
Clear “I think it’s important for you to quit smoking now, and I can help you.”
Strong “As your clinician, I need you to know that quitting smoking now is the most important thing you can do to protect your health.”
Personalized “Continuing to smoke makes your asthma worse.”

42. Smoking Cessation: Willing to Quit
ASSESS
Is the user willing to make a quit attempt at this time?
Provide assistance to dependence treatments.
Provide an intervention shown to increase future quit attempts, such as nicotine gum, quit lines and behavioral counseling.
YES NO

43. Smoking Cessation: Willing to Quit
ASSIST
Offer medication. Provide or refer for counseling or additional behavioral treatment.
Medication examples:
Nicotine lozenge
Varenicline

44. Smoking Cessation: Willing to Quit
ASSIST
Behavioral treatment examples:
Recommend a quit plan, such as STAR.
Set a quit date.
Tell family, friends and coworkers.
Anticipate challenges.
Remove tobacco products.

45. Smoking Cessation: Willing to Quit
ARRANGE
Arrange for follow-up soon after quit date, a second follow-up within the first month and others as needed.
Identify problems and anticipate challenges.
Remind patients of available sources, such as quit lines.
Provide encouragement.

46. Smoking Cessation Treatment
Smoking Cessation Treatment for Those NOT Willing to Quit

47. Smoking Cessation: NOT Willing to Quit
ASK, ASSESS & ADVISE Use the same 5As for users unwilling to quit as those willing to quit.

48. Smoking Cessation: NOT Willing to Quit
ASSIST
Provide motivational interventions designed to increase future quit attempts.

49. Smoking Cessation: NOT Willing to Quit
ASSIST Motivational examples:
The 5 Rs
Relevance
Identify why it is personally relevant to get the patient to quit.
Risks
Ask the patient to identify negative consequences of smoking.
Rewards
Ask the patient to identify the benefits of stopping.
Roadblocks
Identify the patient’s barriers to success and how to approach them.
Repetition
Repeat motivational interventions.

50. Smoking Cessation: NOT Willing to Quit
ASSIST
Motivational examples: Express empathy
Use open-ended questions “How important do you think it is for you to quit?”
Use reflective listening “So you think smoking helps you maintain your weight.”
Normalize patient’s feelings “Many people worry about managing without cigarettes.”
Support their right to choose. “I’m here to help you when you are ready.” t to choose.

51. Smoking Cessation: NOT Willing to Quit
ASSIST
Motivational examples: Develop discrepancy
Highlight the discrepancy between the patient’s smoking versus the patient’s stated values “You’re devoted to your family. How do you think your smoking affects them?”
Reinforce change talk “So, you realize how smoking is making it hard to keep up with your kids.”
Deepen the commitment to change “We would like to help you avoid a stroke like the one your father had.”

52. Smoking Cessation: NOT Willing to Quit
ASSIST
Motivational examples: Roll with resistance
Back off and use reflection “Sounds like you’re feeling pressured about your tobacco use.”
Express empathy “I understand it’s hard to quit.”
Ask permission to provide information “Would you like to hear about some strategies that can help you quit?”

53. Smoking Cessation: NOT Willing to Quit
ASSIST
Motivational examples: Support self-efficacy
Help patients build on past successes “You were fairly successful last time you tried to quit.”
Offer options for small, achievable steps toward change “Can you try smoking one less cigarette a day? A quit line can help you.”

54. Smoking Cessation: NOT Willing to Quit
ARRANGE
More than one motivational intervention may be needed.
Provide follow-up at the next visit.
Offer additional interventions to motivate and support.

55. Treatment for Those Who Recently Quit
ASK
Determine if the smoker is still smoke-free. then,
ASSESS
relapse potential.

56. Treatment for Those Who Recently Quit
ASSESS
Most relapses occur within the first two weeks, but the risk can persist for a long time; therefore,
Identify and address challenges, including
lack of support for cessation,
negative mood or depression,
strong or prolonged withdrawal symptoms,
weight gain and
smoking lapses.

57. Treatment for Those Who Recently Quit
ASSIST
Provide encouragement and relapse prevention to address the challenges of staying smoke-free.
Challenge example
Lack of support
Depression
Prevention response
Schedule follow-ups, urge use of quit lines, identify source of support
Counsel or refer to counseling/support groups

58. Special consideration

59. Smoking is a Complex Phenomenon
Social
Psychological
Spiritual
Bio-
physiological
Smoking is a complex biopsychosocial phenomenon in which genetics, pharmacology, psychology and environment all interact to produce a tenacious pattern of drug use. As you try to help someone stop smoking, you need to think of how you can be helpful on any or all of these levels.
BIOPHYSIOLOGICAL - Nicotine is an addictive substance. The chemical effects of nicotine are strongly related to the conditioning that occurs in many smokers. It is this link between stimulation/triggers in the environment and the immediate chemical, pleasurable effect on the body that often makes stopping smoking so difficult.
BEHAVIOURAL - Conditioning occurs over many years after exposure to things in the environment which stimulate the smoker to want a cigarette. Patterns of behaviour are very difficult to change.
SPIRITUAL - Smoking is closely associated with identity and has powerful symbolic value in many people’s lives. Think of the way smoking is depicted in advertising and in commercial films.
SOCIAL - Smoking begins as a social activity and often continues because of social pressures, and as a way of coping in social situations.

60. Physical and Psychological
When “down”, smoking energizes
When “anxious”, smoking calms
Smoking focuses attention and conveys a sense of well-being, every time

61. Psychological/Behavioural
Conditioning occurs over many years after exposure to things in the environment which stimulate the smoker to want a cigarette
People learn to manage their emotions with tobacco
Patterns of behaviour are very difficult to change

62. Physical and Emotional
Pleasure, arousal, relaxation and the relief of tension and anxiety are therapeutic effects of nicotine
Smoking also treats effects of withdrawal
All of these effects are biological and molecular

63. Myths you may encounter as you work with your patients to help them stop smoking:
Myth 1: Smoking is just a bad habit.
Fact: Tobacco use is an addiction. According to the U.S. Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence, nicotine is a very addictive drug. For some people, it can be as addictive as heroin or cocaine.
Myth 2: Quitting is just a matter of willpower.
Fact: Because smoking is an addiction, quitting is often very difficult. A number of treatments are available that can help.
Myth 3: If you can’t quit the first time you try, you will never.
Fact: Quitting is hard. Usually people make two or three tries, or more, before being able to quit for good.

64. Myths you may encounter as you work with your patients to help them stop smoking:
Myth 4: The best way to quit is “cold turkey.”
Fact: The most effective way to quit smoking is by using a combination of counseling and nicotine replacement therapy (such as the nicotine patch, inhaler, gum, or nasal spray) or non-nicotine medicines (such as bupropion SR).
Myth 5: Quitting is expensive.
Fact: Treatments cost from $3 to $10 a day. A pack-a-day smoker spends almost $1,000 per year. Check with your health insurance plan to find out if smoking. cessation medications and/or counseling are covered.

65. Cigarette contains :
Tar
Carbon monoxide
Nicotine

67. THANK YOU