1. Smoking cessation aids

2. Learning outcomes By the end of this study you will be able to: Learn about smoking cessation aids Understand the opportunity and responsibility that lay on you as a pharmacist persuading and helping smokers to give up Learn about the available products in the pharmacy and the appropriate pharmaceutical and non-pharmaceutical advice to provide

3. Statistics In UK, ▫Smoking is responsible for one in every five deaths in adults aged over 35 ▫Half of all long-term smokers will die prematurely due to a smoking-related disease WHO reported: Tobacco kills up to half of its users. Tobacco kills nearly 6 million people each year. More than five million of those deaths are the result of direct tobacco use while more than 600 000 are the result of non-smokers being exposed to second-hand smoke. The annual death toll could rise to more than eight million by 2030. Nearly 80% of the world's one billion smokers live in low- and middle- income countries. Consumption of tobacco products is increasing globally, though it is decreasing in some high-income and upper middle-income countries.

4. What you get inhaling a cigarette Tobacco smoke include nicotine and about 4000 pyrolysis products, including tar components (aliphatic and aromatic hydrocarbons, phenols and other compounds), alcohols, amines, nitrosamines, ammonia, nitrogen oxides and carbon monoxide.

5. Nicotine Nicotine is the addictive component of tobacco smoke. Readily absorbed through oral mucosa and the lungs, and peak blood concentrations are achieved very rapidly – within 30 seconds of a puff of a cigarette. Acts on the central nervous system, causing transient euphoria, a feeling of relaxation, improved concentration and memory, and reduced appetite. Nicotine is highly addictive, producing withdrawal symptoms of anxiety, difficulty in concentrating and irritability

6. Psychological and behavioural components contribute to dependence on smoking in approximately equal measure to physiological addiction ▫i.e. associations that reinforce the habit, which can be positive (e.g. social drinking and following meals) or negative (e.g. stressful situations) ▫Ritual behaviour associated with lighting, holding and inhaling a cigarette

7. Smoking cessation aids Always tell your patients that giving up smoking is essentially a matter of self-motivation and determination, and most ex-smokers have stopped without using drugs or any kind of assistance The best time to start is to start now Get rid of habits or people help you or share you smoking

8. Nicotine-replacement therapy Use of NRT products replace nicotine from smoking in a regimen that gradually reduces nicotine intake to zero This has been shown to be helpful and are available for people who feel unable to give up smoking unaided Presentations include chewing gum, transdermal patches, a cigarette-shaped inhaler, a sublingual tablet, a lozenge and a nasal spray.

9. NRT All forms of NRT are effective as part of a strategy to promote smoking cessation; they increase the odds of quitting by 50–70%. NRT assists smokers to give up by providing nicotine, although at a lower level than is obtained through smoking, in order to help prevent withdrawal symptoms and cravings.

10. NRT-Transdermal patches Two types of transdermal patch, both of which are changed daily: one is left on for 24 hours; the other is used for 16 hours daily during waking hours only and is removed before going to bed 24 hours patches are better for smokers who crave a cigarette as soon as they wake up, however can produce sleep disturbances. With both 16- and 24-hour patches, nicotine plasma concentrations are about half of those obtained from smoking the average number of cigarettes per day.

11. NRT-Chewing gum Absorbed through the buccal mucosa; peak blood concentrations are reached within about 2 minutes, and the contents of a piece of gum are intended to be released over about 30 minutes. A piece of gum is chewed whenever the urge to smoke is felt. Peak blood levels are lower and the steady-state nicotine concentration is about 30% of that obtained from cigarettes. Chewing provides some of the same kind of behavioural involvement as smoking

12. NRT- Inhaler Address both the physical and the behavioural components of smoking cessation, as it involves putting the inhaler to the mouth and inhaling, as in smoking. The inhaler may be particularly useful for the highly behaviour-dependent smoker. Electrical cigarette!!!

13. NRT- Sublingual tablets &Lozenges One sublingual tablet is bioequivalent to one piece of nicotine 2 mg chewing gum Sublingual tablets and lozenges may be a useful for smokers who do not like, or have difficulty with chewing gum

14. NRT-Nasal spray A fast-acting and flexible method of nicotine delivery for highly dependent smokers. A 50 mL metered spray administered to each nostril delivers a dose of 1 mg nicotine

15. Effectiveness of NRT presentations

17. Patient counselling Individuals should preferably stop smoking completely while using any NRT product Different presentations should not be used together Transdermal patches have the convenience of a once-daily application and most suitable form of NRT for people in whom the behavioural aspects of smoking is relatively unimportant (slow and passive rerelease)

18. Transdermal patches Supplied in three strengths ▫7 mg, 14 mg and 21 mg nicotine over 24 hours ▫5 mg, 10 mg and 15 mg over 16 hours Starting strength is generally the highest, except for light smokers (defined as fewer than 10 -20 cigarettes per day) for whom the medium strength should be used first.

19. Transdermal patches Stabilisation period on the high strength for 4–8 weeks, followed by a progressive stepping down of strength over a further 2–8 weeks, before stopping altogether. Transdermal patches should be applied daily to a clean, dry, non-hairy area of the trunk or upper arm. A new site of application should be chosen each day, and several days should be allowed to elapse before a patch is reapplied to the same area.

20. chewing gum Use of nicotine chewing gum mimics the pattern of peaks and troughs of nicotine provided by smoking, although blood levels are much lower. The recommended daily maximum is 15 pieces per day The recommended course of chewing gum is about 3 months, after which the gum is gradually withdrawn over a few weeks For smoking reduction before attempting to give up, gum may be used between smoking episodes

21. chewing gum The gum is chewed slowly to release nicotine, until the taste becomes strong and ‘peppery’. Chewing is then stopped and the gum is rested between the gum and cheek until the taste fades. This is repeated until the gum has lost its flavour, which should take about 30 minutes.

22. sublingual tablet A sublingual tablet is placed under the tongue, where it slowly disintegrates in about 30 minutes. One tablet is used per hour (8–12 tablets per day), or two tablets per hour (16–24 tablets per day) for heavy smokers (more than 20 cigarettes per day). The absolute maximum dosage is 40 tablets per day. The full dosage should be maintained for 3 months and then gradually tapered off to zero within the next 3 months.

23. Lozenge One lozenge every 1–2 hours can be used, when the urge to smoke is felt. Daily dosage is 8–12 lozenges, but a maximum of 25 lozenges may be used. A lozenge is sucked slowly until the taste becomes strong; it is then ‘parked’ between the cheek and gum until the taste has faded, and the procedure is continued until the lozenge has gone. One lozenge should last for about half an hour.

24. lozenge The 4 mg lozenge is recommended for people who smoke within 30 minutes of waking, and the 2 mg for those who are less dependent and can wait longer before smoking their first cigarette of the day. Users stay on the same strength of lozenge throughout the course, stepping down the frequency of use rather than the strength of the preparation. The total length of treatment is up to 24 weeks

25. Nicotine inhaler and spray Nicotine inhaler might be most useful for moderate smokers with high behavioural dependency. Treatment with inhalers should be completed within 6 months For nasal spray, one metered dose is inhaled into each nostril when necessary to relieve craving, with a maximum rate of two doses per hour and 64 sprays (32 into each nostril) in 24 hours. Nasal spray may be the most effective form of NRT for very heavily dependent smokers.

26. Cautions Caution is advised with the use of NRT products in patients with a history of angina, recent myocardial infarction or cerebrovascular accident, cardiac arrhythmias, hypertension or peripheral vascular disease. Because of the effects of nicotine on metabolism, caution is also advised in patients with diabetes, hyperthyroidism or phaeochromocytoma. Transfer of dependence from smoking to NRT products is unlikely but possible.

27. Cautions Tobacco smoke reduces serum levels of a wide range of drugs and adjustment of dosage may be necessary when smokers have given up. ▫E.g. theophylline, beta-blockers, adrenergic agonists, nifedipine, tricyclic antidepressants, phenothiazines, benzodiazepines and insulin. The long-term use of NRT whilst continuing to smoke smaller numbers of cigarettes cannot be supported by the current evidence.

28. Pre-cessation use of NRT use of an NRT product can help long-term abstinence if initially used while continuing to smoke Using the nicotine patch for a short period before an abrupt stop Based on meta-analysis of four trials, there appears to be evidence that this increases quit rates over that achieved by post-quitting NRT alone.

29. Zyban (bupropion) Bupropion was originally designed to treat depression, but it was discovered that it also helped people quit smoking.Bupropion ▫It's not entirely clear why, but most experts believe it affects parts of the brain involved in addictive behaviour. Bupropion is prescribed as one to two tablets a day. Bupropion take 7-14 days before reach its maximum effect. A course of treatment usually lasts 7 to 9 weeks.

30. Bupropion is not suitable for: ▫Children and young people under 18 ▫Women who are pregnant or breastfeeding ▫People with anorexia or bulimiaanorexiabulimia ▫People with a central nervous system tumour ▫People with severe cirrhosis of the livercirrhosis Bupropion can also increase risk of having a seizure, so it's not suitable for people who already have a higher- than-average risk of having seizures, such as people: ▫with epilepsyepilepsy ▫with bipolar disorderbipolar disorder ▫with serious alcohol misuse problemsalcohol misuse ▫who are treating diabetes with hypoglycaemic medication or insulindiabetes Bupropion side effects includes: dry mouth, upset stomach, insomnia (trouble sleeping), headaches, difficulty concentrating, dizziness and drowsinessinsomnia

31. Champix (varenicline) Varenicline is currently the only medication specifically designed to help quit smoking.Varenicline It works by preventing nicotine from binding to receptors (parts of your brain that respond to nicotine), which eases cravings and reduces the rewarding and reinforcing effects of smoking. If patient has not stopped smoking completely before starting varenicline, aim to do so within 7-14 days of starting treatment. It is recommended to take varenicline for 12 weeks.

32. Varenicline is not suitable for: ▫children and young people under 18 ▫women who are pregnant or breastfeeding ▫people with epilepsy ▫people with advanced kidney disease However, there have been reports of people experiencing feelings of depression and suicidal thoughts after beginning treatment.depression

33. Your Home work What is the regimen for the use of varenicline (how many packs? And in what doses?) What is the evidence for extending the course for extra 12 months?

34. Electronic cigarettes Electronic cigarettes – or e-cigarettes – are electrical devices that mimic real cigarettes but using an electronic cigarette produces a vapour that’s potentially less harmful than tobacco smoke. Some e-cigarettes contain nicotine and, when they do, it’s the vapour that gives the nicotine hit. However, so far, there’s no proof that they can help people to stop smoking They aren’t proven as safe. Some e-cigarettes have been tested and been found to contain toxic chemicals, including some of the same cancer-causing agents produced from tobacco

35. Filters A cigarette filter has the purpose of reducing the amount of smoke, tar, and fine particles inhaled during the combustion of a cigarette. Filters also reduce the harshness of the smoke and keep tobacco flakes out of the smoker's mouth Smokers can easily obstruct the filter ventilation holes with lips or fingers, delivering more concentrated smoke with increased amount of tar, nicotine and CO. Evidence for reduced risk!!

36. Light cigarette Cigarettes marketed as light or ultra- light are designed to deliver reduced levels of tar, nicotine. However, studies showed that smokers who switch to these often change their smoking behaviour (inhale longer or deeper) obtaining the same amount of nicotine as regular cigar. Studies failed to demonstrate reduction in the risk of tobacco-related disease