1. Nico-hosp-intro 1.1 Smoke-free hospital European Training guide From: Nicomède DGS France -A drop in nicotine level leads to smoking -Nicotine inhaled through smoke: the shoot effect -Nicotine dependence criteria according to DSM IV -Withdrawal syndrome according to DSM IV -Abstinence in time -Depression and tobacco -Economical aspects -Quality of life Dependence related motivations

2. Nico-hosp-intro 1.2 Smoke-free hospital European Training guide From: Nicomède DGS France Drop in nicotine level leads to smoking hours Satisfaction level Withdrawal feeling cigarettes The smoker smokes sometimes out of pleasure. Many cigarettes are smoked in order to avoid the unpleasant feeling related to lack of nicotine. The behaviour is the same as for the other drugs when a dependant smoker is suffering from withdrawal symptoms. Nicotine concentration in blood

3. Nico-hosp-intro 1.3 Smoke-free hospital European Training guide From: Nicomède DGS France Inhaled nicotine through smoke: the “shoot” effect Cigarette is a “nicotine syringe”. Nicotine takes 7 seconds to go from the alveolus to the brain: this shoot is two times faster than an intravenous injection ! ! A smoker takes around ten shoots per smoked cigarette: this shoot effect creates and maintains dependence. Nicotine is brought slowly by NRT and is, therefore, not accompanied by this shoot effect. Source : Henningfield

4. Nico-hosp-intro 1.4 Smoke-free hospital European Training guide From: Nicomède DGS France Nicotine dependence criteria according to DSM IV 1) Tolerance: shown by the necessity to increase dosage in order to obtain intoxication, a desired effect or diminution of the effects by a constant dosage of consumption 2) Withdrawal syndromes following abstinence 3) Smoking more or longer than planned 4) A persisting desire to smoke and unsuccessful attempts at diminution or control of consumption 5) A long time spent smoking or obtaining tobacco 6) Abandon or reduce social, professional or leisure activities, because of tobacco 7) Persisting in smoking despite of the knowledge of its effects on health. 3 out of these 7 criteria are necessary in order to be considered as dependent.

5. Nico-hosp-intro 1.5 Smoke-free hospital European Training guide From: Nicomède DGS France Withdrawal syndrome according to DMS IV In the face of at least 4 of the following criteria: - depressed mood - insomnia - irritability, frustration, anger - anxiety - difficulties in concentrating - agitation - pulse slowing down - appetite increase and/or fast weight gain These signs cause a clinical suffering and sometimes a social or family functioning alteration. These signs are not explained by a mental illness.

6. Nico-hosp-intro 1.6 Smoke-free hospital European Training guide From: Nicomède DGS France Abstinence follow up in time 0 20 40 60 80 100 0 36912 months Tobacco GamblingAlcohol Morphine Haschisch Source : Hunt 1971

7. Nico-hosp-intro 1.7 Smoke-free hospital European Training guide From: Nicomède DGS France Fagerström Test 1. How soon after waking up do you smoke your first cigarette ? Within 5 minutes  3 6-30 minutes 2 31-60 minutes 1 After 60 minutes 0 2.Do you find it difficult to refrain from smoking in places where it is prohibited? Yes 1 No 0 3. Which cigarette would you hate most to give up ? The first in the morning 1 Any other 0 4.How many cigarettes per day do you smoke ? 10 or less 0 11-20 1 21-30 2 31 or more 3 5. Do you smoke more frequently during the first hours after awakening than during the rest of the day? Yes 1 No 0 6.Do you smoke if you are so ill thaht you are in bed for most of the day? Yes 1 No 0 Interpretation 0-2 no dependence 3-6 dependence 7-10 high dependence

8. Nico-hosp-intro 1.8 Smoke-free hospital European Training guide From: Nicomède DGS France 1.How soon after you wake up do you smoke your first cigarette ? Within 5 minutes 3 6-30 minutes 2 31-60 minutes 1 After 60 minutes 0 2. How many cigarettes per day do you smoke? 10 or less 0 11-20 1 21-30 2 31 or more 3 Interpretation 0-2 no or low dependence 3-4 dependence 5-6 high dependence These 2 questions are the most important in the Fagerström test. They represent 60% of the final score. The questions could be learnt by heart by health workers, who could evaluate quickly the level of dependence. Short Test

9. Nico-hosp-intro 1.9 Smoke-free hospital European Training guide From: Nicomède DGS France Depression and tobacco Major depressive status is frequent amongst smokers (life time). % depressed (DSMIII) For major depressive subjects: 74% are smokers. The association between smoking and depression is strong (RR=2,9). It is not dependent upon age, sex, ethnic group or socio-cultural level. General pop. non smokers smokers & ex. smokers 5,1% 2,9% 6,6% Source: A Glassman JAMA 1990, 264:1546-49

10. Nico-hosp-intro 1.10 Smoke-free hospital European Training guide From: Nicomède DGS France