Objectives

• Discuss 5A approach to tobacco cessation

• Discuss brief behavioral treatment for smoking cessation

• Pharmacotherapy for Smoking cessation

• Maintenance/ Follow-ups

Tobacco use can kill in so may ways that it is a risk factor for six of the eight leading causes of death in the world. “Margaret Chan Fung Fu-Chun, Director General WHO 2008”

“Tobacco is the only legally available consumer product which kills people when it is used entirely as intended”. (The Oxford Medical Companion, Oxford: Oxford University Press, 1994)

Situation in Pakistan

• Tobacco use is on the rise in Pakistan• 36% of males and 9% of females do smoke (NHS 1996)• Smokeless tobacco is also a major issue here• Cigarette industries pay 140 billion rupees in taxes

and source of livelihood for more than 1.2 million people

• 32% of house officers do smoke in Karachi• 22%nmale and 3.8% of females reported current

smokers at Karachi• 21.5% general students were reported using tobacco in

all forms in a study at Karachi• Tobacco associated cancers in Karachi are 38.3% in

males and 40% in females

Why do people smoke?

Different forms of tobacco

Smoked Tobacco

Smokeless tobacco

Second hand or passive smoking

Smoked tobacco

• Bidi:– Small hand-rolled cigarettes – Three times more carbon

monoxide and nicotine– Five times more tar – Three-fold higher risk of oral

cancer– Increased risk of lung, stomach

and esophageal cancer

• Shisha:– Tobacco mixed with flavorings

and smoked from hookahs – More popular in youths of

Karachi– Linked to lung disease,

cardiovascular disease and cancer

• Second hand or passive smoking– 2 hours is smoky office =4

cigarettes smoked– Two hours in non smoking area

of a restaurants even= 2 cigarettes

– 24 hours with a pack a day smokers = 3 cigarettes

– 3,400 lung cancer deaths and 46,000 heart disease deaths a year in US

– 430 sudden infant deaths– 24500 LBW,71900 preterm

deliveries & 2K childhood asthma

In children:brain tumors, middle ear disease, lymphoma, impaired lung function, asthma, sudden infant death syndrome, leukemia, and lower respiratory illness

Common Problems in Adults due to Passive smoking:stroke, nasal sinus cancer, coronary heart disease, lung cancer, atherosclerosis, COPD, asthma, pre-term delivery & low birth weight babies

• Tobacco in Pakistan is responsible for 90% of Lung Cancers, 90% of COPD, 40% of

overall cancers and 20 other fatal diseases • We are still in the early phase of Tobacco

epidemic, • Yet the full impact of tobacco is awaited

Tobacco Dependence:A cluster of behavioral, cognitive and physiological phenomena that develop after repeated use and typically include a strong desire to smoke, difficulty in controlling its use, persisting in its use despite harmful consequences, increased tolerance to nicotine, and a (physical) withdrawal state (PCS)

• 4000 Toxic Substances• Potent Carcinoges like Nitorsamines,

aromatic hydrocorbons• CO, Tar, ammonia, nitrogen oxide,

hydrogen cyanide and nicotine

Benefits of Stopping smoking?• A reduced risk of dying early

• a reduced risk lung cancer ,CAD, CVA, COPD & other cancers

• Improved respiration•Reduced risks of complications in

pregnancy and childbirth • Improvement in some mental

health symptoms • Fewer sick days off work

• Improvement in recovery from surgery and reduced perioperative

risk • A reversal of the risks of

smoking if cessation is achieved by the age of 35

Stopping smoking will also: • Set a good example for children

and young people (children of non-smokers are less likely to

become regular smokers) • Improve the health of young children of parents who have

ceased smoking • Save money

Patient # 1

• A 8 year old child is brought by his father in your clinic with the upper respiratory tract symptoms– Boy is allergic to smoke & dust

– Your clinical impression is allergic rhinitis

– You ask about any smoker in family

– Father confess that he smokes

o What is one of the major root cause of child’s illness evident from history?

General Approach

• Age , sex • How do u feel about your smoking?• When, why and how did you begin, • how many cigarettes per day, pack year• Previous quit attempts and reasons for failure and aids used? • Any smoker at home?• Past history• Family history • Social history• Personal history• Addictions• Drugs• Examination: Any thing left?

Ne

CAGE QUESTIONNAIRE:

C= DO YOU EVER FEEL OR TRIED TO CUT DOWN YOUR SMOKING?A=DO YOU EVER GET ANNOYED ,WHEN PPL ASK YOU TO QUIT?G= DO U EVER FEEL GUILTY ABOUT SMOKINGE= DO YOU EVER SMOKE EARLY MORNING,WITHIN HALF AN HOUR AFTER WAKING UP?( EYE OPENER)

SCREENING TEST: 2 YES, SCREENING POSITIVE.

• Our patients CAGE score is 3 and fagerstrom is 6

• What should you do as a primary health care provider?

Clinical interventions for tobacco use and dependence

What can a health professional do?

• Do not smoke or use tobacco

• Take a history of smoking/tobacco use

• Give firm advice to patient who uses tobacco

• Learn ―how to counsel patients in order to make them quit smoking/tobacco use

• Educate the public regarding the hazards of active & passive smoking and other forms of tobacco

• Intervention as brief as three minutes increases the cessation rate• Average smoker attempting to quit five times before permanent

successAvailable interventions:

5As: one of the commonly used intervention by Family physicians5Rs: Motivational intervention for unmotivated persons5Ds: to combat withdrawal symptoms

5”As”: 1- Ask

• Adding smoking status as a vital sign to all patients’ charts

• Identification of all tobacco users and documentation of their smoking status at every office visit

• Ask all patents “do you smoke?” ,”Have you ever smoked?”– Take a brief history– Number of cigarettes per day– The year of starting smoking– Previous quit attempts and what happened– Presence of smoking related disease

“Have you ever been a smoker or used other tobacco products?Do you use tobacco now?How much?”

5”As” :2- Advice

• Clear, strong and personalized advise to stop smoking

• Advise firmly but in a no confrontational manner “the best thing you can do for your health is to quit smoking”

• Emphasize the personnel benefits of cessation– Improved health– Not exposing others to tobacco smoke– Positive role model for children and adolescents– Financial benefits

Strong—“As your clinician, I

need you to know that quitting smoking is the most important thing you can do to protect your health

now and in the future. The clinic staff and I

will help you.”

Clear—“It is important that you quit smoking (or using chewing

tobacco) now, and I can help you.”

“Cutting down while you are ill is not enough.” “Occasional

or light smoking is still dangerous.”

5”As” : 3-Asses

• Asses a person's’– Willingness and Barriers

– Smoking history and current level of nicotine dependence

– Timeline for quitting and about previous attempts

• “Have you ever tried to cut back on or quit smoking?

• Are you willing to quit smoking now? What keeps you away from quitting?

• How soon after getting up in the morning do you smoke?”

5”As” :3-Asses: Stages of Readiness to Change

• Pre-contemplation: – No intention to take action within next six

months– Unaware of the need to change; overestimate the

costs ,underestimate the benefits; Consider Reluctance(inertia), Rebellion and Rationalization

• Contemplation:– Considering change within the next six months– Ambivalent about change; perceives that costs

equal benefits

5”As”:3-Asses: Stages of Readiness to Change

• Preparation/determination: – Planning to take action within the next month– May have already made steps towards change– Often concerned about failure

• Action:– Actively changing (first six months of new behavior)– Needs vigilance to

• Prevent relapse • Encouragement to keep up the momentum

• Maintenance:– More than six months since behavior change– Reminders about high-risk situations

5”As”:4-Assist: Readiness to change

• Assist according to patients readiness to change

Not readyEncourage patient to think about their smoking, offer

help, offer written material offer referral

Not sure:Encourage patient contemplate and help to reflect on

the pros and cons of smoking, plus offer help as above

Ready/action:Affirm and encourage the decision to quit, help the

patient to develop a quit plan

Help set a quit date

5”As” :4-Assist: Anticipate challenges

• Help patients to anticipate difficulties and encourage them to prepare their social support systems and their environment

• “I would like to help you quit. Can I tell you aboutSome of the things we know can increase your odds of success?”• “Are you worried about anything in particular

whenIt comes to quitting? • Do you worry about cravingsOr weight gain?”

• Our patient is not much convinced to quit smoking what to do?

For the patient unwilling to quit

• Patients unwilling to make a quit attempt during a visit may:

– Lack information about the harmful effects of tobacco use

– No knowing much about benefits of quitting;

– Lack the required financial resources;

– Have fears or concerns about quitting, or may be demoralized because of previous relapse

• These patients may respond to brief motivational interventions that are based on principles of motivational interviewing

– (1) express empathy

– (2) develop discrepancy

– (3) roll with resistance

– (4) support self-efficacy

Motivational Intervention for the patient unwilling to quit/ for Enhancing

Motivation….

5”As”4- Assist:5-Rs

• 1-Relevance

– Encourage the patient to indicate why quitting is personally relevant, such as children at home, money saved by quitting smoking, history of smoking related illness

• 2-Risks:

– Advise the patient of the harmful effects ,both to the patient and to others

Acute risks: Shortness of breath,

Exacerbation of asthma, Increased risk of respiratory

infections, Harm to pregnancy, Impotence, Infertility.

5”As” :4-Assist: 5Rs

• 3-Rewards– Identify benefits of

stopping tobacco use– Improved health– Improved sense of smell– Save money– Set a good example for

children– Reduced wrinkling/aging

of skin

• 4-Road blocks– Barriers to cessation – Other smokers in the home

or workplace– Failed quit attempts– Severe withdrawal

symptoms/ stress– Psychiatric comorbidity– Low motivation– Weight gain– Enjoyment of smoking

• 5-Repetations:– Motivational interventions

repeated every time

5”As”: 4-Assist: Willing to quit

• Help develop a quit plan• Set a quite date• Tell family and friends for support• Anticipate challenges &discuss challenges / triggers• Remove tobacco products• Avoid

– Alcohol use– Express to tobacco

• Provide supplementary materials• Give nutritional advice• Physical activity may help• Recommend the use of approved pharmacotherapies

5”As” :5-Arrange

• Elicit the benefits ask to anticipate and problem

• Schedule follow up contacts with in one week after quit date– Person – Telephone quit-line

• Four visits or calls are evidence based• Congratulate progress success• Identify problems and anticipate challenges• Evaluate pharmacotherapy use/ problems

• Our patient is willing to quit

• Quit motivated

• Seeks your help

• How will you help him

Algorithm for treating tobacco use

Pre-interventional Counseling

• Discuss

– Tobacco withdrawal S/S

– Benefits of quitting smoking

– Behavioral interventions

– Non-pharmacological and pharmacological aid

– Maintenance/ follow up plans/ relapses

Method for smoking cessation

Non pharmacological

– Behavioral cessation and therapies

– Individual , group, or telephone counseling

• Pharmacological– Nicotine replacement

therapy, transdermal, nasal spray, inhaler, gum, lozenges

– Bupropion sr (zayban)

– Chantix

– Clonidine, transdermal, oral

– Nortryptelline

– Anxiolytic agents

Behavioral intervention

• Brief advice

• Group counselling

• Telephone counselling

• Web based programs

Cognitive strategies

• Keep a diary for one or several days prior to quit day(more aware of their smoking patterns and risk situations)

• Coping with craving

Most common nicotine withdrawal symptoms

• Depression:– Smokers have more

likelihood of depression, hindrance in quitting

– Smoking cessation may trigger depression

– Do screen for depression – Bupropion (zyban) is helpful

• Irritability, anxiety, restlessness– Peak within the first week of

abstinence and last two to four weeks

– Decrease caffeine intake & nrts can be helpful

• Weight gain:– Most smokers gain fewer

than 10 lb(4.5 kg) after quittingWeight gain can vary (10

percent will gain30 lb [13.5 kg])– Concern about weight gain

may interfere– Sustained-release bupropion

or an NRT– (Particularly gum or

lozenges) delay weight gain while in use

– Monitor and adjust food intake/exercise balance

Behavioral strategies cope with craving

• Suggest 4Ds

– Delay acting on the urge to smoke, after five minutes the urge to smoke weakens and your resolve to quit will come back

– Deep breath: take a long slow breath in and slowly release it out again, repeat three times

– Drink water slowly holding it in your mouth a little longer to savour the taste

– Do something else to take your mind off smoking, doing some excerscise is good alternative

First line pharmacotherapies

• Nicotene replacement therapy– Trandermal patch

– Chewing gums

– Lozenge

– Inhaler

– Nasal spray

Non nicotene therapy– Vernacillene

– Buprpion

Second line pharmacotherapy

• Nortryptelline

• Clonidine

First-line therapies for smoking cessation in adults

• Nicotine gum– Available in 2-mg and 4-mg (per

piece) doses– Patients smoking less than 25

cigarettes per day: 2 mg– Patients smoking 25 or more

cigarettes per day: 4 mg– Maximum dosage: 24 pieces per

day– Over the counter– may delay weight gain; – Difficult to use with dentures,

partials, or fillings– FDA pregnancy category C– Side effects: gastrointestinal

distress; mouth or throat irritation

• Nicotine lozenge – Heavy smokers: 4 mg– Light smokers: 2 mg– Maximum: 20 lozenges per day– Over the counter– May delay weight gain;; – Contains 25 percent more

nicotine than gum– FDA pregnancy category D– Side effects: nausea, heartburn,

headache

• Nicotine patch – Doses vary and should be

tapered as therapy progresses– Heavy smokers: 21 mg per day– (Initial dosage)– Light smokers or those weighing

less than 100 lb (45 kg): 10 to 14 mg per day (initial dosage)

– Over the counter– Treatment of up to eight weeks – Site of patch should be changed

daily; – 16- and 24-hour patches have

comparable effectiveness; adolescents may require lower starting dosages because of body habitus and overall smoking patterns (e.G., Less than one-half pack per day)

– FDA pregnancy category D– Side effects: skin reactions (up

to 50 percent), headaches, insomnia (decreased if patient removes patch at night)

• Nasal spray – One dose consists of two 0.5-mg

sprays (one in each nostril)– Initial dosage is one or two

doses per hour (minimum of eight doses per day), increasing as needed for symptom relief

– Maximum: 40 doses per day (five doses per hour)

– Dependence potential is intermediate between other nicotine replacement therapies and cigarettes

– FDA pregnancy category D– Side effects: moderate to severe

nasal irritation within the first two days (94 percent) that often continues throughout use

Bupropion

• Inhibitor of neuronal reuptake of noradrenaline and dopamine– Limits craving(substitution of stimulant effects of

nicotine)

• Marketed as antidepressant and decrease the desire to smoke observed in depressed patients

• Double the success rate of quitting compared to placebo

• Equally effective in patients who are not depressed

Bupropion: Patients issues

• Insomnia

• Dry mouth

• Tremors

• Rashes

• Weight loss

• Seizures

• Hypertension

Varenicline/ chantix

• High affinity partial nicotine acetylcholine receptor antagonist

• specifically designed for smoking cessation

• Alleviates the symptoms of craving and withdrawal , but produce much weaker effect than nicotine

• Prevents inhaled nicotine from a cigaratteactivating the ---- receptors and blocks the pleasurable effect of smoking

• Varenicline (chantix): Continued– Days 1 to 3: 0.5 mg once per day– Days 4 to 7: 0.5 mg twice per day– Day 8 to end of treatment: 1 mg twice per day– Begin therapy one week before quit date and continue for

12 weeks; an additional 12 weeks can be added if quit attempt is successful to increase chances of long-term abstinence

– Should not be combined with a nicotine replacement therapy;

– FDA pregnancy category C– Side effects: headache, nausea (dose related), insomnia,

abnormal dreams, flatulence increased risk of cardiovascular events in smokers with cardiovascular disease should be discussed with patients

– FDA boxed warning: may cause serious neuropsychiatric symptoms in patients, including changes in behavior, hostility, agitation, depressed mood, suicidal thoughts and behavior, and attempted suicide; patient should be monitored closely

Second line treatment

• Nortryptylline– Tricyclic antidepressant

– Mechanism of action in smoking cessation is likely to be separate from antidepressant effect

– Dose is 75 mg per day for 12 weeks

– Side effects• Dry mouth, sedation,over dose risks

– Not registered for smoking cessation in australia

Second line treatment

• Clonidine

– Antihypertensive, centrally acting alpha agonist

– Minimal use for this indication in Australia

Possible future options

• Nicotine vaccines in development.

• The selective type 1 cannabinoid receptor antagonist Rimonabant .

• The Nicotine receptor partial agonist Cystine.

• They have demonstrated some efficacy in studies, but as yet there is insufficient evidence for their use in tobacco cessation.

Follow up

• First visit: after 1 week of quit date.

• Second visit: within the same month.

• At 2 month : telephone call or letter of encouragement.

• At 3 month : cessation validation by expired air CO.

• At 5 month : telephone call or letter of encouragement

• At 6 month : cessation validated by expired air CO

• At 9 month : telephone call or letter of encouragement.

• At 12 month :cessation validated by expired air CO

Model for treatment of tobacco use and dependence

Patient presents to ahealth care setting

Ask

Primaryprevention

Advise toQuit

Preventrelapse

Assesswillingness

to quit

Assist withquitting

Arrangefollowup

Neveruses

CurrentUsers

Formerusers

Yes

Patient remains unwilling

Patient now willing to quitPromotemotivation

No

Abstinent

Relapse

References

• Oxford GP, 3rd Edition

• PCS 2009

• NICE 2010

• CDC

• Royal college of general physicians guidelines 2010

• Clinical guidelines in Family medicine, (E-Book) 2014