بسم ا الرحمن الرحيم
Smoking Cessation Dr. Fayez Basta Head of Cessation Services Department Tobacco Control Program MOH
• A 55 year old male patient with PMHX of DM, HTN, obesity and hyperlipidemia. His BP is 140\90, FBS is 200, HBA1c 8.5, HDL 32. His current medications include Amaryl, Captopril, Atorvastatin and ASA. • He smokes 45 cig/d. The patient should start by : • Giving up smoking. • Reducing his weight. • Both at the same time.
The nicotine addiction scale is expected to be ▫ Medium ▫ High ▫ Low
What is the plan for this patient to quit? • Pharmacotherapy. • Counseling. • Both.
• A 68 year old male patient with mild HTN and borderline DM on glucophage. His wife died 1.5 years ago. The patient starts crying every time he mentions his wife and he lives alone. He smokes 20 cig/d. he smokes his first cig while still in bed early in the morning. The nicotine addiction scale of this petition is ▫ High ▫ Low ▫ Medium
Drug of choice foe smoking cessation is • Nicotine patch (NRT) • Bupropion tab. • Varenicline tab.
Varemicline Tab is contraindicated for this patient False True
• Adverse health effects. • Pathophysiology of nicotine (nicotine addiction). • Fagerstrom addiction scale. • Smoking status. • Smoking cessation. • Methods of cessation. • Steps of management. • Clinical practice guide. • Psychotherapy. • Pharmacotherapy.
Tobacco use is the single most important preventable risk to human health and an important cause of premature death world wide. • < 6 million people die from tobacco use and exposure to tobacco smoke (one death every 6 seconds ) it is the second leading cause of death. • 63% all deaths are caused by NCDs for which tobacco use is one of the greatest risk factors.
Main adverse health effects: 1. CVD : Angina – Coronary artery disease - MI 2. Pulmonary Diseases : Bronchitis- AsthmaCOPD- Cancer 3. Cancer ( )
Nicotine link to circulatory disease: - BP - vasoconstrictor - risk of blood clots Heart: 1- IHD. -
- fat + cholesterol
up to 3 times ♂ & up to 6 times ♀ smoking cessation of second attack (50%) and mortality rote. 2- Risk factor for congestive heart diseacse B.V: Risk and precepitatirg factor for abd. and Thoracic aortic aneurysm. - Cerebrovascular stenosis strockes. - Peripheral vascular disease: stenosis. Buerger disease.
Prevalence: • Locally – 35% ♂, 7% ♀ ,4% of NCDs death rate ( ). • Demographically – Age, Sex, Education & Socioeconomic level.
Although 2/3 of smokers want to quit, and about a third try each year, only 2% succeed. Why??
Nicotine (Pharmacokinetic) • It is distributed quickly Through the bloodstream and can cross the blood – brain barrier to reach the brain around 7 seconds when Inhaled ( ). • The half life of nicotine in the body is around two hours. • The amount of nicotine absorbed by the body from smoking depends on many factors, including the type of tobacco, whether the smoke is inhaled, and whether a filter is used (? Smokeless tobacco). • It is metabolized in the liver by cytochrome p450 enzymes. A major metabolite is cotinine (half -life is 18 – 20h) ( ). • The metabolism of nicotine to cotinine is inhibited by menthol ( the half – life of nicotine in vivo) ( ).
Nicotine addiction (Pharmacodynamic)
• Physiological dependence Pharmacotherapy • Psychological dependence Counseling Time – Place – Habit – Events - Mood – Triggers . ( It is one of the hardest addiction to break ) AHA (It has been shown to be more addictive than cocaine and heroin ).
DOPAMINE REWARD PATHWAY Prefront al cortex
Dopamine release
Nucleus accumbens
Stimulation of Alpha 4 Beta 2 nicotine receptors Ventral tegmental area
Nicotine enters brain
Neuroadaptation of the mesolimbic system in smokers and its target neurons in the nucleus accumbens may be longer lasting than previously believed which could explain the observation that the craving to smoke lasts for months after a smoker stops smoking. Nicotine is unique in comparison to most drugs, as its profile changes from stimulant to sedative /pain killer in increasing dosage and use. Short quick puffs
Deep puffs
low level of blood nicotine
high level of blood nicotine
n. impulse dopamine +norepinephrine n. impulse serotonin + endorphin
â&#x20AC;˘ Nicotine addiction is classified as nicotine use disorder The criteria for this diagnosis include any 3 of the following within a 1- yeartime span: o Tolerance of nicotine with decreased effect and increasing dose to obtain same effect. o Withdrawal symptoms after cessation. o Smoking more than usual. o Persistent desire to smoke despite efforts to decrease intake. o Extensive time spent smoking or purchasing tobacco. o Postponing work, social, or recreational events in order to smoke. o Continuing to smoke despite health hazards. â&#x20AC;˘Nicotine withdrawal is classified as a nicotine - induced disorder Include difficulty concentrating, nervousness, headaches, weight gain due to increased appetite, decreased heart rate, insomnia, irritability, and depression. These symptoms peak in the first few days but eventually disappear within a month.
Karl Fagerstrom Nicotine Tolerance Questionnaire For each statement, circle the most appropriate number that best describes you. Point(s): 1. How many cigarettes do you smoke per day? a) 10 or less b) 11 – 20
0 1
c) 21 – 30 d) 31 or more 2. How soon after you wake up do you smoke your first cigarette? a) 0 – 5 min b) 6 - 30 min c) 31 – 60 min d) After 60 min
2 3 3 2 1 0
3. Do you find it difficult to refrain from smoking in places where smoking is not allowed (e.g. hospitals, government offices, cinemas, libraries etc)? a) Yes b) No
1 0
4. Do you smoke more during the first hours after waking than during the rest of the day? a) Yes b) No 5. Which cigarette would you be the most unwilling to give up? a) First in the morning b) Any of the others 6. Do you smoke even when you are very ill? a) Yes b) No Total Points (s) : ــــــــــــــــــــ
1 0 1 0 1 0
TOTAL SCORE
LEVEL OF DEPENDENCE
points
Low 3 – 0
points
Medium 6 – 4
points
High 10 – 7
The time to first cigarette and total cigarettes per day are the two strongest predictors of nicotine addiction. Nicotine dependence
counseling
pharmacotherapy
points 3 – 0
+
Not recommended at initial assessment
points 6 – 4
+
May be recommended
points 10 – 7
+
Recommended
Smoking Status: • • • • • • • • • • •
Type of smoking. Number of cigarettes (amount). Age of starting ? Causes? Family member who are smoking . Any idea about adverse effects of smoking. Any diseases contributed to smoking. Any other ch. Diseases . Most common places, events , triggers. Feelings related to smoking. Attempts to quit? Why? How? Cause of relapsing? Withdrawal manifestation?
Are you willing to quit? Yes
Intensive intervention
5As
Recently quit
Member of special population
No
Relapse Prevention Intervention
Motivational intervention
3Rs
5Rs
Brief Intervention
As 5 Ask Ask Advise Advise Asses Asses
Relapse Prevention Intervention
3Rs
4- Assist Intensive Intervention
S T A R
Motivational Intervention 5Rs
Smoking Cessation • It is a dynamic process ( continuous change ) which can be divided into : Precontemplation
Contemplation Desire
Motivational Intervention Brief Intervention
Action Relapse Prevention intervention
Maintenance
• Methods of cessation: "cold turkey" : all at once without any assistance Gradual reduction of cigarette consumption Cessation with help : evidence based :strategies Support based strategies Non-evidence based strategies Combining based strategies
Steps of Management •Registration •Smoking Status •CO Monitor & Fagerstrom addiction scale •Plan to quit : counseling ( psychotherapy ) pharmacotherapy •Follow up
Clinical practice guidelines for treating tobacco use and dependence: 1. Tobacco dependence is a chronic disease that often requires repeated intervention and multiple attempts to quit. Effective treatments exist, however, that can significantly increase rates of long-term abstinence. 2.It is essential that clinicians and health care delivery systems consistently identify and document tobacco use status and treat every tobacco user seen in a health care setting. 3.Tobacco dependence treatments are effective across a broad range of populations. Clinicians should encourage every patient willing to make a quit attempt to use the counseling treatments and medications recommended in this Guideline.
4. Brief tobacco dependence treatment is effective. Clinicians should offer every patient who uses tobacco at least the brief treatments shown to be effective. 5. Individual, group, and telephone counseling are effective, and their effectiveness increases with treatment intensity. Two components of counseling are especially effective, and clinicians should use these when counseling patients making a quit attempt: ď&#x201A;&#x2013; Practical counseling (problem solving/skills training). ď&#x201A;&#x2013; Social support delivered as part of treatment.
6. Numerous effective medications are available for tobacco dependence, and clinicians should encourage their use by all patients attempting to quit smokingâ&#x20AC;&#x201D;except when medically contraindicated or with specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). ď&#x201A;§ Seven first-line medications (5 nicotine and 2 non-nicotine) reliably : increase long-term smoking abstinence rates o Bupropion SR. o Nicotine gum. o Nicotine inhaler. o Nicotine lozenge. o Nicotine nasal spray. o Nicotine patch. o Varenicline. ď&#x201A;§
Clinicians also should consider the use of certain combinations of medications identified as effective in this Guideline.
7. Counseling and medication are effective when used by themselves for treating tobacco dependence. The combination of counseling and medication, however, is more effective than either alone. Thus, clinicians should encourage all individuals making a quit attempt to use both counseling and medication. 8. Telephone quitline counseling is effective with diverse populations and has broad reach. Therefore, both clinicians and health care delivery systems should ensure patient access to quitlines and promote quitline use.
9. If a tobacco user currently is unwilling to make a quit attempt, clinicians should use the motivational treatments shown in this Guideline to be effective in increasing future quit attempts. 10. Tobacco dependence treatments are both clinically effective and highly cost-effective relative to interventions for other clinical disorders. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans include the counseling and medication identified as effective in this Guideline as covered benefits.
Pharmacotherapy: First line medications Second line medicedtions NRT •Patch
non NRT Bupropion
• gum • oral inhalation • nasal spray • lozenges
varenicline
Nortryptiline
clonidine
Smoking and the Cardiovascular System Fatal MI is 4 times more common in smokers than non.smokers
With kind permission from Andrew Pipe, MD .Fagerstrom K. Drugs 2002; 62(Suppl 2):1-9
Smoking and the Cardiovascular System The relative risk of stroke increases approximately 3-fold and is dependent on the number of .cigarettes smoked
With kind permission from Andrew Pipe, MD .Bonita R et al. BMJ 1986; 293(6538):6-8
Significant reductions in mortality are observed in patients with established cardiovascular disease .who quit smoking
With kind permission from Andrew Pipe, MD .Critchley JA, Capewell S. JAMA 2003; 290(1):86-97
hours of smoking cessation is 24 associated with rapid restoration of . normal vasodilation With kind permission from Andrew Pipe, MD .Moreno H et al. Am J Physiol 1998; 275(3 Pt 2):H1040-5
weeks of smoking cessation improves 2 .platelet aggregation With kind permission from Andrew Pipe, MD .Morita H et al. J Am Coll Cardiol 2005; 45(4):589-94
HDL increases significantly after smoking .cessation
With kind permission from Andrew Pipe, MD HDL = high-density lipoprotein .Stubbe I et al. BMJ 1982; 284(6328):1511-3
Smokers have reduced number of circulating EPCs, making them more susceptible to cardiovascular disease. Smoking cessation leads to restoration of . EPC levels within 4 weeks
With kind permission from Andrew Pipe, MD EPC = endothelial progenitor cells .Kondo T et al. Arterioscler Thromb Vasc Biol 2004; 24(8):1442-7
Coronary endothelial dysfunction, which is characteristic of patients with MI, is significantly improved by smoking .cessation of 6 months duration With kind permission from Andrew Pipe, MD .Hosokawa S et al. Int J Cardiol 2008; 128(1):48-52
People who quit smoking after a heart attack reduce their risk .of death by 36%
With kind permission from Andrew Pipe, MD .Critchley J, Capewell S. Cochrane Database Syst Rev 2003(4):CD003041
• A 55 year old male patient with PMHX of DM, HTN, obesity and hyperlipidemia. His BP is 140\90, FBS is 200, HBA1c 8.5, HDL 32. His current medications include Amaryl, Captopril, Atorvastatin and ASA. • He smokes 45 cig/d.
â&#x20AC;˘ A 68 year old male patient with mild HTN and borderline DM on glucophage. His wife died 1.5 years ago. The patient starts crying every time he mentions his wife and he lives alone. He smokes 20 cig/d. he smokes his first cig while still in bed early in the morning.
Preparation & Arrangement Mona al sayat Female Department