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Part 1: Learning Objectives
Reasons for including counseling to stopsmoking into routine medical practice
Cognitive behavioral and pharmacologicalprocedures used to help people to stopsmoking
How to tailor smoking cessationprogrammes to the patients state of
readiness to quit
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Part 1: Learning Objectives
Incorporate smoking cessation efforts intonormal medical consultations
Assess the patients smoking history and
willingness to try to stop smoking
Deliver effective advice tailored to thepatients needs and state of readiness and
provide help and follow-up
Prescribe NRT appropriately
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Our Aim
Offer effective interventions for stoppingsmoking to patients during clinic visits
Information can be used to help preventtobacco use
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The Facts
Tobacco products = est to be responsiblefor 3M deaths annually worldwide
Tobacco is known or probable cause ofabout 25 diseases
Vast majority of smokers are in developingcountries, and most of them are men
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Health Risks
CVD
Lung cancer
COPD
Tumors of the mouth, larynx, esophagus,lip and bladder
NB and infant death
Cigarette-caused residential fires
Passive smoking deaths from lung cancer
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Health Risks
Male smokers are 22 times more at risk ofdying from lung cancer than male non-smokers
Female smokers 12 times more at riskthan female non-smokers
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Benefits of stopping smoking
Associated health risks diminishsubstantially in proportion to the period ofabstinence, eventually returning to the
level of non-smoker rates
Former smokers live longer
Reduce chances of having LBW
S i l T Ad l d
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Special Targets: Adolescents and
young adults
Average age begin to smoke
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Use tobacco for social and psychologicalreasons
Physical effects of nicotine initiate an
addiction process
Focus on more immediate health andphysical effects of smoking rather than
long-term consequences
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The clinician as an agent for thepromotion of smoking cessation
Access: high proportion of the populationconsult a PCP each year
Patient-acceptance : have authoritative
power and are generally regarded asreliable and knowledgeable sources ofhealth information
Doctors acceptance of their role: not onlytreating manifest disease but also as ahealth adviser to patients
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The clinician as an agent for thepromotion of smoking cessation
Should ask all patients over 15 aboutsmoking and tobacco use during each visit
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Doctors current performance in
promoting non-smoking
Major gap remains between acceptance ofsmoking risks and its transition into clinicalpractice
Detection of smokers
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The potential of medicalinterventions to stop smoking
Smokers who are advised by their doctorto stop smoking are nearly twice as likelyto do so than those who do not.
When combined with NRT appears to beeven more effective
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How doctors can encourage theirpatients to stop smoking
Pre-contemplation = has not stoppedsmoking and is not planning to stop
Contemplation = thought about quitting butis not ready to do so yet
Preparation = mentally willing to stopsmoking within the next month; made littlechanges to combat their smoking but havenot given up cigarettes completely
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How doctors can encourage theirpatients to stop smoking
Active = actually tried or is in the processof quitting smoking; often have relapsedand need to try to stop again
Maintenance = successfully given up for6mos or more and needs counseling tocontinue to stay off cigarettes
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How doctors can encourage theirpatients to stop smoking
2 main forms of NRT : gum and patch
Short questionnaire which measures thelevel of nicotine dependence
Nicotine gum dosing = 1 dose of 2mg gum inplace of every 2 cigarettes; 20 cigarettes/day= 1 dose of 4mg gum q3-4 cigarettes
Transdermal = >10 cigarettes/day should be
treated with the highest available dose of thebrand used.
After 1-2mos, weaning can be initiated
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How doctors can encourage theirpatients to stop smoking
Gum = total daily intake decreased by oneunit dose each week
Patches = each of the lower dosagesprescribed for 2-4wks
Should be advised of the more commonS/E prior to initiation of treatment
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The role of antidepressants
Depression my be a symptom of nicotinewithdrawal, and smoking cessationsometimes precipitates depression
Smoking appears to be due, in part, todeficits in dopamine, serotonin andnorepinephrine, all of which are increasedby antidepressants
Bupropion (slow release= 300mg/d x 7-12wks) nortriptyline
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Recommended steps in a MedicalIntervention
Structured behavioral approach that assistssmokers to quit is more effective than simpleadvice with or without information about risks
Recommended steps (5 As) Address
Assess
Advise
Assist
arrange
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Recommended steps in a MedicalIntervention
Represent a low cost intervention suitablefor incorporation into the routine practiceof health care providers in developing and
developed nations
More effective if tailored to the particularpatients health beliefs and readiness to
change
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Motivational Intervention
Statements of affirmation, encouragementand diplomacy form a large part of theinterview
Encourage patient to express and explore
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Techniques to aid patient recall ofinformation
Make info simple, clear and specific
Avoid technical terms
Speak slowly and clearly
Present advice in set categories Repeat important pcs of info
Stress importance of advice
Simple diagrams or models
Write down the most important instructions
Provide self-help materials
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Techniques to aid patient recallinformation
End of consultation:
Summarize the information
Check the patients understanding
Make sure there are no outstanding questions
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PART 2: Guidelines for medical
educators on how to teachcognitive-behavioral interventions
to help patients stop smoking
Purpose: describes the methods wherebymedical students can be taught the skillsnecessary for effective interventions to
help patients stop smoking
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The materials
Written language module summarizing thehealth risks of smoking and describing theprinciples and methods of cognitive-
behavioral and pharmacologicalinterventions for stopping smoking
Develop a videotape
Papers describing scientific work andvarious programmes in smoking cessation
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The process
Read the learning material
See one or two videotaped examples ofsmoking cessation intervention conductedby a doctor
Course lecturer
Practice the skills required
role play
Barrier assessment
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Thank you!