Smoking Cessation

Dr Kumar Gaurav SharmaMD, PGDCC

Cardiologist Prime Hospitals

Hyderabad

Cigarette smoking is the single most important cause of disease and premature death in

INDIA

Cigarette smoking is the single most important cause of disease and premature death in

INDIA

Health Effects of Smoking• Heart disease• Lung disease – COPD, asthma• Cancer– Lung, ENT, pancreas– Cervix, colorectal– Skin (squamous cell)

• Vascular disease - impotence• Stroke• Cataracts• Gum disease• Dementia• Early menopause

• Osteoporosis• Wound healing• Anxiety• Miscarriage• SIDS• Hearing loss• Rheumatoid arthritis• Macular degeneration• Tooth decay• Depression• Multiple sclerosis

Smoking in INDIA.Smoking in INDIA.

25% of adults 1/3 are women rate hasn’t dropped in 1990’s 1.3 million quit each year 3,000 teens start each day

adolescent smoking increasing more ex-smokers than current smokers

Involuntary smoking is a cause of disease in

non-smokers

Involuntary smoking is a cause of disease in

non-smokers

Smoking kills more people each year than

alcohol cocaine crack heroin

homicide suicide car accidents fires AIDS

C O M B I N ED!!!

What’s in a cigarette?

• 4,000 chemicals• tar• carbon monoxide• nicotine

The benefits of quitting

8 hours

Nicotine and carbon monoxide levels halved,Blood oxygen levels return to normal

Within hours.......

24 hours Carbon monoxide eliminated from the body

48 hoursNicotine eliminated from the body,Taste buds start to recover

Within months .......

3-9 months Coughing and wheezing decline

1 monthAppearance improves – skin loses greyish pallor, less wrinkled Regeneration of respiratory cilia startsWithdrawal symptoms have stopped

5 years The excess risk of a heart attack reduces by half

10 years The risk of lung cancer halved

Years .......

The cycle of change

Cycle of change

Pre-contemplation

Contemplation

Determination

Action

Maintenance

Relapse

Have you considered quitting?

Do you smoke?

The cycle of change

Be a positive partnerFocus on the positive health effects of cessation

Not yet considered quitting

• Explain importance of cessation• Offer help as and when they want it.

Pre-contemplation

Pre-contemplation

Contemplation

Ambivalent to cessation

• Move them closer to a cessation attempt• Understand how you can help

Be a positive partnerLet them describe their doubts – and fear of failingIdentify how to plan a quit attemptOffer the ongoing medical support

The cycle of change

Pre-contemplation

Contemplation

Determination

Be supportive and enthusiastic!Give time to planning the attemptSet a quit dateDiscuss problems of withdrawal

Ready to make a cessation attempt

• Provide support for a quit attempt

Pre-contemplation

Contemplation

Determination

Action

Congratulate!Arrange review (even if relapse)

Action! a cessation attempt

• Be available to support the quit attempt

Pre-contemplation

Contemplation

Determination

Action

Maintenance

Be positive!Support over timeEmphasise health benefits

Maintain!

• Maintain smoke-free

Pre-contemplation

Contemplation

Determination

Action

Maintenance

Relapse

Cycle of change

Smokers may move backwards or forwards, to and fro across the cycle many times before finally quitting

The 5 ‘A’s

Ask

Assess

Advise

Assist

ArrangeA AAAAA

ASK about smoking status

ASSESS motivation and nicotine dependence

ADVISE on coping strategies

ARRANGE follow up

ASSIST the quit attempt

The 5 ‘A’s

World Health Organization. The Tobacco Atlas. http://www.who.int/tobacco/statistics/tobacco_atlas/en

Nicotine withdrawal: Duration

1 week Sleep disturbance

2 weeksPoor concentrationCraving for nicotine

4 weeksIrritability or aggressionDepressionRestlessness

2 days Lightheadedness

10 weeks Increased appetite

Nicotine withdrawal: the 4 ‘D’s

Delay acting on the urge to smoke

Drink water slowly

Deep breathe.

Do something else (eg exercise)

Nicotine replacement

• Begin NRT on the quit date, (apply patches the night before)

• Use a dose that controls the withdrawal symptoms

• NRT provides levels of nicotine well below smoking

• Prescribe in blocks of two weeks

• Arrange follow up to provide support

• Use a full dose for 6 to 8 weeks then stop

or reduce the dose gradually over 4 weeks.

NRT increases the odds of quitting about 1.5 to 2 fold

PharmacotherapyPharmacotherapy + behavioural counselling improves long-term quit rates

Smokers of 10 or more cigarettes a day who are ready to stop should be encouraged to use pharmacologial support as a cessation aid

Nicotine replacement

• Begin NRT on the quit date, (apply patches the night before)

• Use a dose that controls the withdrawal symptoms

• NRT provides levels of nicotine well below smoking

• Prescribe in blocks of two weeks

• Arrange follow up to provide support

• Use a full dose for 6 to 8 weeks then stop

or reduce the dose gradually over 4 weeks.

NRT: Nicotine patches

• Patches provide a slow, consistent release of nicotine throughout the day• Available in various shapes and sizes,• Common side effects with patches include skin sensitivity and irritation

NRT: Nicotine nasal sp

• Nasal sprays more closely mimic nicotine from cigarettes• Common side effects with nasal sprays include nasal and throat irritation,

coughing and oral burning

NRT: Nicotine gum

• Instruct the patient to ‘chew and park’• Absorption may be impaired by coffee and some acidic drinks • Common side effects with gum include gastrointestinal disturbances and jaw pain• Dentures may be a problem!

Nicotine Tabs• Nicotine tablets deliver 2-mg or 4-mg dosages of nicotine over 30-minutes• Common side effects with gum include burning sensations in the mouth, sore throat,

coughing, dry lips, and mouth ulcers

Bupropion• Begin bupropion a week before the quit date

• Normal dose 150mg bd, (reduce in elderly, liver/renal disease)

• Contra-indicated in patients with epilepsy, anorexia nervosa, bulimia, bipolar disorder or severe liver disease.

• The most common side effects are insomnia (up to 30%), dry mouth (10-15%), headache (10%), nausea (10%), constipation (10%), and agitation (5-10%)

• Interaction with antidepressants, antipsychotics and anti-arrhythmics

Nortryptiline

• Tri-cyclic antidepressant

• Not licensed for smoking cessation

• Low cost

• Side-effects include sedation, dry mouth, light-headedness, cardiac arrhythmia

• Contra-indicated after recent myocardial infarction

Varenicline

• Begin varenicline a week before the quit date, increasing dose gradually.

• Alleviates withdrawal symptoms, reduces urge to smoke

• Common side effects include: nausea (30%), insomnia, (14%), abnormal dreams (13%), headache (13%), constipation (9%), gas (6%) and vomiting (5%).

• Contra-indicated in pregnancy

• New drug

Nicotine replacement and buproprion should always be used in conjunction with behavior modification

Aspects of Addiction• Physical• Psychological• Behavioral

• MENTAL HEALTH

• Psychotic disorders are associated with three times the risk being a heavy smokers (35% vs 9%)

• Smoking may alleviate symptoms of psychosis

• Smoking and depression are related

• The antidepressants, bupropion and nortriptyline are effective in assisting smoking cessation

• Bupropion interacts with other antidepressants

People with mental health problems are more likely to smoke than those without mental illness

Behavior modification

review reasons for quitting (index card) identify triggers (4 day diary) plans to avoid or cope with each trigger change habit: packs only, different brands develop support system (tell everyone) self rewards (day, week, month, year) written commitment to quit day

Conclusions

• We haven’t started winning the war• All smoking patients should be counseled• Always use pharmacological interventions• Be public health advocates