SMOKING CESSATION

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• SMOKING CESSATION

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Learning Objectives

• Understand the hazards of smoking
• Recognize the health benefits of smoking
  cessation
• Describe the rationale for treating tobacco
  dependence
• Explain why tobacco dependence is a chronic
  disease
• Initiate clinical interventions for tobacco users
  who are willing to quit as well as users who are
  not willing to make a quit attempt
• Assist users attempting to quit with strategies
  designed to prevent relapse

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The smoking epidemic

• 1 billion smokers
• Smoking represents the most readily preventable
  risk factor for morbidity and mortality.
• 5 million people die every year because of
  smoking related illnesses.
• By 2030, if current trends continue, smoking will
  kill one in 6 people.
• ( world health organization. 2008.

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The smoking epidemic

• 75 of smokers want to quit
• lt2 of smokers quit each year

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The smoking epidemic

• Effective government policy
• Bans on tobacco advertising and sponsorship
• Regular price rises
• Stronger public health warning labels
• Smoking bans in all public places

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Prevalence of Smoking in Saudi Arabia

• 2.4-52.3 (median 17.5)
• School students 12-29.8 (median 16.5),
• University students 2.4-37 (median 13.5),
• Adults 11.6-52.3 (median 22.6).
• Elderly people 25.
• Males 13-38 (median 26.5)
• Females 1-16 (median 9).

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Prevalence of Smoking in Saudi Arabia

• 17 of primary health care physicians in Riyadh
  city were current smokers, 20 ex-smoker.
• Al- shahri M, Al Almaie S. promotion of
  non-smoking The role of primary health care
  physicians. Ann Saudi Med 199717515-17

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Smoking Health Risks

• Short-term
• Shortness of breath
• Worsening asthma or bronchitis
• Increased risk of respiratory infection
• Harm to pregnancy
• Impotence
• Infertility

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Smoking Health Risks

• Long-term
• Heart attack and stroke
• Lung and other cancers
• Chronic obstructive pulmonary disease (COPD)
• Osteoporosis
• Disability (chronic bronchitis and emphysema)
• Need for extended care

• larynx
• oral cavity
• pharynx
• esophagus
• pancreas
• stomach
• kidney
• bladder
• cervix
• acute myelocytic leukemia

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Tobacco-based products

• Cigarettes
• pipes
• cigars
• hookahs ((shisha/ narghile/ argileh/ hubble
  bubble and goza))
• chewing tobacco etc.

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Why do people continue to smoke?

• Addiction to nicotine
• Perceived benefits (relaxation, stress relief,
  weight loss)
• Social context
• Mental health issues

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Smoking Cessation Barriers

• Withdrawal symptoms
• Fear of failure
• Weight gain
• Lack of support
• Depression
• Enjoyment of tobacco
• Being around other users
• Limited knowledge of effective treatment options

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Physician Barriers to Helping Patients Stop
Smoking

• Time constraints of practice
• Lack of office systems
• Low expectation of success
• Lack of knowledge of what to do
• Reimbursement issues
• Frustration with smokers

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Smoke vs. Quit

• Common Reasons not to Quit

• Common Reasons to Quit

• Family and friends smoke
• Withdrawal symptoms
• Inability to cope with stress
• Connection with smoking
• Previous unsuccessful attempts to quit

• Encouragement from family and friends
• Health improvements
• To save money
• Pregnancy
• Smoke-free environment policies
• Desire to be a role model
• Medical treatment that requires abstinence

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• Tobacco Dependence as a chronic disease

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What is a cigarette?

• Delivers nicotine to the lungs and brain within 7
  sec each time a smoker inhales
• Frequent, small-dose stimulation makes smoking
  highly addictive
• Most cigarettes contain 10 mg of nicotine
• Average smoker absorbs 1-2 mg of nicotine per
  cigarette
• Cigarettes release carbon monoxide which adheres
  to red blood cells faster than oxygen
• Reduced oxygen in the body causes increased heart
  rate

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Whats in a Cigarette?

• 4000 chemicals many of which are highly toxic.
• 40 known cancer-causing substances.
• Tobacco
• Carbon monoxide
• Hydrogen cyanide
• Nitrogen oxide
• Ammonia (sub-micron sized particles)
• Nicotine, phenol, polyaromatic hydrocarbons,
  tobacco specific nitrosamines.
• Tar total particulate matter (nicotine and water)
• Filter with titanium oxide accelerant
• Flavours
• Liquid vapour
• Benzene
• Formaldehyde
• Acrolein
• N-nitrosamines
• Non-particulate matter

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What is Nicotine Dependence?

• Chronic Nicotine consumption with the following
  characteristics
• Substance abuse
• Continues self-administer substance despite
  perceived negative effects
• High tolerance towards the substance
• Manifests withdrawal symptoms when trying to stop
  use

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Effects of Nicotine

• Highly toxic drug
• Increase HR, BP
• Decrease body temp
• Slows circulation
• Affects appetite
• Increase BMR
• changes brain activity - improving reaction
  times, ability to pay attention and brings on
  euphoria Addiction
• Increases dopamine levels Creates a
  feeling of pleasure

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The addiction pathways
Reward pathway(mesolimbic dopamine system)
Withdrawal pathway(locus coeruleus)
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Reward Pathway

• Mesolimbic dopamine system has been characterized
  as a reward "pathway
• Nicotine produces a dopamine surge in the nucleus
  accumbens
• Smoking cessation is followed by pathophysiologic
  withdrawal and craving

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Withdrawal

• Chronic drug use affects brainstem structures
• (locus ceruleus)
• Noradrenergic cells become more excitable
• When a person abstains, the firing rates become
  abnormally high a possible basis of withdrawal
  symptoms

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Nicotine withdrawal syndrome

• acute/uncontrollable need to smoke (craving)
• irritability
• restlessness, anger, anxiety feelings
• tiredness
• increased appetite, especially for sweets and
  resultant weight gain
• trouble to concentrate and focus memory
• depression
• headaches
• insomnia
  
• dizziness

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Benefits of Quitting

• blood pressure and pulse rate return to normal
• blood nicotine CO halved, oxygen back to normal
• CO eliminated lungs start to clear mucus etc.
• nicotine eliminated senses of taste smell much
  improved.
• breathing easier bronchial tubes begin to relax
  energy levels increase

• 20 mins
• 8 hours
• 24 hours
• 48 hours
• 72 hours

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Benefits of Quitting

• circulation improves
• lung function increased by lt10 coughs, wheezing
  decrease
• risk of heart attack halved
• risk of lung cancer halved compared to continued
  smoking
• risk of heart attack equal to never-smokers

• 2-12 weeks
• 3-9 months
• 5 years
• 10 years

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Quitting- other benefits

• Improved health and physical performance
• Improved taste of food and sense of smell
• Better appearance, including reduced
  wrinkling/aging of skin and whiter teeth
• Healthier families, babies and children
• A good example for children and others
• More money in your pocket

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Treatment of Nicotine Addiction

• Combination of counseling and pharmacotherapy is
  more effective than either option alone
• The more intense the intervention, the better the
  outcome of abstinence

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Pharmacologic Options

• Clients/patients attempting to quit smoking
  should always be encouraged to use effective
  medications unless they are contraindicated in
  specific populations
• eg. pregnant women, smokeless tobacco users,
  light smokers, adolescents (Fiore, et al)
• Two categories of pharmaceutical options
• Nicotine replacement therapy (NRT)
• Non-nicotine replacement therapy

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Nicotine Replacement Therapy (NRT)

• Nicotine Patch
• Nicotine Lozenges
• Nicotine Gum
• Nicotine Inhalers
• Provide nicotine to reduce withdrawal symptoms
• Take between 1-4 hours to reach maximum blood
  levels (unlike cigarettes, 7 seconds)
• Do not cause sudden boost to nicotine blood
  levels (prevents addiction to product)
• Dose depends on habits of the smoker but is
  reduced over a 12 week period

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Non-nicotine Therapy

• Bupropion Hydrochloride (Zyban)
• Also marketed as the anti-depressant medication
  Wellbutrin
• Presumed to alleviate cravings associated with
  nicotine withdrawal affecting noradrenaline and
  dopamine
• Varenicline Tartrate (Champix)
• Targets nicotinic acetylcholine receptors to
  decrease cravings and withdrawal
• Clonidine Nortriptyline
• Second-line medications used in smoking cessation
• All of these medications require a prescription

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Counselling

• Intensive intervention that last a minimum of 10
  minutes
• Commonly conducted by nurses in various
  health-care settings
• Motivational Interviewing
• Directive and client-centred standard counselling
  techniques
• Stages of Change theory

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Other options of treatment

• Hypnosis
• Herbal remedies
• Acupuncture
• Laser treatment
• No clinical evidence to verify results from
  these treatments
• Some clients/patients report that they are
  beneficial (Fiore, et al., 2008)

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Protection Second-hand smoke

• Second-hand smoke
• Also known as environmental tobacco smoke
• Combination of
• Side stream smoke (smoke from the end of a
  cigarette)
• Smoke exhaled by the smoker
• 67 of smoke from a burning cigarette is not
  inhaled by the smoker and ends up in the
  surrounding environment

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Second-hand smoke (cont.)

• 4000 chemicals have been identified in
  second-hand smoke
• 50 of these are known carcinogens
• (United States Environmental Protection Agency,
  2000)
• Examples
• - Arsenic compounds
• - Benzene
• - Chromium compounds
• - Ethylene oxide (chemical to sterilize medical
  devices)
• - Vinyl Chloride (chemical used in plastics
  manufacture)
• - Polonium 210 (radioactive species)

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Second-hand smoke (cont.)

• Labeled as a known human carcinogen
• Labeled as a class A cancer-causing substance
  (Class A most dangerous)

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Model for treatment of tobacco use and
dependence
General Population
Patient presents to healthcare setting
Relapse
Yes, willing
Current users
ASK screen all patients for tobacco use
ADVISE to quit
ASSESS willingness to quit
ASSIST with quitting
ARRANGE a follow-up
No, unwilling
Non users
Abstinent
Promote motivation to quit
Patient now willing to quit
Primary prevention
Prevent relapse
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Where to begin?

• ASK- about smoking understand your patient
• ASSESS - what is the next step?
• ADVISE - why cessation is important
• ASSIST - offer to help
• ARRANGE- follow-up process

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The 5 As apply to

• Those who
• are willing to quit,
• arent willing to quit, and
• recently quit.

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Smoking Cessation Treatment

• Smoking Cessation Treatment for Those Willing to
  Quit

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Smoking Cessation Treatment for Those Willing to
Quit

• ASK Identify and document tobacco use status of
  every patient at every visit.
• Example When recording vital signs, include an
  area to note tobacco use.

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Smoking Cessation Treatment for Those Willing to
Quit

• ADVISE In a clear, strong, and personalized
  manner advise every tobacco smoker to quit.

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Smoking Cessation Treatment for Those Willing to
Quit

• Advise examples
• Clear I think its important for you to
  quit smoking now, and I can help you.
• Strong As your clinician, I need you to
  know that quitting smoking now is the most
  important thing you can do to protect your
  health.
• Personalized Continuing to smoke makes your
  asthma worse.

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Smoking Cessation Treatment for Those Willing to
Quit

• ASSESS
• Is the user willing to make a quit attempt at
  this time?
• Provide assistance to dependence treatments.
• Provide an intervention shown to increase future
  quit attempts, such as nicotine gum, quit lines
  and behavioral counseling.

YES
NO
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Smoking Cessation Treatment for Those Willing to
Quit

• ASSIST
• Offer medication. Provide or refer for
  counseling or additional behavioral treatment.
• Medication examples
• Nicotine lozenge
• Varenicline

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Smoking Cessation Treatment for Those Willing to
Quit

• ASSIST
• Behavioral treatment examples
• Recommend a quit plan, such as STAR.
• Set a quit date.
• Tell family, friends and coworkers.
• Anticipate challenges.
• Remove tobacco products.

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Smoking Cessation Treatment for Those Willing to
Quit

• ARRANGE
• Arrange for follow-up soon after quit date, a
  second follow-up within the first month and
  others as needed.
• Identify problems and anticipate challenges.
• Remind patients of available sources, such as
  quit lines.
• Provide encouragement.

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Smoking Cessation Treatment

• Smoking Cessation Treatment for Those NOT Willing
  to Quit

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Smoking Cessation Treatment for Those NOT Willing
to Quit

• ASK, ADVISE ASSESS
• Use the same 5As for users unwilling to quit
  as those willing to quit.

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Smoking Cessation Treatment for Those NOT Willing
to Quit

• ASSIST
• Provide motivational interventions designed
  to increase future quit attempts.

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Smoking Cessation Treatment for Those NOT Willing
to Quit

• ASSIST Motivational examples
• The 5 Rs
• Relevance
• Identify why it is personally relevant to get
  the patient to quit.
• Risks
• Ask the patient to identify negative
  consequences of smoking.
• Rewards
• Ask the patient to identify the benefits of
  stopping.
• Roadblocks
• Identify the patients barriers to success and
  how to approach them.
• Repetition
• Repeat motivational interventions.

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Smoking Cessation Treatment for Those NOT Willing
to Quit

• ASSIST
• Motivational examples Express empathy
• Use open-ended questions. How
  important do you think it is for you to quit?
• Use reflective listening. So you think
  smoking helps you maintain your weight.
• Normalize patients feelings. Many
  people worry about managing without cigarettes.
• Support their right to choose. Im here to
  help you when you are ready. t to choose.

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Smoking Cessation Treatment for Those NOT Willing
to Quit

• ASSIST
• Motivational examples Develop discrepancy
• Highlight the discrepancy between the patients
  smoking versus the patients stated values.
  Youre devoted to your family. How do you
  think your smoking affects them?
• Reinforce change talk. So, you realize
  how smoking is making it hard to keep up with
  your kids.
• Deepen the commitment to change. We
  would like to help you avoid a stroke like the
  one your father had.

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Smoking Cessation Treatment for Those NOT Willing
to Quit

• ASSIST
• Motivational examples Roll with resistance
• Back off and use reflection. Sounds
  like youre feeling pressured about your tobacco
  use.
• Express empathy. I understand its
  hard to quit.
• Ask permission to provide information.
  Would you like to hear about some strategies
  that can help you quit?

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Smoking Cessation Treatment for Those NOT Willing
to Quit

• ASSIST
• Motivational examples Support self-efficacy
• Help patients build on past successes. You
  were fairly successful last time you tried to
  quit.
• Offer options for small, achievable steps toward
  change. Can you try smoking one less
  cigarette a day? A quit line can help you.

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Smoking Cessation Treatment for Those NOT Willing
to Quit

• ARRANGE
• More than one motivational intervention may be
  needed.
• Provide follow-up at the next visit.
• Offer additional interventions to motivate and
  support.

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Smoking Cessation Treatment

• Treatment for Those Who Recently Quit

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Treatment for Those Who Recently Quit

• ASK
• Determine if the smoker is still smoke-free.
  then,
• ASSESS
• relapse potential.

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Treatment for Those Who Recently Quit

• ASSESS
• Most relapses occur within the first two weeks,
  but the risk can persist for a long time
  therefore,
• Identify and address challenges, including
• lack of support for cessation,
• negative mood or depression,
• strong or prolonged withdrawal symptoms,
• weight gain and
• smoking lapses.

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Treatment for Those Who Recently Quit

• ASSIST
• Provide encouragement and relapse prevention
  to address the challenges of staying smoke-free.
• Challenge example
• Lack of support
• Depression
• Prevention response
• Schedule follow-ups, urge use of quit lines,
  identify source of support
• Counsel or refer to counseling/support groups

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Smoking is a Complex Phenomenon
Social
Psychological
Spiritual
Bio- physiological
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Physical and Psychological

• When down, smoking energizes
• When anxious, smoking calms
• Smoking focuses attention and conveys a sense of
  well-being, every time

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Psychological/Behavioural

• Conditioning occurs over many years after
  exposure to things in the environment which
  stimulate the smoker to want a cigarette
• People learn to manage their emotions with
  tobacco
• Patterns of behaviour are very difficult to
  change

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Physical and Emotional

• Pleasure, arousal, relaxation and the relief of
  tension and anxiety are therapeutic effects of
  nicotine
• Smoking also treats effects of withdrawal
  
• All of these effects are biological and molecular

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Emotional, Social Spiritual

• A comforting completion of pleasurable rituals
  friends, drinks, sex, meals and breaks
• A close, comforting friend that has always been
  there
• A way to cement certain social relationships and
  repel unwanted ones
• Part of identity and sense of self

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Bio-physiologic

• Nicotine is an addictive substance. The chemical
  effects of nicotine are strongly related to the
  conditioning that occurs in many smokers. It is
  this link between stimulation/triggers in the
  environment and the immediate chemical,
  pleasurable effect on the body that often makes
  stopping smoking so difficult

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Stages of Change

• PRECOMTEMPLATION
• Unaware or unwilling to change
• CONTEMPLATION
• Ambivalent, but thinking about changing
• PREPARATION
• Decided to change and taking steps
• ACTION
• Started to do things differently
• MAINTENANCE
• Changed for sometime and integrating the change
  into their routine
• 
  Prochaska and DiClemente

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Contemplation Thinking of quitting in the next
six months
Precontemplation Not thinking of quitting in the
next six months
Preparation Planning to quit in the next month
Relapse
Maintenance Quit for more than six months
Action Quit in the last six months
2
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Myths you may encounter as you work with your
patients to help them stop smoking

• Myth 1 Smoking is just a bad habit.
• Fact Tobacco use is an addiction. According to
  the U.S. Public Health Service
• Clinical Practice Guideline, Treating
  Tobacco Use and Dependence, nicotine is a very
  addictive drug. For some people, it can be as
  addictive as heroin or cocaine.
• Myth 2 Quitting is just a matter of willpower.
• Fact Because smoking is an addiction, quitting
  is often very difficult. A number of treatments
  are available that can help.
• Myth 3 If you cant quit the first time you try,
  you will never be able to quit.
• Fact Quitting is hard. Usually people make two
  or three tries, or more, before being able to
  quit for good.

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Myths you may encounter as you work with your
patients to help them stop smoking

• Myth 4 The best way to quit is cold turkey.
• Fact The most effective way to quit smoking is
  by using a combination of counseling and nicotine
  replacement therapy (such as the nicotine patch,
  inhaler, gum, or nasal spray) or non-nicotine
  medicines (such as bupropion SR).
• Myth 5 Quitting is expensive.
• Fact Treatments cost from 3 to 10 a day. A
  pack-a-day smoker spends almost 1,000 per year.
  Check with your health insurance plan to find out
  if smoking. cessation medications and/or
  counseling are covered.
• Source http//www.surgeongeneral.gov/tobacco