smoking

283 views
207 views

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
283
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
1
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • Both smoking and apolipoproteins showed a graded relation with the odds of a myocardial infarction, without either a threshold or a plateau in the dose response. In particular, smoking even five cigarettes per day increased risk. This finding suggests that there is no safe level of smoking and that if quitting is not possible, the risk of myocardial infarction associated with smoking could be significantly reduced by a reduction in the numbers smoked.
  • This is from the 40 year follow up of a cohort of British doctors. It illustrates an average loss of life of about 7.5 years and shows that any given age survival rates for smokers are considerably lower. The use of doctors eliminates any social class or income bias.
  • These charts show the impact of quitting smoking on total mortality – the massage is that there are benefits at any age, but these are greater the earlier cessation takes place.
  • Figure 2. Continuous Abstinence Rates The Ns shown in the key are the denominators used for all 3 periods. P<.001 for all comparisons except varenicline vs sustained-release bupropion (bupropion SR) at weeks 9 through 24 (P = .007), varenicline vs bupropion SR at weeks 9 through 52 (P = .057), and bupropion SR vs placebo at weeks 9 through 52 (P = .001). *Abstinence confirmed by measurement of exhaled carbon monoxide. †Clinic and telephone visits: abstinence confirmed by measurement of exhaled carbon monoxide at clinic visits.
  • The basic epidemiology shows that over 500 million are likely to die from smoking related disease world wide in the first half of the 21 st Century.
  • This shows that the effect of ‘prevention’ of uptake makes little difference to the death toll expected in the first half of the 21 st Century. The problem is that the major health benefits of prevention are delayed for many years and prevention activity may simply cause a delay in initiation. Prevention is a worthy ideal, but it has proved difficult to achieve in practice and the evidence base for it is decidely shaky.
  • Smoking cessation can have a bigger impact – though a halving of smoking by 2020 is implausible. Smoking cessation directly treats those most at risk and the is a good evidence base to support it.
  • Ask the patient why quitting is personally relevant. The greatest impact is felt if reasons to quit are relevant to patient's family, social situation, health concerns, age, gender, or other patient characteristics.
  • Ask the patient why quitting is personally relevant. The greatest impact is felt if reasons to quit are relevant to patient's family, social situation, health concerns, age, gender, or other patient characteristics.
  • Ask the patient why quitting is personally relevant. The greatest impact is felt if reasons to quit are relevant to patient's family, social situation, health concerns, age, gender, or other patient characteristics.
  • Ask the patient why quitting is personally relevant. The greatest impact is felt if reasons to quit are relevant to patient's family, social situation, health concerns, age, gender, or other patient characteristics.
  • Ask the patient why quitting is personally relevant. The greatest impact is felt if reasons to quit are relevant to patient's family, social situation, health concerns, age, gender, or other patient characteristics.
  • Ask the patient why quitting is personally relevant. The greatest impact is felt if reasons to quit are relevant to patient's family, social situation, health concerns, age, gender, or other patient characteristics.
  • smoking

    1. 1. Helping your patients quit smoking
    2. 2. • Is smoking that dangerous• Quitting: research to practice• Neurobiology of smoking• What to target – prevention or quitting
    3. 3. • Is smoking that dangerous• Quitting: research to practice• Neurobiology of smoking• What to target – prevention or quitting
    4. 4. INTERHEART: Smoking and MI 16 8OR (99% CI) 4 2 1 Never 1-5 6-10 11-15 16-20 21-25 26-30Cont 31-40 7489 41+ 727 1031 446 1058 96 230168 56Cases 4223 469 1021 623 1832 254 538 459
    5. 5. INTERHEART: Clinical implications • 9 simple and modifiable risk factors are strongly associated with acute MI worldwide. • These 9 risk factors account for >90% of the PAR globally and in most regions. • Abnormal ApoB-ApoA1 ratio and smoking are the 2 most important risk factors and account for over two thirds of the PAR. • Implementing preventive strategies based on our current knowledge would prevent the majority of premature CHD worldwide.PAR = population attributable riskApo = apolipoprotein Yusuf S et al. Lancet. 2004;364:937-52.
    6. 6. Tobacco products areresponsible for threemillion (30 lakh)deaths annually worldwide or about 6% ofall deaths
    7. 7. • Is smoking that dangerous• Quitting: research to practice• Neurobiology of smoking• What to target – prevention or quitting
    8. 8. Overall risk to smokers and never- smokers 100 Never smoked regularly 80 80 Current cigarette smokers 59 % Alive 60 7.5 years 40 33 20 12 0 40 55 70 85 100 AgeDoll et al BMJ
    9. 9. Effects on survival after ages 45, 55, 65 & 75 of stopping smoking in previous decade 100 100 80 80 nonsmokers % Alive % Alive 60 60 40 40 Former smokers Former smokers 20 stopped 35-44 20 stopped 45-54 smokers 0 0 40 55 70 85 100 40 55 70 85 100 Age Age 100 100 80 80 % Alive % Alive 60 60 40 40 Former smokers Former smokers 20 stopped 55-64 20 stopped 65+ 0 0 40 55 70 85 100 40 55 70 85 100 Age AgeDoll et al BMJ
    10. 10. • Is smoking that dangerous• Quitting: research to practice• Neurobiology of smoking• What to target – prevention or quitting
    11. 11. the first exposureto nicotine cancreate anenduring ‘memorytrace,’ whichinstills the desireto repeat theexperience andamplifies thepleasing effects ofsubsequentnicotine exposure
    12. 12. Molecular and Behavioral Aspects of Nicotine AddictionBenowitz N. N Engl J Med 2010;362:2295-2303
    13. 13. International journal of Biochemistry and cell biology 41 (2009)
    14. 14. Continuous Abstinence Rates The Ns shown in the key are the denominators used for all 3 periods. Gonzales, D. et al. JAMA 2006;296:47-55Copyright restrictions may apply.
    15. 15. Varenicline as Compared with PlaceboHays J, Ebbert J. N Engl J Med 2008;359:2018-2024
    16. 16. • Is smoking that dangerous• Quitting: research to practice• Neurobiology of smoking• What to target – prevention or quitting
    17. 17. Scenarios for future deaths from tobaccoCumulative deaths from tobacco (millions) 520 500 Trend 400 300 220 200 100 70 0 1950 1975 2000 2025 2050 YearSource: Peto et al
    18. 18. Cumulative deaths from tobacco (millions) Scenarios: impact of prevention 520 500 500 Trend If smoking uptake halves 400 by 2020 300 220 200 100 70 0 1950 1975 2000 2025 2050 YearSource: Peto et al
    19. 19. Cumulative deaths from tobacco (millions) Scenarios: impact of cessation 520 500 500 Trend If smoking uptake halves 400 by 2020 300 340 220 If adult smoking 200 halves by 2020 190 100 70 0 1950 1975 2000 2025 2050 YearSource: Peto et al
    20. 20. • Any organ that is spared?
    21. 21. Slama et all,1995
    22. 22. 1. JAMA2006 ; 296 : 47-552. Thorax 2000 ; 55: 987-99
    23. 23.  Ask Advice Assess Assist Arrange follow up
    24. 24. ASK• Action : every patient at every clinical visit, status of tobacco use queried and documented
    25. 25. • Vital signs• Mark with a sticker or• Colouring in the book
    26. 26.  Ask Advice Assess Assist Arrange follow up
    27. 27. ADVISE• ACTION: Clear, Strong and personalized manner
    28. 28. CLEAR- It is important that you quit smoking now and I can help you- Cutting down while you are ill is not enough- Occasional or light smoking is still dangerous
    29. 29. STRONGAs your doctor I feel that quitting smoking is the best thing you can do to protect your health. If you are willing we are here to help you out
    30. 30. • PERSONALISEDContinuing smoking worsens your asthma/increases your child ear infection/you will also get stroke like your father
    31. 31. Frequency of physicians advising patients to quit smoking: 21% of the time Thorndike in 1995
    32. 32.  Ask Advice Assess Assist Arrange follow up
    33. 33. ASSESS• Whether he is willing to quit smoking,• How much is he dependant on smoking
    34. 34. How much is he dependant on NICOTINE
    35. 35.  Ask Advice Assess Assist Arrange follow up
    36. 36. Why he wants to QUIT ? “I will feel healthier right way. More energy, better sense of smell, taste, breathe & focus I will be healthier the rest of my life. I will lower my risk for cancer, heart attacks, strokes, earthly death, cataracts & wrinkling. I will make my wife, kids& friends proud of me I will no longer expose others to my smoke I will have more money to spend. I will be proud of myself. I won’t have worry:when & where I will smoke next”
    37. 37. Keep track of when & why he smokes• “Keep a record of every cigarette you smoke.• Do this for the next few weeks• You will know why and when you smoke• You will learn more about your triggers.• These will help you prepare to fight your urge to smoke”
    38. 38. Addressing cues
    39. 39. Psychological obstacles to quitting
    40. 40. 1. Fear of FailureVery common obstacle -no one want to failQuitting can be a very public event -prospect become even more scaryQuitting a process of change no one can quit - unless he really wants to
    41. 41. 2.Concerns about loss of productivity• Nonsmokers tend to perform better than smokers ,both with and without cigarettes in a task that required concentration.• Smokers who were not allowed to smoke may be thinking about cigarettes, which may distract them
    42. 42. 3.Concerns about Stress• Nicotine is helpful in improving mood and decreasing negative feelings during stressful times.• If he smokes for stress reduction, he must make the decision that he will find other ways to cope.
    43. 43. 4.Concerns about Nicotine Withdrawal• The more he exposes his body to nicotine, the more his body needs it and the less it responds to it.• NWS will cause lots of unpleasantness.
    44. 44. Nicotine Withdrawal Syndrome.• Daily use of nicotine for at least several weeks• Abrupt cessation or reduction of nicotine followed within twenty four hours by at least four of the following symptoms -craving for nicotine -irritability ,frustration or anger -anxiety -difficulty concentrating -restlessness -decreased heart rate -increased appetite or weight gain
    45. 45. • Nicotine Withdrawal Syndrome is experienced by one in four heavy smokers and most light smokers experienced no symptoms at all.• NWS peak in intensity during the first twenty four to forty eight hours after he stops using nicotine.
    46. 46. 5.Concerns about his Age• People over sixty-five who were thinking about quitting, two-thirds were not confident that they could succeed• Almost half of the smokers over sixty- five reported that they did not believe quitting would provide them with health benefits, and an almost equal number did not believe that continuing smoking
    47. 47. 6.Concerns about weight gain• Eight in ten who quit will gain weight over a period of two years• The average weight gain as a result of quitting can be four pounds more than would be expected if you continued smoking
    48. 48. • But why people gain weight the reason being people smoke instead of eating
    49. 49. • Attention to his diet and exercising can counteract any tendency to gain weight.
    50. 50. Common excuses 1• My X lived till he was 85 and he smoked
    51. 51. Common excuses 2• All the damage is already done
    52. 52. Within twenty minutes of last cigarette• blood pressure - normal• pulse to normal rate• body temperature of peripheries -increases
    53. 53. Within eight hours• CO in blood drops to normal• O2 in blood increases to normal
    54. 54. Within forty-eight hours• nerve ending start re-growing• abilities to smell and taste things -enhanced
    55. 55. Within seventy- two hours• The bronchial tube relax, making breathing easier.
    56. 56. Within two weeks to three months• circulation improves• walking becomes easier• LFT increases by up to 30 percent
    57. 57. With in a year• coughing• fatigue improves
    58. 58. Long term benefits1 year - CHD5 years - stroke10 years - lung Ca15 years - risk of death
    59. 59. Common excuses 3• A lot of doctors still smoke
    60. 60. Common excuses 4• What about air pollution
    61. 61. Common excuses 5• I’ve switched to a filter cigarette
    62. 62. Quit plan
    63. 63. INSOMNIACONCENTRATE RELAXATION COUGHING DEPRESSION CRAVING CONTROLING THOUGHTSSTRESS
    64. 64. enjoying mealsaround smokers drinking coffee or teahaving a drink • • facing boredomfacing the morning • • insomniatalking on telephone • traveling by car watching TV Bowel movement
    65. 65.  Ask Advice Assess Assist Arrange follow up
    66. 66. Unmotivated patients
    67. 67. Unmotivated patients• Relevance• Risks• Rewards• Roadblocks• Repetition
    68. 68. • Relevance • Encourage the patient• Risks to identify why quitting is personally• Rewards relevant• Roadblocks• Repetition
    69. 69. • Relevance • Acute• Risks • Long term• Rewards • Environmental• Roadblocks• Repetition
    70. 70. • Relevance • Improved health • Improved sense of smell• Risks • Save money •• Rewards • Feel better about yourself Home, car, clothing, and breath• Roadblocks will smell better • Can stop worrying about quitting• Repetition • Set a good example for children • Have healthier babies and children • Eliminate children exposure to smoke • Feel better physically • Perform better in physical activities • Reduced wrinkling/aging of skin
    71. 71. • Relevance• Risks • Withdrawal symptoms • Fear of failure• Rewards • Weight gain• Roadblocks • Lack of support• Repetition • Depression • Enjoyment of tobacco • Partner or room mate smokes
    72. 72. • Relevance• Risks • Repeat the• Rewards motivational• Roadblocks intervention every time the unmotivated• Repetition patient visits the clinic.
    73. 73. All patients should be askedif they use tobacco andshould have their tobaccouse status documented on aregular basis. Evidence hasshown that clinic screeningsystems, such as expandingthe vital signs to includetobacco use status or the useof other reminder systemssuch as chart stickerssignificantly increase rates ofclinician intervention
    74. 74. Tobaccodependencetreatment iseffective andshould bedelivered even ifspecializedassessments arenot used oravailable
    75. 75. All physicians shouldstrongly advise everypatient who smokes toquit because evidenceshows that physicianadvice to quit smokingincreases abstinencerates.The time for intervention is3-5 mins.
    76. 76. The combination ofcounseling and medicationis more effective forsmoking cessation thaneither medication orcounseling alone.Therefore, wheneverfeasible and appropriate,both counseling andmedication should beprovided to patients tryingto quit smoking.
    77. 77. Bupropion SR Nicotinegum are effectivesmoking cessationtreatment thatpatients should beencouraged to use.
    78. 78. Clinicians shouldencourage all patientsattempting to quit touse effectivemedications fortobacco dependencetreatment, exceptwhere contraindicatedor for specificpopulations for whichthere is insufficientevidence ofeffectiveness
    79. 79. TOGETHER WE CAN ACCOMPLISH GREAT THINGS
    80. 80. THANK YOUFOR YOURPATIENTLISTENINGmajorgowri@gmail.com

    ×