6. 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 risk
Apo = apolipoprotein Yusuf S et al. Lancet. 2004;364:937-52.
9. • Is smoking that dangerous
• Quitting: research to practice
• Neurobiology of smoking
• What to target – prevention or
quitting
10. 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
Age
Doll et al BMJ
11. 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 Age
Doll et al BMJ
12. • Is smoking that dangerous
• Quitting: research to practice
• Neurobiology of smoking
• What to target – prevention or
quitting
13.
14. the first exposure
to nicotine can
create an
enduring ‘memory
trace,’ which
instills the desire
to repeat the
experience and
amplifies the
pleasing effects of
subsequent
nicotine exposure
15. Molecular and Behavioral Aspects of Nicotine Addiction
Benowitz N. N Engl J Med 2010;362:2295-2303
22. Continuous Abstinence Rates The Ns shown in the key are the denominators used for all 3
periods.
Gonzales, D. et al. JAMA 2006;296:47-55
Copyright restrictions may apply.
24. • Is smoking that dangerous
• Quitting: research to practice
• Neurobiology of smoking
• What to target – prevention or
quitting
25. Scenarios for future deaths from
tobacco
Cumulative deaths from tobacco (millions)
520
500
Trend
400
300
220
200
100 70
0
1950 1975 2000 2025 2050
Year
Source: Peto et al
26. 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
Year
Source: Peto et al
27. 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
Year
Source: Peto et al
37. 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
38. STRONG
As 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
46. 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”
47.
48. 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”
51. 1. Fear of Failure
Very common obstacle
-no one want to fail
Quitting can be a very public event
-prospect become even more
scary
Quitting a process of change
no one can quit - unless he really
wants to
52. 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
53. 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.
54. 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.
55. 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
56. • 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.
57. 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
58. 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
59. • But why people gain weight
the reason being people
smoke instead of eating
60. • Attention to his diet and exercising
can counteract any tendency to
gain weight.
79. enjoying meals
around smokers
drinking coffee or tea
having a drink •
• facing boredom
facing the morning •
• insomnia
talking on telephone •
traveling by car
watching TV
Bowel movement
83. • Relevance • Encourage the patient
• Risks to identify why
quitting is personally
• Rewards
relevant
• Roadblocks
• Repetition
84. • Relevance • Acute
• Risks • Long term
• Rewards • Environmental
• Roadblocks
• Repetition
85. • 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
86. • Relevance
• Risks • Withdrawal symptoms
• Fear of failure
• Rewards
• Weight gain
• Roadblocks • Lack of support
• Repetition • Depression
• Enjoyment of tobacco
• Partner or room mate
smokes
87. • Relevance
• Risks • Repeat the
• Rewards motivational
• Roadblocks intervention every
time the unmotivated
• Repetition patient visits the
clinic.
88.
89.
90. All patients should be asked
if they use tobacco and
should have their tobacco
use status documented on a
regular basis. Evidence has
shown that clinic screening
systems, such as expanding
the vital signs to include
tobacco use status or the use
of other reminder systems
such as chart stickers
significantly increase rates of
clinician intervention
92. All physicians should
strongly advise every
patient who smokes to
quit because evidence
shows that physician
advice to quit smoking
increases abstinence
rates.
The time for intervention is
3-5 mins.
93. The combination of
counseling and medication
is more effective for
smoking cessation than
either medication or
counseling alone.
Therefore, whenever
feasible and appropriate,
both counseling and
medication should be
provided to patients trying
to quit smoking.
94. Bupropion SR Nicotine
gum are effective
smoking cessation
treatment that
patients should be
encouraged to use.
95. Clinicians should
encourage all patients
attempting to quit to
use effective
medications for
tobacco dependence
treatment, except
where contraindicated
or for specific
populations for which
there is insufficient
evidence of
effectiveness
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.