This document discusses smoking cessation and tobacco use. It begins with a brief history of tobacco use and cultivation. It then covers nicotine addiction including the mechanisms of action of nicotine in the brain and body. Withdrawal symptoms and reasons for smoking are explored. The 5 A's model of smoking cessation counseling is described involving asking about smoking history, advising smokers to quit, assessing readiness, assisting with a plan, and arranging follow up. Non-pharmacological and pharmacological cessation methods are summarized.

1. SMOKING CESSATION
Dr Kamal Bharathi. S
Department of Pulmonary Medicine
Sri Manakula Vinayagar Medical college and Hospital

2. Tobacco
• The plant is part of the
genus Nicotiana and of
the Solanaceae family.
While more than 70 species of
tobacco are known, the chief
commercial crop is N.
tabacum.
• Nicotiana tabacum is a native
of tropical and sub-
tropical America but it is now
commercially cultivated world
wide.

3. Mayans usage of tobacco
• The phrase "y-otoot 'u-may,"
written on the vessel, translates
as 'the house of his/her tobacco.
• Used as:
a. Making powerful alcohol drink
b. Making bug and snake repellent
c. Snort and snuff
• Proved with Mass Spectroscopy
the traces of nicotine.

4. History of tobacco
• First smoked all over the Americas by Red
Indians in shamanistic rituals.
• The pipe was called Peace pipe.
• In 1492 Christopher Columbus arrived at
‘San Salvador’ where the natives thought
that he and his men were divine beings
sent by the Gods.
• They presented Columbus with gifts
including wooden spears, wild fruits and
dried leaves.
• He did not smoke; indeed he threw the
leaves away!!

6. • Rodrigo de Jerez was one of
the Spanish crewmen who sailed
with Columbus.
• He is credited with being the first
European smoker. Jerez picked up
the tobacco smoking habit to Spain.
• Later he was arrested and spent 7
years in prison.
• Smoking tobacco had caught on.

8. Tobacco Invasion in India
Cannabis
smoking in
India has
been known
since at least
2000 BC and
is first
mentioned in
the
Atharvaveda,
which dates
back a few
hundred
years BC.
During
Mughal rule,
Hookah
smoking was
popular
among local
people. Men
of the same
caste or sub-
caste
gathered
around in the
evenings to
share a
common
hookah.
The
cultivation
of tobacco
started in
southern
Gujarat in
the late
17th
century after
the British
colonized.
Because the
hookah was
tedious to
carry around,
a cheaper
and portable
form of the
hookah was
developed,
called the
chillum.
Bidis were
developed
soon after.
During the
severe
drought of
1899 in
Gujarat,
which
compelled
many
families to
migrate in
search of a
livelihood,
that the bidi
became a
small-scale
industry.
The father of
the modern
bidi and the
industry is
possibly
Mohanlal
Patel of
Gomtipur
District,
Ahmedabad,

9. Tobacco Invasion in India
• It’s mentioned that, tobacco had been cultivated in
Andhra Pradesh during the region of Krishna
Deva Raya.
• The cultivation of the tobacco dates back to 17th
century when it started in Gujarat. A few soon
later, some bidi rollers of this region had settled
down into the parts of the country
• During drought it became as a small-scale
industry.
• Because of the rapid expansion of the railway
network between in 1912 to 1918, the bidis were
also spread out to all parts of the country.
• Now, India is the world’s 2nd largest producer of
tobacco with an estimated annual production of
800 million kgs. And Andhra Pradesh is the
largest producer of tobacco in India.

11. Theintegrated approach to successful
smoking cessation
Professional
involvement
Behavioural
support
Pharmaco
therapy

12. Is smoking a life style choice?
• Smoking a cigarette for a beginner is a symbolic
act of rebellion
• Smoking is not a life style choice
– Creates a dependent state
– Nicotine addiction is a complex process
– Quitting smoking leads to decrements in attention
and cognition
– Impaired concentration, thinking, and performance
associated with nicotine deprivation are strong
motivating factors to smoke

13. Nicotine actions
Nico
tine
• Nicotine
• Binds to nicotinic acetylcholine receptors on the chromaffin cells in the adrenal
• medulla
• Opening of Na+ ion channel
• Influx of sodium
• Depolarization of the cell
• Activation of voltage-gated calcium channels
• Calcium triggers the release of Epinephrine from intracellular vesicles into the
• bloodstream
• Vasoconstriction, increased blood pressure, increased heart rate, and increased
• blood sugar

14. Mechanism of Action of Nicotine in the Central
Nervous System
• Nicotine binds preferentially to nicotinic acetylcholinergic (nACh) receptors in the central
nervous system; the primary is the 42 nicotinic receptor in the Ventral Tegmental Area
(VTA)
• After nicotine binds to the 42 nicotinic receptor in the VTA, it results in a release of
dopamine in the Nucleus Accumbens (nAcc) which is believed to be linked to reward

2 2
4 2 4
42
Nicotinic
Receptor

15. Why do Smokers smoke?
Non-Physiological Reasons
• Peer pressure
• Mass media
• Pleasure and relaxation
• Nature of work
• Improved thinking and
performance
• Relief from negative moods
(anxiety, stress, anger,
irritability and depressed
mood)
• Weight control
Physiological Reasons
• Physical dependence on
nicotine
• Relief from withdrawal
symptoms

16. Nicotine Dependence
• Tobacco smoke
• Nicotine
• Binds to nicotinic acetylcholine receptors on dopaminergic neurons in the cortico-limbic
pathways
• Opening of sodium, calcium, and potassium channels
• Depolarization
• Activation of voltage-gated calcium channels
• More calcium to enter the axon terminal
• Release of Dopamine into the synapse
• Euphoric and addictive properties of nicotine

17. Effects of Nicotine Withdrawal
When nicotine levels drop, most smokers report
physiological withdrawal symptoms such as :
• Anxiety
• Irritability
• Restlessness
• Difficulty in concentrating
• GI disturbance
• Craving
• Drowsiness

18. SMOKING CESSATION
• 5As (Ask ,Advise, Assess, Assist ,Arrange for
follow up)
• 5 Stages of change (Precontemplation ,
Contemplation ,Determination , Action,
Maintenance)
• 5 Rs (Relevance, Risks, Rewards, Roadblocks,
Repetition)

19. 5 A
1. Ask about smoking .
2. Advise every smoker to stop smoking .
3. Assess readiness to quit .
4. Assist the smoker in stopping smoking .
5. Arrange for follow up and monitor the
progress of the smoker

20. “1” ASK: The smoking history
• Since how long you became a smoker ?
• What type of smoke you are using ?
• Why you are smoking ?
• How many cigarette per day ?
• What is frequency of smoking ?
• What is the preferred times for smoking ?
• What are the behaviors associated with smoking ?
• How long you take after walkup in the morning to
smoke?

21. Non Smoker
• Congratulate him .
• Encourage him to continue as non-smoker .
• Advice to avoid indirect smoking ( second –
hand smoker ) .
• Encourage him to participate in smoking
cessation .

22. • Any attempt to stop before ? ( take details about
this attempt).
• Do you have any medical problem due to
smoking?
• Is there any smoker around you ( home , work ) ?
• Is there any family member or friend who had any
medical problem due to smoking ?
• Are you married ? Do you have children ?
• Are you convinced about the risk of smoking?
• Are you willing to quit ?

23. A smoker’s dependence on nicotine can be
estimated from:
1. The duration of smoking history .
2. The number of cigarettes smoked daily .
3. How soon after waking up the smoker has his or
her first morning cigarette.
More dependent smokers have:
1. Smoked for many years .
2. Smoke more cigarettes daily .
3. Smoke within the first 30 minutes of awakening .

24. ADVICE
Advice should be:
1. Clear - I think it is important for you to quit smoking now and I
can help you." "Cutting down while you are ill is not enough.
2. Strong - As your clinician, I need you to know that quitting
smoking is the most important thing you can do to protect your
health now and in the future. The clinic staff and I will help you.
3. Personalized - Tie tobacco use to current health/illness, and/or
its
social and economic costs, motivation level/readiness to quit,
and/or the impact of tobacco use on children and others in the
household.

25. ASSESS
•Determine the patient's willingness to quit smoking
within the next 30 days:
- If the patient is willing to make a quit attempt at this time,
provide assistance.
- If the patient will participate in an intensive treatment, deliver
such a treatment or refer to an intensive intervention.
- If the patient clearly states he or she is unwilling to make a quit
attempt at this time, provide a motivational intervention.
- If the patient is a member of a special population (e.g.,
adolescent, pregnant smoker), provide additional information
specific to that population.

26. “2” Assess: measurements of smoking
intensity
CO measure is useful
for reinforcing patient’s motivation to quit
• (Modified) Fagerstr̈om Test for Nicotine Dependence
• Biochemical
- serum, urine or salivary cotinine
- exhaled carbon monoxide

28. ASSIST
Meta-analyses of clinical trials to study the
Effectiveness of the 5-As Tobacco Cessation
Treatments.
It showed smoking cessation was twice as likely
when smokers
• Attended classes,
• Received counselling, or
• Used pharmacotherapies

29. 5 Stages of change
1. Precontemplation: The patient states he/she is not ready
to
quit. The patient's motivation status should be documented
and monitored at every subsequent visit.
2. Contemplation: The patient is considering smoking
cessation at some point in the future.
3. Determination: The patient is actively considering
cessation
soon and is engaging in some quit-oriented behavior.
4. Action: The patient is actively involved in a quit attempt
and has quit smoking within the last six months.
5. Maintenance: The patient has quit for at least six months.

30. 5R
The model of "5 Rs"
• Relevance,
• Risks,
• Rewards,
• Roadblocks,
• Repetition is helpful to motivate smokers who
are not ready to quit

31. RELEVANCE
Motivational information has the greatest
impact if it is relevant to a patient's disease
status or risk, family or social situation (e.g.,
having children in the home), health concerns,
age, gender, and other important patient
characteristics (e.g., prior quitting experience,
personal barriers to cessation).

32. RISKS
Ask the patient to identify potential negative
consequences of
tobacco use.
• The clinician may suggest and highlight those that
seem most relevant to the patient.
Examples of risks are:
-Acute risks - Shortness of breath, exacerbation
of asthma, harm to pregnancy, impotence,
infertility, and increased serum carbon monoxide.

33. • Long-term risks - Heart attacks and strokes, lung and
other
cancers (larynx, oral cavity, pharynx, esophagus, pancreas,
bladder, cervix), chronic obstructive pulmonary diseases
(chronic bronchitis and emphysema), long-term disability, and
need for extended care.
• Environmental risks - Increased risk of lung cancer and
heart disease in spouses; higher rates of smoking in children
of tobacco users; increased risk for low birth weight, Sudden
Infant Death Syndrome, asthma, middle ear disease, and
respiratory infections in children of smokers.

34. REWARDS
Ask the patient to identify potential benefits of stopping
tobacco use. The clinician may suggest and highlight those that
seem most relevant to the patient.
Examples of rewards include:
– Improved health
– Food will taste better
– Improved sense of smell
– Feel better about yourself
– Home, car, clothing, breath will smell better
– Not worry about exposing others to smoke
– Feel better physically and perform better in physical activities
– Reduced wrinkling/aging of skin

35. ROADLOCKS
• Ask the patient to identify barriers to quitting and note
elements of treatment that could address barriers.
• Typical barriers might include:
– Withdrawal symptoms
– Fear of failure
–Weight gain
– Lack of support
– Depression
– Enjoyment of tobacco

36. REPETITION
• The motivational intervention should be
repeated every time an unmotivated patient
visits the clinic setting.
• Tobacco users who have failed in previous quit
attempts should be told that most people make
repeated quit attempts before they are
successful.

37. DETERMINATION
1. Set a quit date. Ideally, the quit date should be within 2 weeks. He
can select a special date in his life or in the year.
2. Write this date in the patient file .
3. Tell family, friends, and coworkers about quitting and request
understanding and support.
4. Anticipate challenges /triggers to planned quit attempt, particularly
during the critical first few weeks. These include nicotine
withdrawal symptoms.
5. Prior to quitting , avoid smoking in places where you spend a lot of
time (e.g., work, home, car)

38. 6. Remove tobacco products and smell from your environment the
day before quitting .
7. Total abstinence is essential. "Not even a single puff after the quit
date.“
8. Review past quit attempts including identification of what helped
during the quit attempt and what factors contributed to relapse.
9. Alcohol can cause relapse, the patient should consider
limiting/abstaining from alcohol while quitting.
10. Quitting is more difficult when there is another smoker in the
household. Patients should encourage housemates or his
colleagues to quit with them or not smoke in their presence.

39. 11. Provide a supportive clinical environment while encouraging the
patient in his or her quit attempt. "My office staff and I are
available to assist you.“
12. Help the patient develop social support for his or her quit attempt
in his or her environments outside of treatment. "Ask your
spouse/partner, friends, and coworkers to support you in your quit
attempt.“
13. Assess behaviors associated with smoking ( you can use smoker
diary ) to concentrate on them in the quitting process.

40. 14. Recommend the use of pharmacotherapies found to be effective.
Give him the options ,details and what is suitable for his condition
15. Explain how these medications increase smoking cessation success
and reduce withdrawal symptoms .
16. Always remind him about quitting rewards and keep encouraging
him .
17. Tell him that relapse can happen . So, he can know the weaknesses
and try again and again until he succeed .
18. Determination and the will are the cornerstone in the quitting
process.

41. Intervention Strategies
Non-pharmacological
• Self-help
• Behavioural
• Group support
• Hypnosis
Pharmacological
• Nicotine
• Replacement
• Bupropion
• Verinicline

42. Non-pharmacological
• Self-help Programmes:
Smoking Cessation Clinics
• Counselling support
• Behavioural programmes
• If the above programmes are inadequate,
then pharmacological therapies are sought

43. Behavioural Programmes
• Self-management strategies
• Aversion conditioning techniques
• Relapse-prevention methods
• Nicotine fading

44. Self-Management Strategies
• Most commonly used
• Make smokers more aware of their smoking patterns and
cues
Self-monitoring
• Record when, where, and why they smoke
• Promote a behavioural change and design a treatment
plan
Stimulus control (Cue extinction)
• Done before quitting to reduce the strength of the smoking
cue
• Avoiding dominant cues (talking on the phone, finishing a
meal

45. Aversion Conditioning Techniques
• Should only be administered by trained smoking cessation
specialists
• Used to decrease a smoker’s urge to smoke before quit
dates or upon relapse
• Techniques include rapid smoking and satiation
Rapid smoking :
• Smokers puff cigarettes every 6 to 8 seconds until the
cigarette is gone or nausea occurs
Satiation :
• Smokers double or triple their daily cigarette consumption
for brief periods of time

46. Relapse -Prevention Methods
• Designed to prevent smokers from returning to
smoking behaviour
Avoidance :
• Minimising exposure to temptations, e.g. stress, other
smokers
Coping Strategies :
• Techniques such as deep breathing or use of relaxation
tapes, to deal with withdrawal symptoms
Contingency management :
• Rewards and punishments

47. Nicotine Fading
Gradual reduction of nicotine intake :
• Tapering the number of cigarettes smoked
• Switching to brands containing less nicotine
Disadvantage :
• Smokers can compensate by inhaling more
deeply and longer
• Further reinforce each episode of smoking
Results are inconsistent and thus not
recommended for routine use

48. PHARMACOLOGICAL THERAPIES
• Nicotine Replacement Therapies
• Combination Therapy

49. Nicotine Replacement Therapies
• Gum
• Transdermal patches
• Nasal Spray
• Oral Inhaler
• Lozenges

50. 30

51. Nicotine Gum
• Administered on an as-desired basis
• Most people chew 8 to 15 pieces a day; Each piece is
chewed for 20 to 30 mins
• Approximately 50% of nicotine is released
• Providing 8 to 15mg of nicotine per day from the 2-
mg form and 16 to 30mg from 4-mg form
• Approx. one-third or one-half of the usual daily intake
of a person who smokes 30 cigarettes daily
• Recommended use for 4 to 6 months and patients
should be encouraged to wean from nicotine gum, but
the optimal duration of use is unknown.

52. • Efficacy of Nicotine Gum:
• Successful only accompanied by intensive
behavioural programmes
• Acidic drinks, such as coffee or soda, decrease
acidity of saliva and may interfere with the
effects of nicotine gum
• One should never smoke and chew

53. Nicotine Patches
• Delivering a steady amount of nicotine to the
body right through the skin (usually on an
arm, abdomen)
• Easy to use
• Once a day (changing the location each time)

54. Safety and Adverse Effects of Nicotine Patches:
• Skin irritation at the patch site
• Insomnia
• Headache
• Cold and flu-like symptoms
• Nausea
• Myalgia
• Dizziness
• Less common : Sleep disturbance, GI side effects -
diarrhoea, upset stomach

55. Nicotine Lozenge
Use: Allow to dissolve (Don’t Chew but Suck like a hard candy.)
Pros: Flexible dosing (Up to 20 lozenges/ day)
More discreet than gum; Keep mouth busy; OTC;
Cons: Need to use correctly (don’t chew, suck)
May cause insomnia, some nausea, hiccups,
heartburn, coughing
Dosing:
Based on Time To First
Cigarette (TTFC)
4 mg ≤ if 30 mins TTFC
2mg > if 30 mins TTFC
Length of
Treatment:
12 weeks

56. Nicotine Nasal Spray
Dosing:
1-2 doses per hour
1 does = 2 spays (1 spray/nostril)
Use enough to control withdrawal
symptoms
Length of Treatment:
3-6 months

57. Nicotine Nasal Spray
Use: Spray (don’t sniff, swallow, or inhale)
PRN or fixed-schedule (1-2 doses/hour)
Pros: Rapid delivery though nasal mucosa
Flexible dosing (up to 40 doses)
Cons: Nasal irritation, rhinitis, coughing, &
watering eyes.
Some dependence liability
Rx needed

58. Safety of Replacement Therapies
• NRTs should be used with extra caution in
patients with cardiovascular disease
• Smoking while using patch or gum therapy may
increase the risk of cardiovascular and toxic
effects of nicotine
• Patients should stop smoking completely when
starting treatment
• In addition, many smokers see such therapy as
simply prolonging their dependence or fear
becoming dependent on the replacement itself

59. COMBINATION
THERAPY

60. Bupropion
• Works on the biology of nicotine addiction
• By enhancing dopamine levels in the reward
pathway
• Affect noradrenergic neurons in the locus
ceruleus to reduce craving and withdrawal
symptoms

61. Dosage &Administration for Bupropion
• Start with 150mg/day for the first 3 days
• Follow by a dose increase to 300mg/day given
as 150mg b.d. (at 8-hourly interval)
• Maximum dose : 300 mg/day
• Doses above 300mg/day should not be used
due to dose-dependent risk of seizures

62. • Patients should start taking bupropion BEFORE they
quit smoking
• They should set a “target quit date” during the 2nd
week of treatment with bupropion as it takes about 1
week to reach steady-state blood levels
• Treatment with bupropion should be continued for 7-
12 weeks
• Dose tapering is not necessary when discontinuing
bupropion
• Important that patients continue to receive counselling
and support throughout treatment with bupropion,
and for a period of time thereafter

63. Individualization of Therapy
• Need for education/counseling/support
• Discontinue if patient has not made significant
progress toward abstinence by the seventh
week of therapy
• If unsuccessful, re-evaluate later for retrial of
therapy
• Bupropion should be used as a part of a
comprehensive smoking cessation treatment
program

64. Bupropion in Clinical Practice
• Bupropion is indicated for the treatment of
nicotine dependence as an aid to smoking
cessation in subjects aged 18 years and over.
• Adult smokers who are motivated to stop could
benefit from treatment with bupropion.
• For the majority of patients, the recommended
dosage is 150mg once daily for 3 days, increasing
to 150mg twice daily.

65. Varenicline Tartrate
• Indicated for smoking cessation in adults
• Oral administration (tablet)
• Non-nicotine
• a partial agonist selective for the α4β2 nicotinic
acetylcholine receptor
• Dual action with dual benefits
• Partial agonist activity:
Reduces craving and withdrawal symptoms
• Antagonist activity:
Produces a reduction of the rewarding and reinforcing effects
of smoking

66. Varenicline: Dosage
• Treatment period is 12 weeks
• An additional course of 12 weeks of treatment
may be considered for patients who have
successfully quit at end of 12 weeks
• Varenicline is supplied for oral administration
in 2 strengths: 0.5 and 1.0 mg; titration is as
below:

67. Pharmacokinetics of Varenicline
• Half-life ~24 hours max within 3 to 4 hours
• Steady state reached within 4 days Oral bioavailability
unaffected by food 92% of drug is excreted unchanged
• No inhibition of cytochrome P450 enzymes
• No clinically meaningful drug interactions identified
• No dose restrictions in patients with hepatic
insufficiency
• Dose adjustment required for severe renal impairment,
may be considered for moderate renal impairment.
• No dosage adjustment is necessary for elderly patients
absent renal impairment

68. Adverse Effects
• During clinical trials, approximately 4000 individuals
were exposed to varenicline
• Most frequently reported AEs (≥10%) associated with
varenicline 1 mg vs placebo were:
Nausea
Abnormal dreams
Insomnia
Headache
• The percentage of participants who discontinued
treatment due to adverse events receiving varenicline
treatment was comparable; 11.4% vs 9.7%

69. Contraindications & Interactions
Contraindications:
• hypersensitivity to the active substance or to
any of the excipients
No clinically meaningful drug interactions have
been identified with varenicline

70. Precautions
• There are no adequate data from the use of
varenicline in pregnant women
• Varenicline should not be used during pregnancy
• Varenicline may have minor or moderate
influence on the ability to drive and use
machines
• Patients are advised not to engage in potentially
hazardous activities until it is known whether
their ability to perform these activities is affected

71. Second Line Drugs

72. New Medications in the Pipeline
Rimonabant
• Cannabinoid receptor inhibitor
• Blocks reinforcing effects of nicotine
• Also suppresses appetite
• In phase III trials
• Not approved for smoking cessation by FDA
Nicotine Vaccine
• Produces antibodies to nicotine
• Reduces nicotine levels in animals
CYP246 Inhibitors
• CYP246 is a hepatic enzyme that metabolizes nicotine
• Higher blood nicotine levels per cigarette smoked
• Could also increase potency of NRT
• Eg Methoxsalen, Tranylcypromine

73. • THANK YOU…!!!