Smoking cessation


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5 A’s of smoking cessation guidelines, Nicotine replacement therapy (NRT), Bupropion, Varenicline, Tips to quit smoking and Complementary Health Approaches for Smoking Cessation are discussed in this presentation.

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Smoking cessation

  1. 1. Smoking Cessation Dr. P.Naina Mohamed Pharmacologist
  2. 2. Introduction • Most smokers today know that smoking is bad for their health and harmful to people around them. • The smokers might have tried to quit in the past and failed due to addiction. • The Public Health Service (PHS) and the Agency for Healthcare Research and Quality (AHRQ) guidelines for treating tobacco use and dependence, recommends… o Brief clinical interventions o Pharmacotherapy
  3. 3. Brief clinical interventions • • • The Public Health Service (PHS) and the Agency for Healthcare Research and Quality (AHRQ) recommend that health care workers screen all patients for tobacco use and provide advice and followup behavioral treatments to all tobacco users. The PHS guidelines emphasize on use of the 5 A's in clinical settings: o Ask about tobacco use, o Advise to quit, o Assess willingness to make a quit attempt, o Assist in quit attempt, and o Arrange for follow-up. The American Academy of Family Physicians has attempted to simplify this to 2 A's: o Ask about tobacco use and o Act to advise smoker to quit, assess interest in a quitting, assisting in organizing pharmacotherapy and arranging for follow-up.
  4. 4. 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
  5. 5. Nicotine actions 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
  6. 6. Pharmacotherapy • • • • • • Nicotine is the psychoactive drug in tobacco products which produces physical addiction. Research suggests that nicotine may be as addictive as heroin, cocaine, or alcohol. Quitting smoking is difficult and may require multiple attempts. Users often relapse because of stress, weight gain, and withdrawal symptoms. Nicotine withdrawal symptoms may include irritability, anxiety, difficulty concentrating, and increased appetite. Nicotine dependence may be treated by the following… o Nicotine replacement Therapy (NRT) o Over-the-counter (e.g., nicotine patch, gum, lozenge) o Prescription (e.g., nicotine inhaler, nasal spray) o Non-nicotine Prescription medications o Bupropion SR (Zyban®) o Varenicline tartrate (Chantix®)
  7. 7. Nicotine replacement Therapy • • • • • • • Nicotine has both stimulant and depressant actions. Research has shown that using nicotine replacement therapy (NRT) can reduce the number of cigarettes smoked and cut down the amount of dangerous inhaled smoke which contains harmful Polycyclic aromatic hydrocarbons (PAHs) responsible for most of harmful health effects. Patients should be counseled to stop smoking completely prior to initiating NRT to avoid the potential risk of nicotine overdose. Using two forms of nicotine replacement (eg, patch plus resin) results in higher quit rates and should be recommended if other forms of nicotine replacement are not effective alone. use of NRT is recommended for a minimum of 6-8 weeks. Quit rates with use of NRT range between 20% and 24%. Side effects of NRT mainly include local irritation (ie, mouth sores, skin rash, nasal and throat irritation) associated with the route of administration of the medication (ie, mouth, skin, nares).
  8. 8. Mechanism of action of NRT Nicotine replacement Therapy (NRT) Smaller amounts of Nicotine Bind to nicotinic acetylcholine receptors Release of Dopamine Reduced cravings for cigarettes & other tobacco products NRT products still contain nicotine, which is harmful and addictive, but they deliver smaller amounts than cigarettes and without any of the other harmful substances in tobacco, such as tar and carbon monoxide.
  9. 9. Bupropion • • • • • • Bupropion (Zyban) is an antidepressant medicine and can be used to relieve the symptoms of nicotine withdrawal in quitters. Bupropion reduces the desire to smoke and has a similar success rate to NRT. Sustained-release bupropion is started at a dose of 150 mg daily for 3 days before increasing to 150 mg twice daily on day 4. Treatment with bupropion is begun 1-2 weeks before the anticipated quit date. The standard treatment course of bupropion (Zyban) in 8 weeks yields quit rates of about 30%. Bupropion is contraindicated among patients with a history of seizure disorder, current substance abuse, or other conditions that may lower the seizure threshold.
  10. 10. Mechanism of action of Bupropion Bupropion Relatively weak inhibitor of the neuronal reuptake of norepinephrine and dopamine Interruption of areas of the brain that are associated with addiction and the pleasurable effects of nicotine Reduction of the desire to smoke and dampens the physical symptoms of nicotine withdrawal  Bupropion (Zyban) is an alternative to NRT and doesn't contain nicotine. Bupropion (Zyban) may cause side effects such as fever, nausea, agitation, anxiety, dry mouth, headache, skin rashes and constipation. It can also intensify the sleep problems that many people encounter when they stop smoking. Bupropion (Zyban) should not be used by people with epilepsy, liver problems or with eating disorders such as bulimia and anorexia.
  11. 11. Varenicline • • • • • Varenicline (Chantix) is started 1 week prior to the identified quit date, titrating up from a dose of 0.5 mg daily for 3 days, to 0.5 mg twice daily for days 4-7, then to 1 mg twice day beginning on day 8. Rates of continuous abstinence are 44%. It takes about 12 weeks for the nicotine receptors in the brain to switch off (or 'down-regulate') after cessation. Hence, varenicline is usually prescribed for 12 weeks. Those who are abstinent at 12 weeks may continue with another 12 weeks of treatment. Varenicline (Chantix) is an alternative to NRT and doesn't contain nicotine.
  12. 12. Mechanism of action of Varenicline Varenicline Partial agonist of α4β2 nicotinic Ach Receptor Agonistic activity stimulates moderate levels of dopamine in the terminal synapse in the nucleus accumbens & antagonistic property competitively inhibits nicotine at the α 4β2 receptor Reduction of nicotine craving and withdrawal symptoms  varenicline alleviates the symptoms of nicotine craving and withdrawal through its agonist activity while inhibiting the effects of repeated nicotine exposure by its antagonist activity. The most commonly encountered side effects are nausea, insomnia, and abnormal dreams. Other common side effects include headache, difficulty sleeping, abnormal dreams, increased appetite, taste changes, dry mouth, drowsiness, tiredness, dizziness, and gut disturbances such as constipation, diarrhoea or indigestion. Varenicline can double the chances of successfully quitting.
  13. 13. Tips to quit smoking • • • • • • • • • • • • • • Hide the matches, lighters, and ashtrays. Designate the home a non-smoking area. Ask people not to smoke around you. Drink fewer caffeinated beverages which may stimulate the urge to smoke. Avoid alcohol which may also increase the urge to smoke. Change the habits connected with smoking. Keep mints or gum (preferably sugarless) on hand to suppress urge to smoke. Stay active to keep the mind off smoking and help relieve tension. Take a walk, exercise, read a book, brush your teeth, take a shower, take a deep breath or try a new a hobby. Make a list of reasons why you want to quit. Carry this with you at all times. When you have an urge for a cigarette, read your list and it will help strengthen your resolve. Look for support from others. Join a support group or smoking cessation program. Do not go places where many people are smoking such as bars or clubs, and smoking sections of restaurants. Find someone who can support you, for example a family member, friend or doctor.
  14. 14. • • • • • FIRST – make your final decision to quit smoking SECOND – choose the day (“Quit Smoking Day”) when you start quitting smoking THIRD – choose the method which will help you to quit smoking FOURTH - learn how to deal with smoking withdrawal symptoms FIFTH – maintenance stage – just keep your “quit smoking” programme.
  15. 15. Complementary Health Approaches for Smoking Cessation • • • Meditation: o Meditation is a mind-body practice which cultivates abilities to maintain focused and clear attention, and develop increased awareness of the present. o To date, there have been a few randomized studies on mindfulness-based interventions for smoking cessation, but there is not enough evidence. o Meditation is considered to be safe for healthy people. Hypnotherapy: o Hypnosis (also called hypnotherapy) has been studied for a number of conditions, including state anxiety (e.g., before medical procedures or surgeries), headaches, smoking cessation, pain control, hot flashes in breast cancer survivors, and irritable bowel syndrome. o Many studies have investigated the effects of hypnotherapy on smoking cessation. o Hypnosis is considered safe when performed by a health professional trained in hypnotherapy. o Self-hypnosis also appears to be safe for most people. o There are no reported cases of injury resulting from self-hypnosis. Yoga: o Yoga is a mind and body practice with origins in ancient Indian philosophy. o The various styles of yoga typically combine physical postures, breathing techniques, and meditation or relaxation. o Only a few studies have been conducted on yoga for smoking cessation. o Yoga is generally low-impact and safe for healthy people when practiced appropriately under the guidance of a well-trained instructor.
  16. 16. Complementary Health Approaches for Smoking Cessation (Contd) • • Acupuncture: o The term “acupuncture” describes a family of procedures involving the stimulation of points on the body using a variety of techniques. o Several studies have been conducted on the effects of acupuncture or acupressure for smoking cessation. o When not delivered properly, acupuncture can cause serious adverse effects, including infections and punctured organs. Tai Chi: o Tai chi, which originated in China as a martial art, is sometimes referred to as “moving meditation"—practitioners move their bodies slowly, gently, and with awareness, while breathing deeply. o To date, only a few studies have examined the effects of tai chi for smoking cessation. o Tai chi is a relatively safe practice for most people.
  17. 17. • • • • • • • References CURRENT Diagnosis & Treatment in Family Medicine, 3e Jeannette E. South-Paul, Samuel C. Matheny, Evelyn L. Lewis Harrison's Online Featuring the complete contents of Harrison's Principles of Internal Medicine, 18e Dan L. Longo, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, J. Larry Jameson, Joseph Loscalzo, Eds. Behavioral Medicine: A Guide for Clinical Practice, 3e Mitchell D. Feldman, John F. Christensen Goodman & Gilman's The Pharmacological Basis of Therapeutics, 12e Laurence L. Brunton, Bruce A. Chabner, Björn C. Knollmann Hurst's The Heart, 13e Valentin Fuster, Richard A. Walsh, Robert A. Harrington The MD Anderson Manual of Medical Oncology, 2e Hagop M. Kantarjian, Robert A. Wolff, Charles A Koller CURRENT Diagnosis & Treatment in Pulmonary Medicine Michael E. Hanley and Carolyn H. Welsh
  18. 18. References • s/fact_sheets/cessation/quitting/index.htm • omtobacco/guidetoquittingsmoking/guideto-quitting-smoking-benefits • Betterlives.aspx • st/smoking-science