A short and brief presentation on Nicotine Dependence in Indian context

1. Nicotine Dependence
Dr Balaji Sainath
DPM, DNB(Psychiatry)

2. • Tobacco use is COMMON amongst men and women worldwide
• Tobacco dependence is invariably present in all substance
users
• The need to abstain and understand its harmful consequences
remains unrealized in large populace
• Tobacco is used in a wide variety of ways – smoking, chewing,
applying, sucking, and gargling

3. Types of Tobacco
• Smoked tobacco products – cigarette, beedi, cigar, hookah..
• Smokeless tobacco products (SMT) – gutka, mava, tambaku
paan, zarda, snuff..
• Heated tobacco products (HTPs) – heat-not-burnt
• Nicotine only products – consists nicotine in the absence of
tobacco – e-cigarette, vape, NRTs

4. Epidemiology
• Global data – 1/4th of the world population are using tobacco
• 80% of them are from low to middle income countries
• Approx 8 million people are dying from tobacco related causes
worldwide per year
• 1 out of 8 such deaths are happening in India
• Indian data - around 30% of adults are using tobacco
• Men 56%, Women 15%
• Among men smoking and smokeless forms are roughly similar
• Among women smokeless >> smoking
• Recent trend – initiation before 10 years is increasing, SMTs are
rising

5. Consequences of tobacco use
• Tobacco related cancers – constitute approx 50% of all cancers in
India
• Vascular diseases
• Early myocardial infarction
• Chronic obstructive pulmonary disease (COPD) – 82% of cases
because of tobacco smoking
• Precancerous lesions – leucoplakia, Erythroplakia, oral submucous
fibrosis (OSMF) – relative risk is 400times
• Lower sperm counts, poor sperm quality
• Decreased foetal growth, spontaneous abortions, foetal deaths, and
pregnancy complications
• Exposure to second hand smoke

6. Benefits of quitting?

7. Cause of Addiction?
(addiction triangle)
•Nicotine is a stimulant
• 1000 times more potent than alcohol, 10-100 times than in
barbiturates, 5-10 times than cocaine or morphine in addictive
potential
•Psychological dependence upon tobacco
use as a means of handling stress or reducing unpleasant
emotions
•Learned response to certain environmental/social
cues

8. Trying to quit on own?
(willpower)
• Majority of smokers (around 70%) want to quit smoking
• Success rate is 3% only – if they try on own
• Around 20% could succeed with a course of treatment

9. Assessment
• Measuring Dependence
Fagerstrom test for nicotine dependence;
Heaviness of Smoking Index (HSI);
Concentrations of cotinine in blood, urine, or saliva;
Carbon monoxide concentrations of expired air
• Measuring Motivation
Simple qualitative test of motivation;
Stages of Change

10. Stages of Change
(Prochaska & Diclemente, 1992)
Precontemplation
Contemplation Relapse
Preparation
Action Maintenance
Termination (Exit)

11. Clinical intervention goals
Low
Dependence
Low
• Unlikely to stop
• Could do so without help
• Goal – to increase
motivation
• Likely to stop
• With minimal help
• Goal – to trigger a quit
attempt
• Unlikely to stop
• Goal – to increase
motivation, make the user
receptive for treatment
• Unlikely to stop, without
help
• Goal – intensive
treatment
Motivation
High
High

12. Brief interventions
• Screening
• Brief behavioural counselling (around 3 min)
• Pharmacotherapy
• 5 As – Ask, Advise, Assess, Assist, Arrange

13. Medication and Nicotine Replacement
Therapy
• Varenicline
• Bupropion
• Nortriptyline
• Clonidine
• Single NRT
• Combination NRT

14. Varenicline
• 0.5mg OD on Day 1-3
• 0.5mg BD on Day 4-7
• 1mg BD on Day 8-84 (12 Weeks)
• Consider 1mg BD for another 12 Weeks for maintenance

15. Bupropion
• 150mg OD on Day 1-6
• 150mg BD on Day 7-49 (7 Weeks)
• 150mg OD for another 2 Weeks for maintenance

16. Category Product Dose Duration
>20 Cigarettes/Day
Or
Smoke within 30min
after wakeup
Transdermal Patch 21mg 4 Weeks
14mg 4 Weeks
7mg 4 Weeks
Total 12 Weeks
Gum 2mg Hourly
Lozenge 1mg Hourly
Total 2 Weeks 
Tapering Doses 
SOS
<20 Cigarettes/Day
Or
Do not smoke within
30min after wakeup
Transdermal Patch 14mg 4 Weeks
7mg 4 Weeks
7mg 4 Weeks
Total 12 Weeks
Gum 4mg Hourly (not more than
15/Day)
Lozenge 2mg Hourly (not more than
15/Day)
Total 2 Weeks 
Tapering Doses 
SOS

17. Combination NRT
Category Product Dose Duration
>20
Cigarettes/Day
Or
Smoke within
30min after
wakeup
Transdermal Patch
+
Gum/Lozenge
As mentioned
above
2mg/1mg
As mentioned
above
SOS
Total 12 Weeks
<20
Cigarettes/Day
Or
Do not smoke
within 30min after
wakeup
Transdermal Patch
+
Gum/Lozenge
As mentioned
above
4mg/2mg
As mentioned
above
SOS
Total 12 Weeks

18.  Varenicline = Combination NRT
 Bupropion = Single NRT
 First line: Varenicline or Combination NRT
 Second line: Bupropion
 No pharmacological interactions for NRT/Varenicline

19. Behavioural methods
Skills to assist users to make the quit attempt
• Setting a quit date
• Overcoming psychological dependence
• Using past quit experience
• Anticipating triggers or challenges
• Avoiding alcohol
• Self help guides

20. Skills to deal with problem that may occur immediately after
stopping or withdrawals
Withdrawal problems Suggested coping skills
Cravings Five D’s
Delay, Distract, Drink water, Deep breaths,
Discuss
Difficulty in concentrating Taking a break, doing different tasks
Insomnia Avoid caffeine drinks after 6pm
Drink lots of fruit juices/water
Relaxation techniques
Depression and tiredness Identify specific feelings and address
Recreational activities
Irritability, restlessness, anger, and frustration Short walks, exercise, hot bath, relaxation
techniques, regular physical an mental breaks
Increased appetite and weight gain More physical activities, drink more water, eat
fresh fruits

21. Skills to avoid lapse or relapse
• Congratulate first on successful quitting
• Identifying high risk situations
• Anticipating triggers or challenges – use the 4 A’s – avoid, alter,
alternatives, activities
• Do not discourage relapse
• Mark the progress
• Follow-up

22. Neuromodulation
(for smoking cessation)
• Brainsway Deep TMS with H4 coil
• US-FDA approved
• Along with provocative techniques
• Protocol – 10Hz, 3Sec train, 15Sec ITI, 60 number of trains
@120% MT – total 1800 pulses over 18min
• Area – bilateral Insula and PFC
• CQR is statistically significant over sham coil treatment
• Reduction in the number of cigarettes is significant

23. In a Nutshell
• All-cause mortality related to tobacco is a concern
• Remains unrealized of harmful consequences is still high
• Wanting to quit population is high up to 70%
• But, Addiction is very strong
• Interventions are necessary for better CQR
• Detailed assessment, brief interventions, pharmacotherapy, and
behavioural methods are widely used
• Repetitive Transcranial Magnetic Stimulation (RTMS) is a new
offering

24. Thankyou

25. Integrated Tobacco Deaddiction Programme
(ITDP)
• Initial assessment – detailed history including assessment of
dependence and motivation
• CO analysis, Cotinine levels, Pulmonary Function Test, FNDS &
HSI – at the beginning and the end of Deep TMS
• MET – three sessions over 3-6 days
• Pharmacotherapy (Varenicline/NRT/others) – prescription
• Deep TMS with H4 coil – 8 min of iTBS, total 18 sessions over
3-6 days, with provocation techniques