The presentation by Dr.M.S.Chandragupta, Chief Dental Surgeon, Dr. Gupta's Dental Specialities Centre, deals with Tobacco Cessation Methodologies. Tobacco is the number one killer in the world and kills around 9 lakh people annually in India alone. The victims succumb to tobacco in the most productive years of their life. To curb this issue the World Health Organization has brought out a public health legal treaty called ‘Frame Work Convention on Tobacco Control (FCTC)’ which more than 176 countries have signed and ratified the same. India has signed in the year 2005 and initiated measures to bring down the demand and supply of tobacco in India as mandated by the FCTC. India has the second highest number of tobacco users in the world, at an alarming number of 274 million users (GATS Report, 2010) and it is high time we act together to make India Tobacco Free for a healthier and wealthier tomorrow

2. IS IT EASY TO QUIT TOBACCO???????
If a non-smoker is being questioned, he says YES
confidently…
But for a tobacco user, he says it is very difficult to come
out of the habit……………
Any idea why is it so??????????
Because there is something called as Addiction ! ! !

3. WHAT IS ADDICTION?
 A mal-adaptive pattern of substance use,
leading to clinically significant impairment
or distress
 Tolerance to a substance
 Withdrawal from a substance
 Taking a substance in larger amount or over
a longer period of time than intended.
So what causes addiction……….

4. NICOTINE
WHAT DOES IT DO?
 Tobacco dependence is caused by Nicotine, which is a
neuro –chemical, anatomical and molecular basis of its
action is that of a psycho-stimulant
Sites of action
 In Brain: midbrain, brain stem, cerebral cortex,
 Other parts of body (muscles, adrenal glands, heart, etc.).
Mechanism Of Action
 Through its nAChRS(nicotine acetyl choline receptors) By
causing secretion of dopamine, it produces reinforcing,
stimulant and dependence properties.
 By acting on non-dopaminergic sites, it produces positive
rewarding actions and some of the withdrawal symptoms.

5. Nicotine - Dependence

6.  The resultant release of acetylcholine,
noradrenaline, serotonin, vasopressin, etc., it
causes:
1.An immediate rise in blood pressure,
2. Increase in heart, respiratory and pulse rates &
3. Rise in blood sugar levels
In addition, it leads to alertness (arousal,
concentration and stress reactions),memory
enhancement and muscles contractions.

7. Y
what happens if u don’t quit????????????
what happens if u quit????????????
How to encounter it or HOW TO QUIT?????

8. WHAT HAPPENS IF U DON’T QUIT???

10. WHAT HAPPENS ONCE U QUIT???
After 20 Minutes • Blood Pressure and Pulse drop to a normal rate.
• Temperature of hands and feet increases to normal
After 8 Hours • Carbon Monoxide level in the blood drops to normal.
• Oxygen level in the blood goes up to normal
After 24 Hours • Chance of Heart Attack starts going down
After 48 Hours • Nerve endings start growing again.
• Ability to taste and smell begins to improve.
2 weeks to 3 months • Circulation improves.
• Walking gets easier
• Lung function improves up to 30%
1 month to 9 months • Coughing, sinus congestion, tiredness and shortage of
breath decrease.
• Cilia grow back in the lungs to better handle mucus, clean
the lungs and reduce infection.
After 1 year • Risk of coronary artery disease is half that of a smoker.
After 5 years • Lung Cancer death rate goes down by one half
• Risk of stroke becomes the same as a non-smoker.
• Risk of cancer in the mouth, throat, esophagus, bladder,
kidney and pancreas goes down.

11. • Craving for tobacco
• Reason: Reduced levels of nicotine
• Duration: Few days, up to months & years sometimes
• Dizziness
• Reason: Increased flow of oxygen to the brain
• Duration: Few days
• Insomnia
• Reason: An emotional and mental response to withdrawal besides the disturbed
sleep pattern
• Duration: 1 week
• Headaches
• Reason: Increased blood flow to the brain; and, tension to stay quit
• Duration: 1 to 2 weeks
• Chest discomfort
• Reason: Excessive mucus flow which blocks the airways and increased muscular
effort to cough out the mucus and tar deposited in lungs
• Duration: 1 to 3 weeks
WITHDRAWAL SYPTOMS

12. • Constipation
• Reason: Transient reduction in intestinal movement; and, the psychological trigger
to move the bowels is missing
• 1 to 2 weeks
• Irritability
• Reason: Due to craving for nicotine
• Duration: 2 to 4 weeks
• Fatigue
• Reason: Inability to get the “kick/ stimulation” from nicotine
• Duration: 2 to 4 weeks
• Cough or nasal drip
• Reason: Revived cilia action to clear the respiratory passages
• Duration: Few weeks
• Lack of concentration
• Reason: Biochemical dysfunction due to relative deficiency of nicotine
• Duration: Few weeks
• Hunger
• Reason: The appetite suppressant action of tobacco is no more there.
• Duration: Up to several Weeks

13. HOW TO QUIT?????
PSYCHO BEHAVIOURAL THERAPY
PHARMACOTHERAPY
•Nicotine Replacement Therapy (NRT)
•Non Nicotine Replacement Therapy

14. PSYCHO BEHAVIOURAL THERAPY
• Brief clinical interventions (i.e., when a doctor takes 10
minutes or less to deliver advice and assistance about
quitting)
• Counseling (e.g., individual, group, or telephone
counseling)
• Counseling along with medication
TCC
MEDIAGOVERNMENT
NGO

15. 5AS
Ask-about tobacco use
Advise- to quit
Assess- commitment and barriers to
change
Assist-users committed to change
Arrange-follow up to monitor progress

16. • Be positive -you should not get blogged down by negative
thoughts
• Distract yourself - engage yourself in some physical activity or
some hobby that you enjoy doing
• Eat healthy - Eats lots of fruits, vegetables, and whole grains,
enjoy a low-fat diet
• Pamper yourself - when you quit do not neglect yourself as
this is the time when you need to pamper yourself.
• Walk everyday - to stay healthy and fight cravings
• Drink lot of fluids -will keep you hydrated, help you detox
more quickly and work as a craving buster
• Know quitting is long and hard - quitting is a long process as
your body is coping with the withdrawal symptoms- you need to
be patient
• Reward yourself –on smoke free day

17. NICOTINE REPLACEMENT THERAPY (NRT)
Nicotine Gums
Nicotine Patches
Nicotine Lozenges
Nicotine Inhalers
Nicotine Nasal Sprays

18. NICOTINE REPLACEMENT THERAPY (NRT)
Dosage and
duration
Side effects Contraindications
a. Nicotine gum For 1-24
cigarettes/bidis -
2mg gum (up to 24
pieces/day) for 12
weeks.
For ≥25 cigarettes/
bidis – 4mg gum (up
to 24 pieces/day) for
12 weeks
Chewers need about
half or a quarter of
the dose as
prescribed for
smokers.
Mouth soreness,
burning in the
mouth, throat
irritation, dyspepsia,
nausea, vomiting,
hiccups and excess
salivation
Gastric
Ulcers,myocardial
infarction or stroke
in the past two
weeks or poorly
controlled CVD

19. NICOTINE GUMS

20. Please note that the Tobacco
Cessation therapy is team effort of a
group of professionals
Its Dangerous to take medicine
without the guidance of Trained
Doctors

21. Dosage and
duration
Side effects Contraindication
b. Nicotine patch 21mg/24 hours for 4
weeks then
15mg/24 hours for 2
weeks then 7mg/ 24
hours for 2 weeks.
Local skin reaction,
insomnia
myocardial infarction
or stroke in the past
two weeks or poorly
controlled CVD
c.Nicotine inhaler 6-16 cartridges/day
for 6 months
Local irritation of
mouth and throat
- As above -
d.nicotine nasal
spray
1-2 doses / hr for 3
to 6 months
Nasal irritation and
Irritation of throat,
coughing and
watering of eyes.
- As above -

22. NON NICOTINE REPLACEMENT THERAPY
First Line
•Bupropion
•Varenicline
•Fluoxetine
Second-line
•Clonidine
•nortriptyline

23. Bupropion :
•It is a smoking cessation aid.
•The drug is an antidepressant that has both dopaminergic and
adrenergic actions as its primary pharmacological action is
to reduce the craving of smokers for their cigarettes.
•After 1 -2 weeks of Bupropion treatment a person is
ready to quit.
 DOSE: 150MG/DAY x 1 TO 3 days
300mg/day x 7 to 12 weeks

24.  Side effects: GI upsets, agitation,
restlessness, insomnia, headache, lowering
of seizure threshold, etc.
 Contraindications: H/O Allergy, CNS tumors,
Uncontrolled seizures, Hepatic diseases,
Patients on MonoAmineOxidase
(antidepressent) drugs or undergoing
unsupervised alcohol withdrawal, Pregnancy,
lactation, Children below 18 years , etc

25. Varenicline: This is a partial nicotine agonist that selectively binds to the alpha (4) and
beta (2) nicotinic acetylcholine receptors in the brain. It lessens the physical pleasure from
taking in nicotine and helps lessen the symptoms of nicotine craving. Tobacco use may be
stopped one week after initiating treatment with Varenicline
DOSE : 0.5 mg / day x 1 to 3 days
0.5mg BID x 4-7 days
1 mg BID x 12 weeks

26.  Side effects: GI upsets, depression, restlessness,
insomnia, headache, bad dreams, suicidal
ideations, etc.
 Contraindications: Pregnant women, children and
people with H/O mental illnesses. Stop immediately
if changes in moods, & behavior, agitation, suicidal
ideation occur

27. THE WHO FRAMEWORK CONVENTION ON
TOBACCO CONTOL (FCTC)
 The FCTC is the first international treaty negotiated
under the auspices of the WHO, aimed at curbing
tobacco related deaths and disease.
 In a historic leap towards promoting public health,
the Govt. of India ratified the FCTC on FEB 5th
2004. India was the 7th country to ratify the
convention.
 This exhibits a strong commitment to tobacco
control, in light of the fact that India is a major
tobacco consuming and producing nation
 There is totally 38 articles.

28. FCTC - ARTICLE 14
Demand reduction measures concerning tobacco
dependence and cessation
1. Each Party shall develop and disseminate appropriate, comprehensive
and integrated guidelines based on scientific evidence and best
practices, taking into account national circumstances and priorities, and
shall take effective measures to promote cessation of tobacco use and
adequate treatment for tobacco dependence.
2. Towards this end, each Party shall endeavour to:
(a) design and implement effective programmes aimed at promoting the
cessation of tobacco use, in such locations as educational institutions,
health care facilities, workplaces and sporting environments;

29. (b) include diagnosis and treatment of tobacco dependence and
counselling services on cessation of tobacco use in national health and
education programmes, plans and strategies, with the participation of
health workers, community workers and social workers as appropriate
(c) establish in health care facilities and rehabilitation centres programmes
for diagnosing, counselling, preventing and treating tobacco
dependence
(d) collaborate with other Parties to facilitate accessibility and affordability
for treatment of tobacco dependence including pharmaceutical products
pursuant to Article 22.
Such products and their constituents may include medicines, products
used to administer medicines and diagnostics when appropriate