How e cigarettes should be regulated in uk ecig summitMatt Stan
This document summarizes a presentation on proposed changes to e-cigarette regulation in the UK and EU. It discusses the current state of e-cigarette use and harm reduction, NICE guidance supporting harm reduction approaches, and the ongoing revision of the EU Tobacco Products Directive to determine regulations for e-cigarettes. Key points addressed include evidence that cutting down smoking provides little health benefit on its own but may with nicotine replacement therapy, and NICE's recommendation that licensed nicotine products are less harmful than tobacco for harm reduction.
1) Tobacco cessation is the process of discontinuing tobacco use and is one of the most important weapons for effective tobacco control by reducing the demand for tobacco products.
2) Quitting tobacco improves health as it leads to a healthy and long life by avoiding the harmful effects of nicotine, which is highly addictive.
3) While tobacco cessation is challenging due to nicotine addiction, it is possible through increasing motivation, receiving expert counseling and medication support, and using self-help tips like delaying cravings by distracting oneself until the urge passes.
Dr. Priyanka Kumawat presented on smoking cessation treatments. Key points:
1) Quitting smoking reduces health risks but is difficult due to nicotine addiction. Over 1 billion people smoke worldwide and smoking causes many cancers and pulmonary/cardiovascular diseases.
2) FDA-approved smoking cessation treatments include nicotine replacement therapies, bupropion, and varenicline. Emerging treatments include e-cigarettes, vaccines, and drugs targeting nicotine receptors or withdrawal symptoms.
3) All smokers trying to quit should be offered medication. Higher doses of nicotine replacements may help highly dependent smokers. Second-line drugs like clonidine may help those unable to use first-line
E-Cigarette Summit Speaker: Professor Robert WestLindsay Fox
Trends in electronic cigarette use in England
Slides from Prof Robert West's presentation at the E-Cigarette Summit, London November 12, 2013.
Full summary of the E-Cigarette Summit: http://ecigarettereviewed.com/e-cigarette-summit-london-summary
The document discusses nicotine addiction and pharmacotherapy options for smoking cessation. It begins by explaining how nicotine acts on the brain's reward pathway similarly to drugs like heroin and cocaine. Nicotine rapidly increases dopamine release in the nucleus accumbens, reinforcing the behavior. Pharmacotherapies like nicotine replacement therapy, bupropion, and varenicline can help relieve withdrawal symptoms and cravings by interacting with nicotinic receptors. NRT is considered low risk and safer than smoking, delivering nicotine without other harmful chemicals. Combining medication with behavioral counseling improves quit rates.
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
This document discusses smoking cessation and nicotine addiction. It covers physiological and psychological reasons for smoking, effects of nicotine and withdrawal symptoms. It describes nicotine as highly addictive due to its effects on the brain's reward pathway. A combination of behavioral support and proven pharmacotherapy like nicotine replacement therapy, bupropion, and varenicline is recommended for successful smoking cessation. Quitting provides major health benefits but is challenging due to nicotine addiction in the brain and body.
How e cigarettes should be regulated in uk ecig summitMatt Stan
This document summarizes a presentation on proposed changes to e-cigarette regulation in the UK and EU. It discusses the current state of e-cigarette use and harm reduction, NICE guidance supporting harm reduction approaches, and the ongoing revision of the EU Tobacco Products Directive to determine regulations for e-cigarettes. Key points addressed include evidence that cutting down smoking provides little health benefit on its own but may with nicotine replacement therapy, and NICE's recommendation that licensed nicotine products are less harmful than tobacco for harm reduction.
1) Tobacco cessation is the process of discontinuing tobacco use and is one of the most important weapons for effective tobacco control by reducing the demand for tobacco products.
2) Quitting tobacco improves health as it leads to a healthy and long life by avoiding the harmful effects of nicotine, which is highly addictive.
3) While tobacco cessation is challenging due to nicotine addiction, it is possible through increasing motivation, receiving expert counseling and medication support, and using self-help tips like delaying cravings by distracting oneself until the urge passes.
Dr. Priyanka Kumawat presented on smoking cessation treatments. Key points:
1) Quitting smoking reduces health risks but is difficult due to nicotine addiction. Over 1 billion people smoke worldwide and smoking causes many cancers and pulmonary/cardiovascular diseases.
2) FDA-approved smoking cessation treatments include nicotine replacement therapies, bupropion, and varenicline. Emerging treatments include e-cigarettes, vaccines, and drugs targeting nicotine receptors or withdrawal symptoms.
3) All smokers trying to quit should be offered medication. Higher doses of nicotine replacements may help highly dependent smokers. Second-line drugs like clonidine may help those unable to use first-line
E-Cigarette Summit Speaker: Professor Robert WestLindsay Fox
Trends in electronic cigarette use in England
Slides from Prof Robert West's presentation at the E-Cigarette Summit, London November 12, 2013.
Full summary of the E-Cigarette Summit: http://ecigarettereviewed.com/e-cigarette-summit-london-summary
The document discusses nicotine addiction and pharmacotherapy options for smoking cessation. It begins by explaining how nicotine acts on the brain's reward pathway similarly to drugs like heroin and cocaine. Nicotine rapidly increases dopamine release in the nucleus accumbens, reinforcing the behavior. Pharmacotherapies like nicotine replacement therapy, bupropion, and varenicline can help relieve withdrawal symptoms and cravings by interacting with nicotinic receptors. NRT is considered low risk and safer than smoking, delivering nicotine without other harmful chemicals. Combining medication with behavioral counseling improves quit rates.
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
This document discusses smoking cessation and nicotine addiction. It covers physiological and psychological reasons for smoking, effects of nicotine and withdrawal symptoms. It describes nicotine as highly addictive due to its effects on the brain's reward pathway. A combination of behavioral support and proven pharmacotherapy like nicotine replacement therapy, bupropion, and varenicline is recommended for successful smoking cessation. Quitting provides major health benefits but is challenging due to nicotine addiction in the brain and body.
1) Smoking is an addiction caused by nicotine binding to acetylcholine receptors in the brain. This results in the release of dopamine and creates dependence.
2) Smoking cessation requires motivation, easing withdrawal symptoms, and preventing relapse as smoking is a chronic disease similar to other disorders.
3) Effective smoking cessation approaches include counseling and pharmacotherapy. Combining the two gives the best results, such as using nicotine replacements and drugs like varenicline.
This document provides an overview of a tobacco cessation programme, including:
- Details on tobacco production, consumption, and the Global Adult Tobacco Survey.
- Scales to measure nicotine dependence like the Fagerstrom test.
- Models of behavior change like the Transtheoretical Model.
- Approaches to cessation like nicotine replacement therapy, pharmacotherapy, and behavioral counseling.
- Studies showing the success of tobacco cessation programs in India, including higher success rates for programs involving hospitals, counseling, and certain drug combinations.
- Barriers to cessation like a lack of trained health professionals and knowledge about tobacco's harms.
Nicotine replacement therapies (NRT) such as gum, patches, lozenges, inhalers, and sprays provide nicotine to help people quit smoking without the harmful chemicals in cigarettes. They are available in varying doses by prescription or over-the-counter to address different levels of nicotine addiction. While NRTs are more effective for quitting than going cold turkey, some people prefer alternative cessation medications like Zyban or Champix that do not contain nicotine but help curb cravings and withdrawal symptoms. Recent studies show that stop smoking programs combined with NRT can quadruple success rates for quitting permanently.
This document discusses guidelines for smoking cessation interventions and treatment. It outlines recommendations from the WHO and US Public Health Service on promoting non-smoking as the norm, prohibiting tobacco promotion, and reducing tobacco industries. The goals of smoking cessation treatment are achieving long-term abstinence, offering treatment to all tobacco users, and consistently identifying and treating tobacco use. Dental professionals can play a key role in educating patients and the community about the harms of tobacco and helping to enroll them in cessation programs. Assessment tools like the Fagerstrom Test and stages of change model are also discussed to guide treatment and counseling approaches. A variety of nicotine replacement therapies and non-nicotine medications are described for treating nic
Tobacco use is responsible for many preventable deaths worldwide each year and results from neurochemical, environmental, and individual factors. Common pharmacological treatments for tobacco dependence include nicotine replacement therapies, bupropion, and varenicline, which work by reducing withdrawal symptoms and cravings. Non-pharmacological interventions such as counseling can also help smokers quit when combined with medication.
Tobacco use is responsible for many preventable deaths worldwide each year and results from neurochemical, environmental, and individual factors. Common pharmacological treatments for tobacco dependence include nicotine replacement therapies, bupropion, and varenicline, which work through different mechanisms to reduce withdrawal symptoms and cravings. Non-pharmacological interventions such as counseling can also help treat tobacco dependence, and combining pharmacological and non-pharmacological treatments tends to be most effective.
This document summarizes the key determinants and management approaches for tobacco dependence. It discusses neurochemical, environmental, and individual factors that contribute to tobacco use. Regarding management, it outlines the 5 A's approach and describes effective pharmacotherapies like NRT, bupropion, and varenicline. Non-pharmacologic interventions are also encouraged to help patients quit smoking.
The Center for Tobacco Products (CTP) was established in June 2010 to implement the Family Smoking Prevention and Tobacco Control Act. The CTP aims to reduce tobacco use through preventing youth initiation, promoting cessation, informing consumers, and developing science-based regulations. Tobacco use remains the leading preventable cause of death in the US, killing over 400,000 Americans annually. While adult smoking rates had declined for decades, the rate has now stalled at around 20%. Youth smoking rates have also plateaued despite health initiatives. The CTP will enforce new graphic health warnings, restrictions on misleading terms like "light" and "mild", and potential regulation of modified risk claims. It will continue implementing the Tobacco Control Act to protect public
Snus as a Substitution for Smoking: The Swedish ExperienceTobaccoFindings
The document summarizes a study on tobacco use in Sweden. It finds that among males, use of snus (a form of smokeless tobacco) is more common than smoking, but less common among females. Snus seems to reduce smoking initiation and increase smoking cessation rates. The study shows snus is an effective smoking cessation aid commonly used by males in Sweden.
Regulation of tobacco ingredients for largest possible reduction of health risksTobaccoFindings
Oral presentation by Lars Ramström at Workshop on tobacco ingredients, National Institute for Public Health and the Environment, Bilthoven, The Netherlands, 30 and 31 October 2003
The document discusses statistics on tobacco-related deaths from various WHO regions in 1998. It then discusses the percentage of total deaths attributable to tobacco use in different regions in 1990 and projections for 2020. The document also discusses why people smoke and maintain smoking habits, signs of nicotine addiction, classification of tobacco use disorders, and different intervention strategies to reduce tobacco-related harm including decreasing uptake, increasing cessation, and exploring potentially less harmful tobacco products.
The role of harm reduction in tobacco controlTobaccoFindings
The document discusses the role of harm reduction in tobacco control. It argues that for current tobacco users who cannot quit, switching to a nicotine product that is markedly less harmful than cigarettes, such as nicotine replacement therapy or low-nitrosamine smokeless tobacco, can significantly reduce health risks compared to continuing smoking. While prevention and smoking cessation efforts are important, harm reduction strategies are also needed to help smokers unable or unwilling to quit nicotine use altogether. Regulating alternative nicotine products to ensure they are much safer than cigarettes can achieve public health benefits as part of a comprehensive approach to tobacco control.
Meaningful public education by labelling on tobacco packages: Some elements o...TobaccoFindings
Information provided on tobacco packages should clarify that:
1. A smoker's nicotine intake from cigarettes varies widely based on how they smoke and depends on their personal nicotine needs, not machine-measured yields.
2. Intake of other harmful substances depends on the brand-specific ratio of each substance to nicotine.
3. Health risk information should make clear that nicotine itself poses little risk, while combustion products in smoked tobacco are highly dangerous, and nicotine replacement therapies and smokeless tobacco are much less risky than smoking.
The rationale for establishing low-toxicity smokeless nicotine product polici...TobaccoFindings
The document discusses tobacco harm reduction through the use of low-toxicity smokeless tobacco products like Swedish snus. It summarizes evidence from Swedish population studies that finds little risk of snus leading to smoking, strengthening nicotine addiction, or weakening smokers' efforts to quit. The evidence suggests that snus use can substantially reduce tobacco-related disease risk and that some smokers who switch to snus do subsequently quit nicotine altogether. There is little scientific evidence to support arguments against tobacco harm reduction and good evidence to reject such arguments.
1) Smoking is an addiction caused by nicotine binding to acetylcholine receptors in the brain. This results in the release of dopamine and creates dependence.
2) Smoking cessation requires motivation, easing withdrawal symptoms, and preventing relapse as smoking is a chronic disease similar to other disorders.
3) Effective smoking cessation approaches include counseling and pharmacotherapy. Combining the two gives the best results, such as using nicotine replacements and drugs like varenicline.
This document provides an overview of a tobacco cessation programme, including:
- Details on tobacco production, consumption, and the Global Adult Tobacco Survey.
- Scales to measure nicotine dependence like the Fagerstrom test.
- Models of behavior change like the Transtheoretical Model.
- Approaches to cessation like nicotine replacement therapy, pharmacotherapy, and behavioral counseling.
- Studies showing the success of tobacco cessation programs in India, including higher success rates for programs involving hospitals, counseling, and certain drug combinations.
- Barriers to cessation like a lack of trained health professionals and knowledge about tobacco's harms.
Nicotine replacement therapies (NRT) such as gum, patches, lozenges, inhalers, and sprays provide nicotine to help people quit smoking without the harmful chemicals in cigarettes. They are available in varying doses by prescription or over-the-counter to address different levels of nicotine addiction. While NRTs are more effective for quitting than going cold turkey, some people prefer alternative cessation medications like Zyban or Champix that do not contain nicotine but help curb cravings and withdrawal symptoms. Recent studies show that stop smoking programs combined with NRT can quadruple success rates for quitting permanently.
This document discusses guidelines for smoking cessation interventions and treatment. It outlines recommendations from the WHO and US Public Health Service on promoting non-smoking as the norm, prohibiting tobacco promotion, and reducing tobacco industries. The goals of smoking cessation treatment are achieving long-term abstinence, offering treatment to all tobacco users, and consistently identifying and treating tobacco use. Dental professionals can play a key role in educating patients and the community about the harms of tobacco and helping to enroll them in cessation programs. Assessment tools like the Fagerstrom Test and stages of change model are also discussed to guide treatment and counseling approaches. A variety of nicotine replacement therapies and non-nicotine medications are described for treating nic
Tobacco use is responsible for many preventable deaths worldwide each year and results from neurochemical, environmental, and individual factors. Common pharmacological treatments for tobacco dependence include nicotine replacement therapies, bupropion, and varenicline, which work by reducing withdrawal symptoms and cravings. Non-pharmacological interventions such as counseling can also help smokers quit when combined with medication.
Tobacco use is responsible for many preventable deaths worldwide each year and results from neurochemical, environmental, and individual factors. Common pharmacological treatments for tobacco dependence include nicotine replacement therapies, bupropion, and varenicline, which work through different mechanisms to reduce withdrawal symptoms and cravings. Non-pharmacological interventions such as counseling can also help treat tobacco dependence, and combining pharmacological and non-pharmacological treatments tends to be most effective.
This document summarizes the key determinants and management approaches for tobacco dependence. It discusses neurochemical, environmental, and individual factors that contribute to tobacco use. Regarding management, it outlines the 5 A's approach and describes effective pharmacotherapies like NRT, bupropion, and varenicline. Non-pharmacologic interventions are also encouraged to help patients quit smoking.
The Center for Tobacco Products (CTP) was established in June 2010 to implement the Family Smoking Prevention and Tobacco Control Act. The CTP aims to reduce tobacco use through preventing youth initiation, promoting cessation, informing consumers, and developing science-based regulations. Tobacco use remains the leading preventable cause of death in the US, killing over 400,000 Americans annually. While adult smoking rates had declined for decades, the rate has now stalled at around 20%. Youth smoking rates have also plateaued despite health initiatives. The CTP will enforce new graphic health warnings, restrictions on misleading terms like "light" and "mild", and potential regulation of modified risk claims. It will continue implementing the Tobacco Control Act to protect public
Snus as a Substitution for Smoking: The Swedish ExperienceTobaccoFindings
The document summarizes a study on tobacco use in Sweden. It finds that among males, use of snus (a form of smokeless tobacco) is more common than smoking, but less common among females. Snus seems to reduce smoking initiation and increase smoking cessation rates. The study shows snus is an effective smoking cessation aid commonly used by males in Sweden.
Regulation of tobacco ingredients for largest possible reduction of health risksTobaccoFindings
Oral presentation by Lars Ramström at Workshop on tobacco ingredients, National Institute for Public Health and the Environment, Bilthoven, The Netherlands, 30 and 31 October 2003
The document discusses statistics on tobacco-related deaths from various WHO regions in 1998. It then discusses the percentage of total deaths attributable to tobacco use in different regions in 1990 and projections for 2020. The document also discusses why people smoke and maintain smoking habits, signs of nicotine addiction, classification of tobacco use disorders, and different intervention strategies to reduce tobacco-related harm including decreasing uptake, increasing cessation, and exploring potentially less harmful tobacco products.
The role of harm reduction in tobacco controlTobaccoFindings
The document discusses the role of harm reduction in tobacco control. It argues that for current tobacco users who cannot quit, switching to a nicotine product that is markedly less harmful than cigarettes, such as nicotine replacement therapy or low-nitrosamine smokeless tobacco, can significantly reduce health risks compared to continuing smoking. While prevention and smoking cessation efforts are important, harm reduction strategies are also needed to help smokers unable or unwilling to quit nicotine use altogether. Regulating alternative nicotine products to ensure they are much safer than cigarettes can achieve public health benefits as part of a comprehensive approach to tobacco control.
Meaningful public education by labelling on tobacco packages: Some elements o...TobaccoFindings
Information provided on tobacco packages should clarify that:
1. A smoker's nicotine intake from cigarettes varies widely based on how they smoke and depends on their personal nicotine needs, not machine-measured yields.
2. Intake of other harmful substances depends on the brand-specific ratio of each substance to nicotine.
3. Health risk information should make clear that nicotine itself poses little risk, while combustion products in smoked tobacco are highly dangerous, and nicotine replacement therapies and smokeless tobacco are much less risky than smoking.
The rationale for establishing low-toxicity smokeless nicotine product polici...TobaccoFindings
The document discusses tobacco harm reduction through the use of low-toxicity smokeless tobacco products like Swedish snus. It summarizes evidence from Swedish population studies that finds little risk of snus leading to smoking, strengthening nicotine addiction, or weakening smokers' efforts to quit. The evidence suggests that snus use can substantially reduce tobacco-related disease risk and that some smokers who switch to snus do subsequently quit nicotine altogether. There is little scientific evidence to support arguments against tobacco harm reduction and good evidence to reject such arguments.
Tobacco use is the leading preventable cause of death in the United States, killing over 400,000 Americans each year from diseases like lung cancer, heart disease, and stroke. Tobacco contains over 7,000 chemicals, including nicotine, tar, carbon monoxide, ammonia, and arsenic. While tobacco companies promote myths that some tobacco products like cigars, hookahs, and cloves are safer, all tobacco products are addictive and cause serious health issues. Quitting smoking can significantly reduce health risks, and medications and support groups can help in quitting.
The document discusses the health effects and consequences of smoking. It covers causes of smoking like peer pressure, reasons for quitting like health and cost, and possible solutions like nicotine gum and increased cigarette prices. Health risks of smoking include diseases and reduced life expectancy. The document provides statistics on smoking prevalence and deaths worldwide.
This document discusses tobacco harm reduction strategies for engaging healthcare professionals in Nigeria. It defines harm reduction as improving lives without focusing solely on abstinence. Tobacco harm reduction aims to provide safer nicotine delivery alternatives to cigarettes like e-cigarettes and smokeless tobacco. Healthcare professionals can advocate for harm reduction, educate about reduced risk products, and support spiritual and physical wellbeing to help people quit smoking. Embracing harm reduction strategies is key to achieving global smoke-free goals.
NYU College of Global Health - E-cigarette seminar - New YorkClive Bates
E-Cigarettes: The Tectonic Shift in Nicotine and Tobacco Consumption: Opportunity or Threat to Saving Lives?
Clive Bates
Friday, October 19, 2018
NYU School of Law, Greenberg Lounge
40 Washington Square South, New York, New York
Tobacco use can lead to nicotine dependence and serious health problems. Cessation can significantly reduce the risk of suffering from smoking-related diseases. Tobacco dependence is a chronic condition that often requires repeated interventions, but effective treatments and helpful resources exist. Smokers can and do quit smoking. In fact, today there are more former smokers than current smokers.
The WHO FCTC provides solutions to the global tobacco epidemic through six key measures: monitor tobacco use, protect from smoke, offer help to quit, warn about dangers, ban advertising and promotions, and raise taxes. Implementation has led to rapid decreases in smoke exposure and heart attacks. Most countries have implemented some measures, though few have comprehensively adopted all six. Recent developments include new legislation in several countries. The success of the WHO FCTC depends on empowering comprehensive implementation of all effective measures.
This document provides information on tobacco dependence treatment. It begins with objectives and an introduction noting the global impact of tobacco use. It then describes various types of tobacco products and their significant health side effects. Signs and symptoms of nicotine dependence are outlined using the Fagerstrom Test. The benefits of quitting and roles of medical staff in treatment are discussed. Treatment methods covered include counseling, nicotine replacement therapy, medications, and support groups. Nicotine withdrawal symptoms and specifics of nicotine patches, gum, and other replacement products are also summarized.
Rethinking nicotine: illusions, delusions and some conclusionsClive Bates
presentation to the UK E-cigarette Summit on 9 December 2022. Looks at how our approach to nicotine must evolve from a "tobacco harm reduction" to treating nicotine like a socially acceptable recreational stimulant with minimal harm.
Improving smoking cessation approaches at the individual levelGeorgi Daskalov
This document discusses approaches to improving smoking cessation at the individual level. It notes that most smokers are addicted to nicotine and experience withdrawal symptoms when trying to quit. The two main approaches to assisting cessation are pharmacotherapy and behavioral support. Pharmacotherapy such as nicotine replacement therapy, bupropion, and varenicline can help reduce withdrawal symptoms and urges to smoke. Behavioral support through programs and counseling can boost motivation and help people avoid smoking cues. The document argues that treating tobacco addiction and assisting with cessation should be part of medical treatment due to the health risks of smoking.
This document discusses approaches to improving smoking cessation at the individual level. It first explains that smoking is an addiction and describes withdrawal symptoms experienced when trying to quit. The two main approaches to assisting cessation are pharmacotherapy and behavioral support. Pharmacotherapy such as nicotine replacement therapy, bupropion, and varenicline can help reduce urges to smoke and withdrawal symptoms. Behavioral support aims to boost motivation and develop skills to avoid smoking. The document argues that treating tobacco addiction and assisting with cessation should be part of medical treatment due to the health risks of smoking.
Improving smoking cessation approaches at the individual levelGeorgi Daskalov
This document discusses approaches to improving smoking cessation at the individual level. It first explains that smoking is an addiction and describes withdrawal symptoms experienced when trying to quit. The two main approaches to assisting cessation are pharmacotherapy and behavioral support. Pharmacotherapy such as nicotine replacement therapy, bupropion, and varenicline can help reduce urges to smoke and withdrawal symptoms. Behavioral support aims to boost motivation and develop skills to avoid smoking. The document argues that treating tobacco addiction and assisting with cessation should be part of medical treatment due to the health risks of smoking.
Tobacco Harm Reduction - an introductionClive Bates
This document provides an introduction to tobacco harm reduction and alternative nicotine products such as e-cigarettes. It summarizes statements from public health organizations that find e-cigarettes to be much less harmful than combustible cigarettes. Research shows e-cigarettes help smokers quit at the population level and are effective cessation tools. The document argues for risk-proportionate regulation and taxation of nicotine products to incentivize smokers to switch to less harmful options and further reduce smoking rates.
Innovation for Consumers: E-cigarettes and novel tobacco products - Part of t...Clive Bates
This document discusses e-cigarettes and novel tobacco products. It argues that they are substantially less harmful than combustible cigarettes and have the potential to significantly reduce smoking rates and associated deaths. However, regulations should balance this potential benefit with preventing unintended consequences like perpetuating smoking or increasing youth uptake. The document proposes risk-proportionate regulations and taxes to incentivize switching from cigarettes, along with standards, marketing restrictions, and age limits, while ensuring products remain appealing to smokers trying to quit. The goal is harm reduction for populations according to the WHO framework convention on tobacco control.
The document discusses tobacco cessation and control. It outlines the diseases caused by smoking in both children and adults. It recommends offering help to quit tobacco use through cessation advice, legislation, and pharmacological therapy. Health professionals have an important role to play in tobacco control through advising patients, promoting tobacco-free policies, and building cessation infrastructure. Brief counseling and motivational interventions can help patients quit smoking. Government initiatives like the COTPA act have implemented various bans and warnings. Increasing tobacco taxes and prices is also effective for reducing consumption. The National Tobacco Control Programme aims to reduce tobacco use in India.
This document summarizes a seminar presentation on tobacco cessation. It discusses the large number of tobacco users in India and the health impacts of tobacco use. It outlines regulatory, service-based, and educational approaches to tobacco control and the role of dentists in counseling patients. The 5 A's model for tobacco cessation counseling is described. Nicotine replacement therapies and other pharmacological aids are discussed. The presentation emphasizes the importance of dentists' involvement in tobacco control through counseling, advocacy, and community education efforts.
Over the past 50 years, cigarette smoking and other combusted tobacco products have caused over 20 million American deaths. The tobacco epidemic was driven by misleading and aggressive strategies of the tobacco industry. While electronic nicotine delivery systems like e-cigarettes may help reduce harm if they replace combusted tobacco entirely, they must be regulated to prevent youth uptake and minimize risks. The 2014 Surgeon General's report recommends fully funding tobacco control programs, raising cigarette taxes, and making cessation treatment widely available to continue progress against the tobacco epidemic.
Tobacco Harm Reduction by Somchai Bovornkitti* in Crimson Publishers: Telemedicine and e-Health open access journals
Cigarette smoke contain approximately 250 different chemicals known to be harmful to human health. Thousands of harmful chemical substances produce by the combustion of tobacco. The health impacts such as cancer and chronic lung disease are not only associated with smokers but also people who are exposed to secondhand smoke. Tobacco Harm Reduction is a concept to minimize the impacts of tobacco on the individual and on society at large. A key component of this strategy is using alternative source of nicotine as a substitute to tobacco cigarettes. Electronic cigarette and heated tobacco are alternatives that might have potential in reduce harm from smokes. This paper elaborates on available research associated with electronic cigarette and heated tobacco with harm reduction and risk perspective.
https://crimsonpublishers.com/tteh/fulltext/TTEH.000522.php
For more Open access journals in Crimson Publishers
Please click on: https://crimsonpublishers.com/
For more Articles on Telemedicine and e-Health open access journals
please click on link: https://crimsonpublishers.com/tteh/index.php
Please follow the below link for our LinkedIn page
https://www.linkedin.com/company/crimsonpublishers
The document discusses strategies for reducing tobacco harm in New Zealand. It agrees that increasing options for smokers who find quitting difficult is urgent. However, it argues that more can be done with existing nicotine replacement therapies (NRT) before introducing new tobacco products like Swedish snus. Specifically, the document suggests exploring longer-term NRT treatment and faster-acting NRT products first to help more smokers reduce harm from tobacco use. Introducing snus raises concerns about evidence of effectiveness, impacts on indigenous Māori populations, ties to the tobacco industry, and potential health risks from tobacco-specific nitrosamines.
1) Tobacco smoking remains the leading preventable cause of disease and death worldwide. While smoking rates have decreased in developed countries, certain high risk groups have greater difficulty quitting.
2) Brief advice from doctors and other healthcare professionals on smoking cessation can more than double quit rates compared to no advice. Comprehensive treatment involving both behavioral support and pharmacotherapy is most effective for treating nicotine dependence.
3) Effective cessation medications include nicotine replacement therapy, varenicline, bupropion, and others depending on location. Behavioral support through counseling, telephone quitlines, internet programs, and motivational interviewing can also significantly increase success rates.
Proposed Changes to How E-Cigarettes Are Regulated - Prof. Linda BauldLindsay Fox
Proposed changes to how e-cigarettes are regulated: UK and EU context
Slides from Prof. Linda Bauld's presentation at the E-Cigarette Summit, London November 12, 2013.
Full summary of the E-Cigarette Summit: http://ecigarettereviewed.com/e-cigarette-summit-london-summary
This document discusses harm reduction strategies in tobacco control. It notes that while some smokers can quit abruptly, others are unable to and need alternative support to reduce harm from tobacco use. This could involve using safer nicotine sources while reducing tobacco consumption. The document reviews why harm reduction and tobacco control are relevant now, given newer less harmful nicotine delivery methods. It acknowledges the controversy but argues regulation should be proportionate to risk and avoid unintended consequences. A group work activity asks about the potential role and form of harm reduction in tobacco control, as well as alternative strategies.
This document discusses tobacco control strategies according to the WHO MPOWER framework. It summarizes the six policies of MPOWER: Monitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help to quit tobacco use; Warn about the dangers of tobacco; Enforce bans on tobacco advertising, promotion and sponsorship; and Raise taxes on tobacco. For each policy, it provides details on effective implementation strategies, such as establishing comprehensive smoke-free laws and public education campaigns about the health risks of tobacco use and secondhand smoke exposure.
Similar to Policies for helping smokers who cannot quit: a prerequisite for maximum prevention of tobacco induced diseases (20)
CLASSIFICATION OF H1 ANTIHISTAMINICS-
FIRST GENERATION ANTIHISTAMINICS-
1)HIGHLY SEDATIVE-DIPHENHYDRAMINE,DIMENHYDRINATE,PROMETHAZINE,HYDROXYZINE 2)MODERATELY SEDATIVE- PHENARIMINE,CYPROHEPTADINE, MECLIZINE,CINNARIZINE
3)MILD SEDATIVE-CHLORPHENIRAMINE,DEXCHLORPHENIRAMINE
TRIPROLIDINE,CLEMASTINE
SECOND GENERATION ANTIHISTAMINICS-FEXOFENADINE,
LORATADINE,DESLORATADINE,CETIRIZINE,LEVOCETIRIZINE,
AZELASTINE,MIZOLASTINE,EBASTINE,RUPATADINE. Mechanism of action of 2nd generation antihistaminics-
These drugs competitively antagonize actions of
histamine at the H1 receptors.
Pharmacological actions-
Antagonism of histamine-The H1 antagonists effectively block histamine induced bronchoconstriction, contraction of intestinal and other smooth muscle and triple response especially wheal, flare and itch. Constriction of larger blood vessel by histamine is also antagonized.
2) Antiallergic actions-Many manifestations of immediate hypersensitivity (type I reactions)are suppressed. Urticaria, itching and angioedema are well controlled.3) CNS action-The older antihistamines produce variable degree of CNS depression.But in case of 2nd gen antihistaminics there is less CNS depressant property as these cross BBB to significantly lesser extent.
4) Anticholinergic action- many H1 blockers
in addition antagonize muscarinic actions of ACh. BUT IN 2ND gen histaminics there is Higher H1 selectivitiy : no anticholinergic side effects
Discover the benefits of homeopathic medicine for irregular periods with our guide on 5 common remedies. Learn how these natural treatments can help regulate menstrual cycles and improve overall menstrual health.
Visit Us: https://drdeepikashomeopathy.com/service/irregular-periods-treatment/
STUDIES IN SUPPORT OF SPECIAL POPULATIONS: GERIATRICS E7shruti jagirdar
Unit 4: MRA 103T Regulatory affairs
This guideline is directed principally toward new Molecular Entities that are
likely to have significant use in the elderly, either because the disease intended
to be treated is characteristically a disease of aging ( e.g., Alzheimer's disease) or
because the population to be treated is known to include substantial numbers of
geriatric patients (e.g., hypertension).
Dr. Tan's Balance Method.pdf (From Academy of Oriental Medicine at Austin)GeorgeKieling1
Home
Organization
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
Academy of Oriental Medicine at Austin
About AOMA: The Academy of Oriental Medicine at Austin offers a masters-level graduate program in acupuncture and Oriental medicine, preparing its students for careers as skilled, professional practitioners. AOMA is known for its internationally recognized faculty, award-winning student clinical internship program, and herbal medicine program. Since its founding in 1993, AOMA has grown rapidly in size and reputation, drawing students from around the nation and faculty from around the world. AOMA also conducts more than 20,000 patient visits annually in its student and professional clinics. AOMA collaborates with Western healthcare institutions including the Seton Family of Hospitals, and gives back to the community through partnerships with nonprofit organizations and by providing free and reduced price treatments to people who cannot afford them. The Academy of Oriental Medicine at Austin is located at 2700 West Anderson Lane. AOMA also serves patients and retail customers at its south Austin location, 4701 West Gate Blvd. For more information see www.aoma.edu or call 512-492-303434.
Pictorial and detailed description of patellar instability with sign and symptoms and how to diagnose , what investigations you should go with and how to approach with treatment options . I have presented this slide in my 2nd year junior residency in orthopedics at LLRM medical college Meerut and got good reviews for it
After getting it read you will definitely understand the topic.
Spontaneous Bacterial Peritonitis - Pathogenesis , Clinical Features & Manage...Jim Jacob Roy
In this presentation , SBP ( spontaneous bacterial peritonitis ) , which is a common complication in patients with cirrhosis and ascites is described in detail.
The reference for this presentation is Sleisenger and Fordtran's Gastrointestinal and Liver Disease Textbook ( 11th edition ).
Nutritional deficiency Disorder are problems in india.
It is very important to learn about Indian child's nutritional parameters as well the Disease related to alteration in their Nutrition.
Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
- Video recording of this lecture in English language: https://youtu.be/RvdYsTzgQq8
- Video recording of this lecture in Arabic language: https://youtu.be/ECILGWtgZko
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
The biomechanics of running involves the study of the mechanical principles underlying running movements. It includes the analysis of the running gait cycle, which consists of the stance phase (foot contact to push-off) and the swing phase (foot lift-off to next contact). Key aspects include kinematics (joint angles and movements, stride length and frequency) and kinetics (forces involved in running, including ground reaction and muscle forces). Understanding these factors helps in improving running performance, optimizing technique, and preventing injuries.
Storyboard on Acne-Innovative Learning-M. pharm. (2nd sem.) CosmeticsMuskanShingari
Acne is a common skin condition that occurs when hair follicles become clogged with oil and dead skin cells. It typically manifests as pimples, blackheads, or whiteheads, often on the face, chest, shoulders, or back. Acne can range from mild to severe and may cause emotional distress and scarring in some cases.
**Causes:**
1. **Excess Oil Production:** Hormonal changes during adolescence or certain times in adulthood can increase sebum (oil) production, leading to clogged pores.
2. **Clogged Pores:** When dead skin cells and oil block hair follicles, bacteria (usually Propionibacterium acnes) can thrive, causing inflammation and acne lesions.
3. **Hormonal Factors:** Fluctuations in hormone levels, such as during puberty, menstrual cycles, pregnancy, or certain medical conditions, can contribute to acne.
4. **Genetics:** A family history of acne can increase the likelihood of developing the condition.
**Types of Acne:**
- **Whiteheads:** Closed plugged pores.
- **Blackheads:** Open plugged pores with a dark surface.
- **Papules:** Small red, tender bumps.
- **Pustules:** Pimples with pus at their tips.
- **Nodules:** Large, solid, painful lumps beneath the surface.
- **Cysts:** Painful, pus-filled lumps beneath the surface that can cause scarring.
**Treatment:**
Treatment depends on the severity and type of acne but may include:
- **Topical Treatments:** Such as benzoyl peroxide, salicylic acid, or retinoids to reduce bacteria and unclog pores.
- **Oral Medications:** Antibiotics or oral contraceptives for hormonal acne.
- **Procedures:** Such as chemical peels, extraction of comedones, or light therapy for more severe cases.
**Prevention and Management:**
- **Cleanse:** Regularly wash skin with a gentle cleanser.
- **Moisturize:** Use non-comedogenic moisturizers to keep skin hydrated without clogging pores.
- **Avoid Irritants:** Such as harsh cosmetics or excessive scrubbing.
- **Sun Protection:** Use sunscreen to prevent exacerbation of acne scars and inflammation.
Acne treatment can take time, and consistency in skincare routines and treatments is crucial. Consulting a dermatologist can help tailor a treatment plan that suits individual needs and reduces the risk of scarring or long-term skin damage.
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Congestive Heart failure is caused by low cardiac output and high sympathetic discharge. Diuretics reduce preload, ACE inhibitors lower afterload, beta blockers reduce sympathetic activity, and digitalis has inotropic effects. Newer medications target vasodilation and myosin activation to improve heart efficiency while lowering energy requirements. Combination therapy, following an assessment of cardiac function and volume status, is the most effective strategy to heart failure care.
Pharmacology of Drugs for Congestive Heart Failure
Policies for helping smokers who cannot quit: a prerequisite for maximum prevention of tobacco induced diseases
1. Policies for helping smokers who cannot quit: a prerequisite for maximum prevention of tobacco induced diseases Lars M. Ramström Institute for Tobacco Studies Stockholm, Sweden 7th Annual Conference of ISPTID, Kyoto, Japan, 26-28 September, 2008
2.
3.
4.
5.
6.
7.
8.
9. Main area #4 Helping those who cannot quit: considering the potential of a harm reduction approach in tobacco control to help people whose addiction to nicotine makes it extremely difficult to quit altogether.
10.
11. People smoke because they are addicted to nicotine, but nicotine itself is not especially hazardous; it is the other constituents of tobacco smoke that cause most of the harm. Use of smoke-free nicotine would benefit smokers directly by reducing the personal harm caused by nicotine addiction What is harm reduction, and how would it work for smoking? Excerpts from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008.
12. The safest form of nicotine is medicinal or ‘pure’ nicotine, such as that contained in nicotine replacement therapy (NRT) products including skin patches and chewing gum. However, although helpful, few smokers find NRT to be a satisfying alternative to smoking What is the safest way to provide nicotine without smoke? Excerpts from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008.
13. Nicotine can also be obtained without smoke from a range of tobacco products, usually referred to as ‘smokeless’ tobacco. In Sweden, the availability and use by men of an oral tobacco product called snus, one of the less hazardous smokeless tobacco products, is widely recognised to have contributed to the low prevalence of smoking in Swedish men and consequent low rates of lung cancer. All smokeless tobacco products are therefore more hazardous than medicinal nicotine, and in some cases especially so, but all are also substantially less hazardous than smoking. What are the alternatives to medicinal nicotine? Excerpts from: Ending tobacco smoking in Britain; Radical strategies for prevention and harm reduction in nicotine addiction, Royal College of Physicians of London, 2008.
14.
15.
16.
17.
Editor's Notes
Prevention of tobacco induced diseases is a very multifaceted issue. I am here going to focus on an aspect that, in recent years, has gained increasing attention, namely the need to help smokers who cannot quit so that they can find other means to minimise their risk for tobacco induced diseases. In order to put these matters in context, we need an overview of goals and objectives in the field of tobacco control.
The overall goal for tobacco control can be formulated as: ” Maximum prevention of tobacco induced diseases”. This goal includes intermediate objectives concerning measures to help specific target groups such as: Never tobacco users, and Current tobacco users.
The objective of measures to help never tobacco users should be: PREVENTING ONSET OF TOBACCO USE. The strength of such measures is: In individuals for whom these measures have been successful, tobacco induced diseases will not occur. But there are weaknesses: - Measures to prevent onset of tobacco use have limited success rate. - Even when they are successful, there is virtually no reduction of disease in the nearest 30-40 years, because, in that period, virtually all cases of tobacco induced diseases will occur among those who already smoke. This is further illustrated by data published in a report from the World Bank .
The curves in this graph show the estimated cumulative tobacco deaths 1950 to 2050 by different intervention policies, The black curve represents a ”no intervention” scenario. The red curve represents a scenario where onset of smoking in young people has been cut to half from the year 2000 to 2020 - a quite optimistic scenario. But the result in terms of reduction of deaths is very modest. However, in a still longer time perspective, prevention of onset will yield substantial health gains. So, primary prevention policies are important - but not enough. The World Bank has also estimated the outcome of a scenario where adult smoking is cut to half from the year 2000 to 2020.
As illustrated by the blue curve, quitting smoking makes a substantial difference, and the health gain appears quite soon. Therefore……..
The #1 objective of measures to help current tobacco users should be: QUITTING ALL TOBACCO/NICOTINE USE The strength of such measures is that they can make disease risks decrease substantially, eventually approaching never-user levels. But there are weaknesses: - Treatments in clinical settings reach a limited fraction of smokers and have limited success rate. - Quit attempts made outside clinical settings (the majority of all quit attempts) get no or inadequate support. In summary; Cessation policies are important - but not enough. Some reasons behind the weaknesses of cessation policies can be illustrated by ”real life” data regarding quit attempts.
Some smokers do not make any quit attempt at all. In Sweden this group is quite small, less than 10% of all ever daily smokers, but in many other countries the percentage is substantially higher. Even more important is the outcome of actual quit attempts. Among those who have made one or more quit attempts, there are large proportions who do still smoke. These proportions differ substantially according to level of nicotine dependence.
The proportion of those who do still smoke is increasing with increasing level of nicotine dependence. For those with very high level of dependence it may be virtually impossible to quit nicotine use. Consequently there is a need to help these people minimise their health risks by other means. P reviously, this need has been largely neglected in governmental policies, but a few months ago it was recognised by the British Department of Health.
In the background document for a ”Consultation on the future of tobacco control”, the Brtish Department of Health identifies four main areas. One is: ”Helping those who cannot quit”: considering…… (text on slide) ……..… quit altogether.” Just two weeks ago The Royal College of Physicians of London responded to the consultation by publishing a report summarizing updated scientific evidence in the field.
Already in the subtitle the report highlights the harm reduction component of the suggested ”Radical strategies” for ”Ending tobacco smoking in Britain”.
Here are some excerpts from the section discussing the overall principles concerned. What is harm .... (text on the slide) ………... by nicotine addiction. The issue on smoke-free nicotine is discussed more in detail in a following section.
What is …. (text on the slide) ………...alternative to smoking. The latter remark implies a discussion on alternatives to medicinal nicotine.
Nicotine can … (text on the slide) ……less hazardous than smoking. The last remark, that smokeless tobacco products are substantially less hazardous than smoking, deserves particular attention, since there is a common misunderstanding that the difference were just a small one. This point can be further clarified by examples of quantitative data.
In this chart each bar represents the relative risk of death for males with different tobacco use The green sector of each bar represents never smokers’ death risk, taken as a reference. The red sector in the bars for snus users and cigarette smokers represents the excess risk, above that of never smokers. For users of snus, the Swedish kind of smokeless tobacco that was mentioned by the Royal College of Physicians, the death risk is much closer to that of never smokers than to that of cigarette smokers. The pieces of evidence that have now been presented, imply a need for an additional objective for measures to help current tobacco users.
This objective should be: Switching to a nicotine product that is markedly less harmful. The strength of this strategy is, that it offers a realistic alternative even for highly nicotine dependent people, and also, that disease risks can decrease almost as much as when quitting. And there are weaknesses: - Continued exposure to nicotine - Maintenance of nicotine dependence - Limited availability of appropriate products Now, as a final summary:
Primary… (text on slide) ………………enough.
In order to…. (text on slide) ………..smokeless tobacco.