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.

1. Smoking
Cessation
Dr. P.Naina Mohamed
Pharmacologist

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. Brief clinical interventions
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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. 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. 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. Pharmacotherapy
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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. Nicotine replacement Therapy
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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. 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. Bupropion
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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. 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. Varenicline
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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. 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. Tips to quit smoking
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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.

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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. Complementary Health Approaches
for Smoking Cessation
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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.
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Many studies have investigated the effects of hypnotherapy on smoking cessation.
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Hypnosis is considered safe when performed by a health professional trained in hypnotherapy.
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Self-hypnosis also appears to be safe for most people.
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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.
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Only a few studies have been conducted on yoga for smoking cessation.
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Yoga is generally low-impact and safe for healthy people when practiced appropriately under
the guidance of a well-trained instructor.

16. Complementary Health Approaches
for Smoking Cessation (Contd)
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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.

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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

19. References
• http://www.cdc.gov/tobacco/data_statistic
s/fact_sheets/cessation/quitting/index.htm
• http://www.cancer.org/healthy/stayawayfr
omtobacco/guidetoquittingsmoking/guideto-quitting-smoking-benefits
• http://www.nhs.uk/Livewell/smoking/Pages/
Betterlives.aspx
• http://nccam.nih.gov/health/providers/dige
st/smoking-science