This document provides an overview of smoking cessation. It begins with an introduction discussing the negative health impacts of smoking and statistics on smoking rates. It then covers the chemical components in cigarettes and negative effects of smoking on various parts of the body. Benefits of smoking cessation are outlined. The document also summarizes several research studies on smoking cessation methods and their effectiveness, including enhanced motivational interviewing versus brief advice, nicotine replacement therapy, and a randomized trial of nicotine replacement therapy patches in pregnancy. Barriers to smoking cessation and electronic cigarettes are also discussed.

1. SMOKING
CESSATION
Laila Mahzari
Sara Alajmi
Bushra Alenazi
Weam Nasser
Fatimah Alduheem

2. Objectives
• Introduction.
• Chemical components in cigarettes.
• The negative effects of smoking.
• Benefits of Smoking Cessation.
• Electronic Cigarettes: Human Health Effects.
• Enhanced Motivational Interviewing Versus Brief
Advice For Adolescent Smoking Cessation: Results
From A Randomized Clinical Trial.
• Nicotine Replacement Therapy.
• A Randomized Trial of Nicotine-Replacement Therapy
Patches in Pregnancy.
• Zyban for smoking cessation in a general: the
response to an invitation to make a quit attempt.
• Perceived barriers to smoking cessation in selected
vulnerable groups: a systematic review of the
qualitative and quantitative literature.
• Barriers and motivators to gaining access to smoking
cessation services amongst deprived smokers.
• Conclusion

3. INTRODUCTION
Laila Mahzari

4. Introduction
• Cigarette smoking is one of the major preventable causes
of morbidity and mortality all over the world.
• According to World Health Organization (WHO, 2008)
Tobacco is the second major cause of death. It is currently
responsible for the death of 1 in 10 adults.

5. Cont.
• In 2005, tobacco caused 5.4 million deaths which was 1 in
every 6 seconds.
• It is the major risk factor for the development of chronic
obstructive pulmonary disease (COPD), lung cancer and
contributes to risk for heart disease and many other
conditions.

6. Cont.
• There are more than 15 billion cigarettes smoked a day
around the world .(World Health Organization; U.S. Centers for Disease
Control and Prevention; Action on Smoking and Health (ASH)).
• Smoking is the main cause of behind the death of 13,544
in Saudi Arabia, according to statistics published by the
Saudi Charitable Society to Combat Smoking on its
website (Ghafour, 2008).

7. Cont.
• The cigarette imports in the country were SR1.7 billion in
2005 and the economic losses caused by smoking were
SR25 billion in the five years from 2005 to 2010.
• The majority of Saudi smokers who took part in a recent
survey said they started practicing the damaging habit as
a result of the influence of friends.
• Some participants (8.4 percent) said it was the family
impression that made them smokers while 5.9 percent
blamed work pressure for smoking.

8. Cont.
• The total population of the Kingdom is 26.5 million
according to a July 2012 estimate by Central Intelligence
Agency (CIA), US. It is estimated that about a quarter of
Saudi Arabia's residents smoke.
• Smokers in Saudi Arabia spend more than SR5 billion to
buy some 40,000 tons of tobacco yearly, not to mention
other losses related to the high cost of the treatment of
serious diseases associated with smoking (Fakeeh,
2011).

9. • Chemical components in cigarettes
Because the nicotine in tobacco is addictive, quitting smoking
can be challenging.

10. The negative effects of tobacco and
smoking are :
Eyes Macular degeneration
Hair Hair loss
Skin Aging, wrinkles, wound infection
Brain Stroke
Mouth
and
pharynx
Cancer, gum disease
Lungs Cancer, chronic obstructive pulmonary disease
(emphysema and chronic bronchitis), pneumonia,
asthma
Heart Coronary artery disease, raised blood pressure

11. Cont.
Stomach Cancer, ulcer
Pancreas Cancer, increase blood glucose levels and less
control over blood glucose levels
Bladder Cancer
Women Cervical cancer, early menopause, irregular and
painful periods, infertility
Men Impotence
Arteries Peripheral vascular disease
Bone Osteoporosis

12. Cont.
• Smoking during pregnancy Increased risk of:
• miscarriage
• premature birth
• low birth weight infant
• Effect of tobacco smoke on children Increases the risk
of:
• respiratory infections
• middle ear infections
• meningococcal infections
• asthma.

14. Health benefits of quitting
12 hours Blood levels of carbon monoxide are significantly
decreased
5 days Improvements in the sense of taste and smell
6 weeks Risk of wound infection after surgery substantially
reduced
3 months Lung function is improving as cilia recover
1 year Risk of coronary heart disease is halved after one year
compared to continuing smokers
10 years Risk of lung cancer is halved and continues to decline
15 years All cause mortality falls to the same level as for those
who have never smoked

15. Electronic Cigarettes:
Human Health Effects
May 2014 Sara Alajmi

16. • Methods:
Systematic literature searches were conducted through September
2013 to identify research related to e-cigarettes and health effects. Five
reference databases (Web of Knowledge, PubMed, SciFinder, Embase
and EBSCOhost)
• e-cigarette components.

17. Physiological effects observed in clinical studies:
• mouth and throat irritation and dry cough at initial use.
• no change in heart rate, carbon monoxide (CO) level, or plasma
nicotine level.
• increase respiratory flow resistance similar to cigarette use.
• no change in complete blood count (CBC) indices.

18. • Exposure risks for non-users:
react with ambient nitrous acid to produce TSNAs, leading
to inhalation, ingestion, or dermal exposure to carcinogens.
• Potential for reduced harm or cigarette smoking
cessation.
• Marketing information frequently includes a stated or
implied claim that using e-cigarettes will help smokers quit
or reduce cigarette use. Supporting data, however, are
quite limited. small studies have demonstrated short-term
reduction in cigarette smoking while using e-cigarettes.

19. These 81 respondents included 72
daily users of ecigarettes, one non-
daily user and eight former users .

20. • Conclusions
• e-cigarettes have potential advantages over traditional
cigarettes, there are many deficiencies in the available
data.
• There are not adequate data to support the safety of long-
term use of electronic cigarettes at this time.
• No e-cigarette has been approved by FDA as a cessation
aid.

21. Enhanced Motivational Interviewing Versus
Brief Advice For Adolescent Smoking
Cessation: Results From A Randomized Clinical
Trial
Published in 2012

22. Methods
• Adolescent cigarette smokers 14–18 years old (n = 162)
• 85 males
• 77 females
• smoke at least once per week for the past month.
• MI = 79 BA= 83
• Patients with recent traumatic injury (in medical settings)
were excluded

23. MI
• therapeutic style:
1) establishing rapport
2) exploring pros and cons of smoking and quitting.
3) delivery of computer-generated personalized assessment
feedback.
4) imagining the future with and without smoking.
5) reviewing a menu of change options and .developing a change
plan.
6) enhancing self-efficacy for change.

24. • Telephone boosters.
discussion was designed to reinforce progress toward goals in
MI , In BA, the 5-minute discussion reiterated strong directive
advice to quit smoking and maintain abstinence .
• Parent intervention:
in MI focused on increasing parent support for the
adolescent’s goals for changing smoking
Parents in both conditions were mailed informational
materials on helping adolescents quit smoking.

25. Finally
• There is a need for efficacious interventions for
adolescent smokers. In this trial, MI modestly reduced
smoking rates (average cigarettes per day) in the short-
term compared to BA.
• MI may provide an efficacious first step toward smoking
cessation. An important direction for future intervention
development research is how best to capitalize on these
proximal effects to lead to longer-term abstinence for
adolescent smokers.

26. NICOTINE REPLACEMENT
THERAPY
Bushra Alenazi

27. How It Works?
• It helps to reduce nicotine withdrawal and craving (by
supplying the body with nicotine).
• It contains about one-third to one-half the amount of
nicotine found in most cigarettes.
• Nicotine replacement therapy is safe when used
properly.
• Nicotine by itself is not nearly as harmful as smoking.
• Tars, carbon monoxide, and other toxic chemicals in
tobacco cause harmful effects, not the nicotine

28. Types of NRT
• The US Food and Drug Administration (FDA) has
approved 5 forms of nicotine replacement therapy:

29. Studies

30. Adverse events associated with nicotine replacement
therapy (NRT) for smoking cessation.
 A systematic review and meta-analysis of one hundred and twenty studies
involving 177,390 individuals
 Edward J Mills1*, Ping Wu2, Ian Lockhart3, Kumanan Wilson4, Jon O Ebbert5
 Published in 2010

31. METHOD
10 electronic databases
from inception to
November 2009
Ninety-two RCTs involving
32,185 participants
28 observational studies
involving 145, 205
participants were
identified.

32. RESULT
pooled RCT evidence of varying NRT formulations found :
• increased risk of:
heart palpitations
and chest pains
nausea and vomiting gastrointestinal complaints
insomnia

33. Cont: Result
• Pooled evidence specific to the NRT:
patch found an
increase in skin irritations
Orally administered NRT was associated
with mouth and throat soreness , mouth
ulcers ; hiccoughs and coughing

34. Cont: Result
• There was no statistically significant increase in anxiety
or depressive symptoms associated with NRT use.

35. Discussion
• Although NRT was associated with an increased risk of heart
palpitations, the review did not observe an increased incident of heart
attack or death.
• The most serious adverse event reported in both RCTs and
observational studies were heart palpitations and chest pains.
• Psychological adverse events, particularly suicidal ideation, are a major
concern in patients initiating smoking cessation. They found only one
large retrospective observational study that discussed this topic and
reported no significant difference in fatal and non-fatal self-harm
associated with NRT compared to other frequently used
pharmacotherapies, bupropion or varenicline.

36. conclusion
• This review demonstrates that NRT is associated with adverse
effects that may be discomforting for the patient but are not life-
threatening.
• Clinicians should inform patients of potential side effects which
are associated with the use of NRT for the treatment of tobacco
dependence.

37. Second study
• A Randomized Trial of Nicotine-Replacement Therapy
Patches in Pregnancy
• march 1, 2012

38. METHODS
They took participants from 7 hospitals in England who where:
 16 to 50 years of age
 with pregnancies of 12 to 24 weeks’ gestation
 smoked 5 or more cigarettes per day.
Participants received:
1- behavioral cessation support
2- and they randomly assigned to 8 weeks of treatment :
 With active nicotine patches (15 mg per 16 hours)
 or matched placebo patches.

39. Cont: METHOD
• Abstinence from the date of smoking cessation until
delivery:
Validated by measurement of exhaled carbon
monoxide or salivary cotinine.
• Safety was assessed by monitoring for adverse
pregnancy and birth outcomes.

40. Result
• Of 1050 participants, 521 were randomly assigned to
nicotine-replacement therapy and 529 to placebo:

41. • There was No significant difference in the rate of abstinence from
the quit date until delivery between the nicotine-replacement and
placebo groups.

42. conclusion
Adding a nicotine patch (15 mg per
16 hours) to behavioral cessation
support for women who smoked
during pregnancy did not
significantly increase the rate of
abstinence from smoking until
delivery or the risk of adverse
pregnancy or birth outcomes.

43. Weam Nasser

44. • The objective of this study to assess the feasibility and
success of Zyban as part of smoking cessation
programme within UK general practice.
Sample:
smokers
Never used Zyban
Had participated in previous NRT trial
(PATCH 2 study in 2000 )
N= 479

45. Continuing smokers from
the Patch 2 study, who had
never used Zyban
(n=479)
Excluded (n=240)
- Previous use of Zyban
- -risk of seizures
- -clinical contra-
indications
- Other medications
- Light or x-smokers
- Moved away
- Died
- Refused contact
- Other
INVITED (n=239)
Refused (n=65)
No Reply (n=40)
Accepted (n=134)
Failed to contact
their GP
Made and kept GP
appointment (n=79)
Eligible to enter the
study (n=74)
Met the nurse and set
quitdate (n-63)
Made a quit attempt
(n=54)
Figure 1. Flow diagram of Participation.

46. 1. The
participan
ts discuss
the study
with their
GP
2. The GP
then
prescripti
on for
Zyban
(60 × 150
mg
tablets)
3. the
study
schedule
followed
was 150
mg once
daily for
six days
4.
increasin
g to
twice
daily
(total
300
mg/day)
from day
7
5. If
tolerated
,
makin
g the
quit
attem
pt

47. Fagerstrom test

48. Hospital Anxiety and Depression Scale (HADS)

49. the Eysenck Personality
questionnaire.

50. Testing scales
and
questionnaires
Smoking
status
(cotinin
e)
@8-12-
26-52
weeks
They were
Geno-typed
(SNPs)

51. 3×10
marked
difference
between
men and
women
P<0.05

52. successful quitters at six and twelve
months in PATCH 3 showed a trend to
lower mean nicotine dependency
score (11.8 and 12.2 respectively)
than those who made an
unsuccessful quit attempt (14.4).
The most notable positive finding was
that women fared less well than men,
which is a not uncommon finding and
suggests that additional ways to help
female smokers overcome the
problems they face may be
warranted.
Too few subjects!!

53. Weam Nasser

54. between July 2011 and July 2013
Randomized double blinded, placebo control trial
Done @ 61 center In 10 countries
(Australia, Canada, Czech Republic, Egypt, Germany, Japan, Mexico,
Taiwan, United Kingdom, and United States)
Participants were recruited through advertising.
24 weeks:
12 weeks reduction
12 weeks of abstinence
28 weeks: follow-up

55. Eligibility
- Age >=18
- Smoke around >=10 cigarettes/day
- No abstinence period >3months/past year
- Exhaled CO > 10ppm
- Not willing or able to quit smoking the next month,
But willing to reduce smoking the next 3 months
Exclusion:
history of a suicide attempt or suicidal behaviour
major depressive
Psychosis
panic disorder
posttraumatic stress disorder
or schizophrenia
severe chronic obstructive pulmonary disease
alcohol or substance abuse
significant cardiovascular or cerebrovascular disease
pregnancy, lactating
Of 1747 potentially eligible participants
screened, 1510 (86%) was accepted

57. Method Week 1
Week 4: 50%
Week 6
Week 8:
75%
Week 12:
Quitting
Counselling training was provided
-Advices on reduction techniques
-focus on problem solving
-skills training
-highlight successes.
Vareneciline or
placebo at dose of
0.5mg once/day
for
3 days
0.5mg twice/day
from day 4-7
1.0mg twice/day

58. • continuous abstinence rate (CAR) during the last 10
weeks of treatment (weeks 15-24)
• CARs during weeks 21 through 24
• during weeks 21 through 52.

59. Enrollment

60. Results

61. Time Vareneciline placebo
4 Weeks 50% 47.1% 31.1%
8 Weeks 75% 26.3% 15.1%

62. Conclusion
• Among cigarette smokers not willing or able to quit within
the next month, but willing to reduce cigarette
consumption and make a quit attempt at 3 months, use of
Vareneciline for 24 weeks compared with placebo
significantly :
increased smoking cessation rates at the end of treatment

63. PERCEIVED BARRIERS TO SMOKING
CESSATION IN SELECTED VULNERABLE
GROUPS: A SYSTEMATIC REVIEW OF THE
QUALITATIVE AND QUANTITATIVE
LITERATURE
Received 25 August 2014
Accepted 20 November 2014
Published 22 December 2014
Fatimah Alduheem

64. Design
A systematic review was carried out to identify the
perceived barriers to smoking cessation within six
vulnerable groups.

65. Objectives
To identify barriers that are common and unique to six
selected vulnerable groups: low socioeconomic status;
Indigenous; mental illness and substance abuse;
homeless; prisoners; and at-risk youth.

66. Aims
A.Identify barriers that are common across all vulnerable
groups included in the review.
B.Identify barriers that may be unique to specific groups.
The results of the review will be used to develop a practical
model to help understand the barriers to quitting among
vulnerable groups and to aid smoking cessation
intervention development.

67. Methods
• Study design.
• Databases and search.
• Inclusion and exclusion criteria.
• Risk of bias in individual studies.

70. Discussion
• Main barriers identified across all vulnerable
groups :
1.Stress management.
2.Lack of support to quit from health professionals
and other service providers.
3.High prevalence and acceptability of smoking.

71. Barriers specific to certain groups
• Indigenous groups :
Indigenous groups identified unique stressors linked to
smoking including racism and historical factors; cultural
practices including ceremonial use of tobacco and cultural
values that promote sharing.
• Prisoners :
Prisoners identified unique stressors within their living
conditions that contributed to their smoking including social
isolation, anxiety regarding legal matters and transfers to
other prisons.
• People with a mental illness :
Low motivation to quit smoking.

72. Conclusion
Vulnerable groups experience common barriers to
smoking cessation, in addition to barriers that are
unique to specific vulnerable groups. Individual-
level, community-level and social network-level
interventions are priority areas for future smoking
cessation interventions within vulnerable groups.

73. BARRIERS AND MOTIVATORS TO GAINING
ACCESS TO SMOKING CESSATION SERVICES
AMONGST DEPRIVED SMOKERS
qualitative study
Received: 2 August 2006
Accepted: 6 November 2006
Published: 6 November 2006

74. Background
Smoking is strongly associated with disadvantage and is an
important contributor to inequalities in health. Smoking
cessation services have been implemented in the UK
targeting disadvantaged smokers, but there is little
evidence available on how to design services to attract this
priority group.

75. Methods
We conducted focus groups with 39 smokers aged 21–75
from the most socio-economically deprived areas of
Nottingham UK who had made an unsuccessful attempt to
quit within the last year without using smoking cessation
services, to identify specific barriers or motivators to
gaining access to these services.

76. Discussion
The participants in this study were smokers who had previously
attempted to quit smoking without formal support, and who lived
in extremely deprived areas. Although motivated to quit smoking,
they felt that their smoking was intractable and were torn
between thinking that only intensive measures would help them
to stop but also that all that was really required was willpower.
They felt increasingly marginalised by society and government
and felt that their addiction was not taken as seriously as
addiction to heroin or alcohol. They knew little about the services
available to help them, but perceived them to be ineffective and
expensive despite evidence to the contrary. Participants stated
the need for a wide variety of cessation group timings and
locations without being aware that these services already
existed.

77. Results
• Barriers to use of existing services related to fear of being judged,
fear of failure, a perceived lack of knowledge about existing services,
a perception that available interventions – particularly Nicotine
Replacement Therapy – are expensive and ineffective, and negative
media publicity about bupropion.
• Participants expressed a preference for a personalised, non-
judgemental approach combining counselling with affordable,
accessible and effective pharmacological therapies; convenient and
flexible timing of service delivery, and the possibility of subsidised
complementary therapies.

78. Conclusion
We conclude that smokers from these deprived areas
generally had low awareness of the services available to
help them, and misconceptions about their availability and
effectiveness. A more personalized approach to promoting
services that are non-judgmental, and with free
pharmacotherapy and flexible support may encourage
more deprived smokers to quit smoking.

79. Conclusion

80. Summary
• Cigarette smoking is one of the major preventable causes of morbidity and
mortality all over the world.
• The earlier smoking is stopped, the greater the health gain.
• No e-cigarette has been approved by FDA as a cessation aid
• There is a need for efficacious interventions for adolescent smokers
• This review demonstrates that NRT is associated with adverse effects that
may be discomforting for the patient but are not life-threatening.

81. Cont.
• Adding a nicotine patch during pregnancy did not significantly increase the
rate of abstinence from smoking until delivery or the risk of adverse
pregnancy or birth outcomes.
• Zyban can reduce the nicotine dependency score within a 12 months course.
• Gender and genotype may play a role in smoke cessation, but further studies
are needed to ensure that.
• Vareneciline helped in smoke cessation for smokers whose unable to stop
within 3 months.
• There are many barriers to quit smoking but with the strong motivation they
can quit smoking.