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.

1. Dr. Badriya Al-mahrouqi
7/12/2016

2. OBJECTIVES
To know type of tobacco available
Side effect of tobacco
Sign and symptoms of tobacco dependence
Importance of tobacco dependence treatment
Modalities of treatment

3. INTRODUCTION
 Tobacco use is the greatest potentially remedial problem throughout
the world,
 it is the number one preventable cause of death in the developed
world.
 Clinicians have a particularly important role as patient advocates in
health promotion, discouraging smoking initiation, encouraging and
assisting smoking patients to quit, and participating in social efforts
designed to curb smoking at various level
 Professional group therapy or counseling achieves an initial
cessation rate of 60-100% and a 1-year cessation rate of
approximately 20%.

4. TYPE OF NICOTINE
Cigarrate smoking
Shisha
Midwakh
pipe
Unsmoked tobacco (afdhal)

5. NICOTINE SIDE EFFECT
 Cancers associated with tobacco use:
 Lung cancer Oral cancer Laryngeal cancer Esophageal cancer Kidney
and bladder cancers Cervical cancer Pancreatic cancer Stomach cancer
Colorectal cancer Acute Myelod Leukemia Liver cancer
 Cardiovascular Effects Heart attack (coronary heart disease) Stroke
(cerebro-vascular disease) Peripheral arterial disease, resulting in increased risk
of amputations
 Respiratory Effects COPD Tuberculosis

6.  Smoking and diabetes: Smoking raises blood glucose, increases the body’s
resistance to insulin, and causes changes in LDL and HDL profiles. Smoking is thus
an important risk factor for diabetes.
 Smoking and infertility: Smoking is associated with impotence and
infertility and is a probable cause of unsuccessful pregnancies
 Smoking increases frequency of menstrual abnormalities :
NICOTINE SIDE EFFECT

7.  Smoking increases the risk of erectile dysfunction
 Smoking and pregnancy effects: Smoking causes intrauterine growth
retardation, leading to low birth weight babies Smoking causes ectopic
pregnancy
 Smoking and other health effects: Rheumatoid arthritis Impaired
immune function Age-related macular degeneration poor oral health
 Smoking cause nicotine dependence

8. SYMPTOMS AND SIGN OF
NICOTINE DEPENDENCE
 Fagerström Test for Nicotine Dependence (FTND), which is composed of six
questions. The Fagerstrom scale is a validated tool and widely used. The total test
score determines level of dependence:
 – 0-2 Very low dependence
 – 3-4 Low dependence
 – 5 Medium/moderate dependence
 – 6-7 High dependence
 – 8-10 Very high dependence

9. FAGERSTRÖM TEST FOR NICOTINE
DEPENDENCE
 1. How soon after you wake up do you smoke your first cigarette
Within 5 minutes 3 - 6–30 minutes 2 - 31–60 minutes 1- After 60 minutes 0
 2. Do you find it difficult to refrain from smoking in places where it is forbidden
(e.g., in places of religious worship, at the library, cinema, etc.)?
 3. Which cigarette would you hate most to give up?
The first one in the morning 1 - Any other 0
 4. How many cigarettes a day do you smoke?
 10 or less 0 -11–20 1 - 21–30 2 - 31 or more 3
 5. Do you smoke more frequently during the first hours after waking than during
the rest of the day? Yes 1 – No 0
 6. Do you smoke if you are so ill that you are in bed most of the day? Yes 1 – No 0

10. BENEFITS OF QUITTING
A. Immediate gains
Heart rate and blood pressure begin to normalize
 CO levels drop within hours
 Within weeks, circulation has improved, and coughing
and phlegm production decreased
Within months, lung function and sense of smell/taste
have improved

11. B. Long-term benefits
 Coronary heart disease risk is substantially reduced within 1 to 2 years of cessation
 Reduced risk of developing and dying from cancer (e.g. lung, oesophageal, bladder).
However o Decline in risk of cancer takes a number of years after quitting but
benefit increases the longer a person remains smoke free
 Risk of diseases such as PVD and COPD decreases

12. ROLE OF MEDICAL STAFF

13. TREATMENT METHODS
 counseling,
 NOCOTINE REPLACEMENT THERAPT (NRT)
 antidepressant medications
 behavioral training
 group therapy
 hypnosis
 quitting “cold turkey.

14. COUNSELING
According to US Preventive Services Task Force
(USPSTF) guidelines, clinicians should ask all
adults about use of tobacco products and should
provide cessation interventions to all current
tobacco users.
A: Ask about tobacco use
A: Advise to quit.
R: Refer patient to TDT clinics

15. A: Ask about tobacco use
 Ask every patient about tobacco use at every visit (at
least once a year) to determine if patient is current,
former, or never tobacco user.
 Determine what form of tobacco is used.
 Determine frequency of use (e.g. number of cigarettes or
waterpipes smoked daily/weekly).
 Document tobacco use status in patient’s clinical record.

16. A: Advise to quit.
 In a clear, strong, and personalized manner, urge every
tobacco user to quit.
 If relevant, explain how smoking is related to the
existing health problems and how stopping smoking might
help.
 Highlight the benefits of quitting smoking.
 Tobacco users who have not succeeded in previous quit
attempts should be told that most people try repeatedly
before permanent quitting is achieved.
 Document advice given in patient’s clinical record.

17. R: Refer patient to TDT clinics
 Assist those interested in quitting by providing
information on TDT clinics. If you do not have the
expertise or time to help people to stop smoking, refer
smokers to smoking cessation services. If you do have
expertise and are thus able to, provide Face-to-Face
support.
 For all smokers, provide self-help material (if available).
 Document what was done for the patient in patient’s
record.

18. NDT CLINIC

19. COUNCELLING
The guidelines advocate a “5-A” approach to counseling
that includes the following[31] :
A sk about tobacco use
A dvise to quit through personalized messages
A ssess willingness to quit
A ssist with quitting
A rrange follow-up care and support

20.  Assessing level of motivation to quit
Assessing importance:
On a scale of 0 to 10, how important is it for you to quit
smoking today?
Assessing confidence:
On a scale of 0 to 10, how confident are you in your ability to
quit smoking today?
Assess willingness to quit

21. Designing a Quit Plan
 1. Setting a target quit date (TQD)
 o Patients given a week (maximum 2 weeks if nicotine dependence is high)
 2. Determine best pharmacotherapy for patient
 o Instruct patient on how to start medications (oral - Bupropion, Varenicline) in
the week before TQD
 o Instruct patient on how to start NRTs on TQD
 o Advise patient on major side effects for medications.
Assist with quitting

22. Designing a Quit Plan
 3. During the week before TQD, patient must put in substantial effort to start the
quitting process. Advise your patients to:
 o Learn not to smoke in closed places
 o Change favorite location to smoke
 o Remove all ashtrays from house to avoid visual triggers
 o keep in-door air free from smoke
Assist with quitting

23.  o Learn how to deal with acute urges: Manage the urge by:
 Drinking water
 Changing place: go out and walk
 Going to bed early if urge is around bedtime
 Taking a hot shower
 Going to the gym
 Chewing or sucking on items with strong taste as a minty
sugarless gum or miswak
 Staying away from alcohol or coffee/tea
Assist with quitting

24. o Cut back gradually in number of cigarettes smoked
4. Emphasize to patients that these changes in the week
before the TQD are important to commit to and will help
increase chance of success
5. Provide support and encouragement.
6. Provide any needed information.
ASSIST WITH QUITTING

25. NICOTINE WITHDRAWAL
SYMPTOMS
 The following are symptoms that a smoker may experience upon reduction of or
quitting tobacco use. Symptoms can vary in severity from one smoker to another
and most of them disappear within four weeks of abstinence.
 Symptoms include:
 Irritation Anger Weight gain Insomnia Concentration difficulties
Anxiety Restlessness Dysphoria Decreased heart rate Performance
deficits Craving for smoking Headache

26. NICOTINE REPLACEMENT
THERAPY
 There are at least 3 mechanisms by which NRT could be effective, as follows:
 Reducing general withdrawal symptoms, thus allowing people to learn to get by
without cigarettes
 Reducing the reinforcing effects of tobacco-delivered nicotine
 Exerting some psychological effects on mood and attention states
 Nicotine replacement medications should not be viewed as standalone medications
that make people stop smoking; reassurance and guidance from health
professionals are still critical for helping patients achieve and sustain abstinence.

27.  There are 6 types of nicotine replacement products currently on the market, as
follows:
 Transdermal nicotine patch
 Nicotine nasal spray
 Nicotine gum
 Nicotine lozenge
 Sublingual nicotine tablet
 Nicotine inhaler
NICOTINE REPLACEMENT
THERAPY

28.  Currently, 4 patch formulations are on the market; they vary widely with regard
to design, pharmacokinetics, and duration of wear (eg, 16 or 24 hours). For some
products, progressively lower doses may be given to allow weaning over a period of
several weeks or longer so that the patient can gradually adjust to lower nicotine
levels and ultimately to a nicotine-free state. Those who smoke more than 10
cigarettes per day should use the 21-mg/day patch for the first 6 weeks, the 14-
mg/day patch for 2 weeks, and the 7-mg/day patch for the final 2 weeks.
 individualized for each patient according to the patient’s level of nicotine
dependence. Most patients are started with 1 or 2 doses per hour, which may be
increased up to the maximum of 40 doses per day.

29.  Efficacy of NRT
 In a Cochrane meta-analysis of 132 trials involving the use of any type of NRT
along with a placebo or non-NRT control group, the risk ratio (RR) of abstinence
for any form of NRT relative to control was 1.58 (95% confidence interval [CI],
1.50-1.66).[3] The pooled RRs for each type were as follows:
 1.43 (95% CI, 1.33 to 1.53; 53 trials) for nicotine gum
 1.66 (95% CI, 1.53-1.81; 41 trials) for the transdermal nicotine patch
 1.90 (95% CI, 1.36-2.67; 4 trials) for the nicotine inhaler
 2.00 (95% CI, 1.63-2.45; 6 trials) for oral tablets or lozenges
 2.02 (95% CI, 1.49-3.73, 4 trials) for the nicotine nasal spray

30.  Long-term NRT
 Smoking cessation treatments with NRT enable smokers to cease tobacco use and
subsequently to withdraw from nicotine altogether. However, for some smokers,
complete withdrawal from smoking may be difficult. In those individuals, it may
be beneficial to continue NRT for longer periods, even indefinitely, to prevent
relapse to smoking. This strategy is essentially the same as that currently used in
methadone maintenance programs for heroin-dependent patients, where patients
may be maintained on daily doses of methadone for years.
 Although nicotine is not entirely without risk, nicotine maintenance is clearly
safer than cigarette smoke–delivered nicotine, with its numerous accompanying
toxins. Therefore, indefinite NRT to prevent resumption of smoking may be
considered for some individuals.

31. ORAL MEDICATION
 Bupropion
 Bupropion acts by alleviating some of the symptoms of nicotine withdrawal, which
include depression.[41, 42] One clinical trial demonstrated that highly nicotine-
dependent smokers who receive bupropion are more likely to experience a decrease in
depressive symptoms during active treatment. Like NRT products, bupropion has been
endorsed by the US Clinical Practice Guideline as a first-line therapy.[4]
 Compared with placebo, bupropion approximately doubles smoking cessation rates,
and it is equally effective for men and women. It may yield higher cessation rates
when combined with NRT than when used alone. However, Planer et al found that
bupropion was not effective in hospitalized patients with acute coronary syndrome
(patients who are at high risk for subsequent ischemic events) despite continuous and
intensive nurse counseling about smoking cessation.[43]
 The recommended and maximum dosage of bupropion is 300 mg/day, given as 150 mg
twice daily. Dry mouth and insomnia are the most common adverse events associated
with use. A very small risk of seizure exists, which can be reduced by not prescribing
the medication to persons with a history of seizure or a predisposition toward seizure.

32.  Varenicline
 Varenicline is a partial agonist that is selective for alpha-4, beta-2 nicotinic
acetylcholine receptors (nAChRs). Its action is thought to result from activity at a
nicotinic receptor subtype, where its binding produces agonist activity while
simultaneously preventing nicotine binding. Its agonistic activity is significantly
lower than that of nicotine. Varenicline helps smokers quit by preventing
withdrawal symptoms while moderate levels of dopamine are maintained in the
brain.
ORAL MEDICATION

33. COMBINATION
PHARMACOTHERAPY
 To improve smoking cessation, medications can be combined. For example, passive
nicotine delivery (eg, via a transdermal patch) may be used in conjunction with
another medication that permits acute dosing (eg, gum, nasal spray, or inhaler).
Combining the nicotine patch (which may prevent the appearance of severe
withdrawal) with acute-dosing formulations (which can provide relief in trigger-to-
smoke contexts) may provide an excellent treatment alternative to the use of
either therapy alone.[47, 48]
 Bupropion in combination with a nicotine patch appears to be more efficacious
than a nicotine patch alone, possibly because the 2 medications act via different
pharmacologic mechanisms.[49] Despite the possibility of increased efficacy, the US
Clinical Practice Guideline recommends that such combination therapy be
prescribed under the direction of an experienced clinician or a specialty clinic.

34.  Long-Term Monitoring
 Highly nicotine-dependent smokers may require initial therapy for 6 months or
longer. Some individuals may require low-dose maintenance therapy for years.
 Long-term follow-up is recommended because individuals who successfully quit
smoking are at high risk for relapse. Relapse during the first year after achieving
smoking cessation occurs in approximately 50% of patients, irrespective of
therapeutic regimen. The changes in the central nervous system (eg, in neuron
genetics, cell structure, and cell function) induced by smoking are not reversed by
pharmacologic therapy.
ARRANGE FOLLOW-UP CARE
AND SUPPORT

35. RELAPSE
PREVENTION
 1. Address relapse at the initial assessment
 2. Identify with the patient situations that can cause relapse.:
 o Triggers to relapse
 a. Negative emotions: anger, frustration, boredom
 b. Interpersonal conflicts: marriage, employer-employee
 c. Social pressure: other tobacco users
 o Pattern of use: morning, work, etc…
 o Exposure to SHS and smoking cues
 o Urge stimulants such as alcohol and coffee
 o Note that not all relapse triggers are stressful or negative situations:

36.  3. Build patient’s confidence by developing ways to guide them safely through
such situations: o Build patient’s coping skills:
 a. Cognitive: things patient can tell him or herself
 b. Behavioral: things patient can do (see below) o Teach them how to reduce the
urge in trigger situations o Remind them of how they avoided relapse in similar
situations 4. Use of imagery
RELAPSE
PREVENTION

37.  5. Individualize the medication plan – reinstate, adjust or combine medications.
 Examples: building patient’s cognitive coping skills
 Tell myself, “I can do this.” Recall the reasons I want to quit. Tally the
progress I’ve made so far. Remind myself smoking will not solve the problem(s)
I’m facing right now. “I’m not smoking today.” Play the cigarette through to
the end.
 Examples: building patient’s behavioral coping skills
 Leave the situation Take a deep breath Use a strong mint Eat something
Go for a walk Call a friend Exercise
RELAPSE
PREVENTION

38. TAKE HOME MESSAGE
 Tobacco dependence is a chronic relapsing disease that requires
treatment, same as other chronic diseases. It takes 20-25 minutes to
help a smoker to quit (5-10 minutes at an initial visit and then
several minutes at subsequent follow-up visits).
 Clinicians should encourage all patients who smoke to use
medications as medically appropriate for treating tobacco
dependence.
 When it is not possible to use pharmacological treatment, using non-
pharmacological therapy such as counseling sessions remains
recommended, so that all smokers receive therapeutic support.

39. REFFERANCES
 Jordan Guidelines for Tobacco Dependence Treatment “Helping Smokers Quit”
 http://emedicine.medscape.com/article/287555-treatment#showall
 AMERICAN COLLEGE OG MEDICAL TOXICOLOGY