Helping your patients quit smoking

• Is smoking that dangerous• Quitting: research to practice • Neurobiology of smoking • What to target – prevention or

quitting

• Is smoking that dangerous• Quitting: research to practice • Neurobiology of smoking • What to target – prevention or

quitting

INTERHEART: Smoking and MI

1

2

4

8

16

Cont 7489 727 1031 446 1058 96 230 168 56Cases 4223 469 1021 623 1832 254 538 459 218OR 1 1.38 2.10 2.99 3.83 5.80 5.26 6.34 9.16

Never 1-5 6-10 11-15 16-20 21-25 26-30 31-40 41+

OR

(9

9%

CI)

INTERHEART: Clinical implications

Yusuf S et al. Lancet. 2004;364:937-52.PAR = population attributable riskApo = apolipoprotein

• 9 simple and modifiable risk factors are strongly associated with acute MI worldwide.

• These 9 risk factors account for >90% of the PAR globally and in most regions.

• Abnormal ApoB-ApoA1 ratio and smoking are the 2 most important risk factors and account for over two thirds of the PAR.

• Implementing preventive strategies based on our current knowledge would prevent the majority of premature CHD worldwide.

Tobacco products are responsible for three million (30 lakh) deaths annually world wide or about 6% of all deaths

• Is smoking that dangerous• Quitting: research to practice • Neurobiology of smoking • What to target – prevention or

quitting

40 55 70 85 100

Age

0

20

40

60

80

100

% A

live 59

12

80

33

80

33

Doll et al BMJ

7.5 years

Current cigarette

smokers

Never smoked

regularly

Overall risk to smokers and never-smokers

40 55 70 85 100

Age

0

20

40

60

80

100

% A

live

40 55 70 85 100

Age

0

20

40

60

80

100

% A

live

40 55 70 85 100

Age

0

20

40

60

80

100

% A

live

40 55 70 85 100

Age

0

20

40

60

80

100

% A

live

Former smokers

stopped 35-44

Former smokers

stopped 45-54

Former smokers

stopped 65+

Former smokers

stopped 55-64

Effects on survival after ages 45, 55, 65 & 75

of stopping smoking in previous decade

Doll et al BMJ

nonsmokers

smokers

• Is smoking that dangerous• Quitting: research to practice • Neurobiology of smoking • What to target – prevention or

quitting

the first exposure to nicotine can create an enduring ‘memory trace,’ which instills the desire to repeat the experience and amplifies the pleasing effects of subsequent nicotine exposure

Molecular and Behavioral Aspects of Nicotine Addiction

Benowitz N. N Engl J Med 2010;362:2295-2303

International journal of Biochemistry and cell biology 41 (2009)

Continuous Abstinence Rates The Ns shown in the key are the denominators used for all 3 periods.

Gonzales, D. et al. JAMA 2006;296:47-55

Copyright restrictions may apply.

Varenicline as Compared with Placebo

Hays J, Ebbert J. N Engl J Med 2008;359:2018-2024

• Is smoking that dangerous• Quitting: research to practice • Neurobiology of smoking • What to target – prevention or

quitting

1950 1975 2000 2025 2050

Year

0

100

200

300

400

500

Cu

mu

lati

ve d

eath

s fr

om

to

bac

co (

mil

lio

ns)

Trend

520

70

220

Source: Peto et al

Scenarios for future deaths from tobacco

1950 1975 2000 2025 2050

Year

0

100

200

300

400

500

Cu

mu

lati

ve d

eath

s fr

om

to

bac

co (

mil

lio

ns)

If smokinguptake halves

by 2020

Trend

520

70

220

500

Source: Peto et al

Scenarios: impact of prevention

1950 1975 2000 2025 2050

Year

0

100

200

300

400

500

Cu

mu

lati

ve d

eath

s fr

om

to

bac

co (

mil

lio

ns)

If adult smokinghalves by 2020

If smokinguptake halves

by 2020

Trend

520

70

220

190

500

340

Source: Peto et al

Scenarios: impact of cessation

• Any organ that is spared?

Slama et all,1995

1. JAMA2006 ; 296 : 47-552. Thorax 2000 ; 55: 987-99

Ask Advice Assess Assist Arrange follow up

ASK

• Action : every patient at every clinical visit, status of tobacco use queried and documented

• Vital signs • Mark with a sticker or • Colouring in the book

Ask

Advice Assess Assist Arrange follow up

ADVISE

• ACTION: Clear, Strong and personalized manner

CLEAR- It is important that you quit

smoking now and I can help you- Cutting down while you are ill is

not enough- Occasional or light smoking is still

dangerous

STRONG As your doctor I feel that quitting

smoking is the best thing you can do to protect your health. If you are willing we are here to help you out

• PERSONALISEDContinuing smoking worsens your

asthma/increases your child ear infection/you will also get stroke like your father

Frequency of physicians advising patients to quit smoking:

21% of the time

Thorndike in 1995

Ask Advice

Assess Assist Arrange follow up

ASSESS

• Whether he is willing to quit smoking,

• How much is he dependant on smoking

How much is he dependant on NICOTINE

Ask Advice Assess

Assist Arrange follow up

Why he wants to QUIT ? “I will feel healthier right way. More energy,

better sense of smell, taste, breathe & focus I will be healthier the rest of my life. I will lower

my risk for cancer, heart attacks, strokes, earthly death, cataracts & wrinkling.

I will make my wife, kids& friends proud of me I will no longer expose others to my smoke I will have more money to spend. I will be proud of myself. I won’t have worry:when & where I will smoke

next”

Keep track of when & why he smokes

• “Keep a record of every cigarette you smoke.

• Do this for the next few weeks• You will know why and when you smoke• You will learn more about your triggers.• These will help you prepare to fight your

urge to smoke”

Addressing cues

Psychological obstacles to quitting

1. Fear of Failure

Very common obstacle -no one want to fail Quitting can be a very public event -prospect become even more scary Quitting a process of change no one can quit - unless he really

wants to

2.Concerns about loss of productivity

• Nonsmokers tend to perform better than smokers ,both with and without cigarettes in a task that required concentration.

• Smokers who were not allowed to smoke may be thinking about cigarettes, which may distract them

3.Concerns about Stress

• Nicotine is helpful in improving mood and decreasing negative feelings during stressful times.

• If he smokes for stress reduction, he must make the decision that he will find other ways to cope.

4.Concerns about Nicotine Withdrawal

• The more he exposes his body to nicotine, the more his body needs it and the less it responds to it.

• NWS will cause lots of unpleasantness.

Nicotine Withdrawal Syndrome.

• Daily use of nicotine for at least several weeks • Abrupt cessation or reduction of nicotine

followed within twenty four hours by at least four of the following symptoms

-craving for nicotine -irritability ,frustration or anger -anxiety -difficulty concentrating -restlessness -decreased heart rate -increased appetite or weight gain

• Nicotine Withdrawal Syndrome is experienced by one in four heavy smokers and most light smokers experienced no symptoms at all.

• NWS peak in intensity during the first twenty four to forty eight hours after he stops using nicotine.

5.Concerns about his Age

• People over sixty-five who were thinking about quitting, two-thirds were not confident that they could succeed

• Almost half of the smokers over sixty- five reported that they did not believe quitting would provide them with health benefits, and an almost equal number did not believe that continuing smoking would harm them

6.Concerns about weight gain

• Eight in ten who quit will gain weight over a period of two years

• The average weight gain as a result of quitting can be four pounds more than would be expected if you continued smoking

• But why people gain weight the reason being people

smoke instead of eating

• Attention to his diet and exercising can counteract any tendency to gain weight.

Common excuses 1

• My X lived till he was 85 and he smoked

Common excuses 2

• All the damage is already done

Within twenty minutes of last cigarette

• blood pressure - normal • pulse to normal rate• body temperature of peripheries -

increases

Within eight hours

• CO in blood drops to normal • O2 in blood increases to normal

Within forty-eight hours

• nerve ending start re-growing • abilities to smell and taste things -

enhanced

Within seventy- two hours

• The bronchial tube relax, making breathing easier.

Within two weeks to three months

• circulation improves • walking becomes easier• LFT increases by up to 30 percent

With in a year

• coughing• fatigue improves

Long term benefits

1 year - CHD5 years - stroke 10 years - lung Ca15 years - risk of death

Common excuses 3

• A lot of doctors still smoke

Common excuses 4

• What about air pollution

Common excuses 5

• I’ve switched to a filter cigarette

Quit plan

DEPRESSION

CONCENTRATE

STRESS

CRAVING

COUGHING

RELAXATION

CONTROLING THOUGHTS

INSOMNIA

• • • • •

around smokers

facing the morning

enjoying meals

talking on telephone

drinking coffee or tea

having a drink

facing boredom

insomnia

traveling by car

Bowel movement

watching TV

Ask Advice Assess Assist

Arrange follow up

Unmotivated patients

Unmotivated patients

• Relevance • Risks• Rewards • Roadblocks • Repetition

• Relevance • Risks• Rewards • Roadblocks • Repetition

• Encourage the patient to identify why quitting is personally relevant

• Relevance

• Risks• Rewards • Roadblocks • Repetition

• Acute • Long term • Environmental

• Relevance • Risks

• Rewards • Roadblocks • Repetition

• Improved health • Improved sense of smell • Save money • Feel better about yourself • Home, car, clothing, and breath will

smell better • Can stop worrying about quitting • Set a good example for children • Have healthier babies and children • Eliminate children exposure to

smoke • Feel better physically • Perform better in physical activities • Reduced wrinkling/aging of skin

• Relevance • Risks• Rewards • Roadblocks • Repetition

• Withdrawal symptoms • Fear of failure • Weight gain • Lack of support • Depression • Enjoyment of tobacco • Partner or room mate

smokes

• Relevance • Risks• Rewards • Roadblocks

• Repetition

• Repeat the motivational intervention every time the unmotivated patient visits the clinic.

All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis. Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco use status or the use of other reminder systems such as chart stickers significantly increase rates of clinician intervention

Tobacco dependence treatment is effective and should be delivered even if specialized assessments are not used or available

All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates.The time for intervention is 3-5 mins.

The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore, whenever feasible and appropriate, both counseling and medication should be provided to patients trying to quit smoking.

Bupropion SR Nicotine gum are effective smoking cessation treatment that patients should be encouraged to use.

Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations for which there is insufficient evidence of effectiveness

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