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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
TOGETHER WE CAN ACCOMPLISH GREAT THINGS
THANK YOU FOR YOUR PATIENT LISTENING