Cigarette smoking is the single most important cause of disease and premature death in
INDIA
Cigarette smoking is the single most important cause of disease and premature death in
INDIA
Health Effects of Smoking• Heart disease• Lung disease – COPD, asthma• Cancer– Lung, ENT, pancreas– Cervix, colorectal– Skin (squamous cell)
• Vascular disease - impotence• Stroke• Cataracts• Gum disease• Dementia• Early menopause
• Osteoporosis• Wound healing• Anxiety• Miscarriage• SIDS• Hearing loss• Rheumatoid arthritis• Macular degeneration• Tooth decay• Depression• Multiple sclerosis
Smoking in INDIA.Smoking in INDIA.
25% of adults 1/3 are women rate hasn’t dropped in 1990’s 1.3 million quit each year 3,000 teens start each day
adolescent smoking increasing more ex-smokers than current smokers
Involuntary smoking is a cause of disease in
non-smokers
Involuntary smoking is a cause of disease in
non-smokers
Smoking kills more people each year than
alcohol cocaine crack heroin
homicide suicide car accidents fires AIDS
C O M B I N ED!!!
The benefits of quitting
8 hours
Nicotine and carbon monoxide levels halved,Blood oxygen levels return to normal
Within hours.......
24 hours Carbon monoxide eliminated from the body
48 hoursNicotine eliminated from the body,Taste buds start to recover
Within months .......
3-9 months Coughing and wheezing decline
1 monthAppearance improves – skin loses greyish pallor, less wrinkled Regeneration of respiratory cilia startsWithdrawal symptoms have stopped
5 years The excess risk of a heart attack reduces by half
10 years The risk of lung cancer halved
Years .......
The cycle of change
Cycle of change
Pre-contemplation
Contemplation
Determination
Action
Maintenance
Relapse
Have you considered quitting?
Do you smoke?
The cycle of change
Be a positive partnerFocus on the positive health effects of cessation
Not yet considered quitting
• Explain importance of cessation• Offer help as and when they want it.
Pre-contemplation
Pre-contemplation
Contemplation
Ambivalent to cessation
• Move them closer to a cessation attempt• Understand how you can help
Be a positive partnerLet them describe their doubts – and fear of failingIdentify how to plan a quit attemptOffer the ongoing medical support
The cycle of change
Pre-contemplation
Contemplation
Determination
Be supportive and enthusiastic!Give time to planning the attemptSet a quit dateDiscuss problems of withdrawal
Ready to make a cessation attempt
• Provide support for a quit attempt
Pre-contemplation
Contemplation
Determination
Action
Congratulate!Arrange review (even if relapse)
Action! a cessation attempt
• Be available to support the quit attempt
Pre-contemplation
Contemplation
Determination
Action
Maintenance
Be positive!Support over timeEmphasise health benefits
Maintain!
• Maintain smoke-free
Pre-contemplation
Contemplation
Determination
Action
Maintenance
Relapse
Cycle of change
Smokers may move backwards or forwards, to and fro across the cycle many times before finally quitting
ASK about smoking status
ASSESS motivation and nicotine dependence
ADVISE on coping strategies
ARRANGE follow up
ASSIST the quit attempt
The 5 ‘A’s
World Health Organization. The Tobacco Atlas. http://www.who.int/tobacco/statistics/tobacco_atlas/en
Nicotine withdrawal: Duration
1 week Sleep disturbance
2 weeksPoor concentrationCraving for nicotine
4 weeksIrritability or aggressionDepressionRestlessness
2 days Lightheadedness
10 weeks Increased appetite
Nicotine withdrawal: the 4 ‘D’s
Delay acting on the urge to smoke
Drink water slowly
Deep breathe.
Do something else (eg exercise)
Nicotine replacement
• Begin NRT on the quit date, (apply patches the night before)
• Use a dose that controls the withdrawal symptoms
• NRT provides levels of nicotine well below smoking
• Prescribe in blocks of two weeks
• Arrange follow up to provide support
• Use a full dose for 6 to 8 weeks then stop
or reduce the dose gradually over 4 weeks.
NRT increases the odds of quitting about 1.5 to 2 fold
PharmacotherapyPharmacotherapy + behavioural counselling improves long-term quit rates
Smokers of 10 or more cigarettes a day who are ready to stop should be encouraged to use pharmacologial support as a cessation aid
Nicotine replacement
• Begin NRT on the quit date, (apply patches the night before)
• Use a dose that controls the withdrawal symptoms
• NRT provides levels of nicotine well below smoking
• Prescribe in blocks of two weeks
• Arrange follow up to provide support
• Use a full dose for 6 to 8 weeks then stop
or reduce the dose gradually over 4 weeks.
NRT: Nicotine patches
• Patches provide a slow, consistent release of nicotine throughout the day• Available in various shapes and sizes,• Common side effects with patches include skin sensitivity and irritation
NRT: Nicotine nasal sp
• Nasal sprays more closely mimic nicotine from cigarettes• Common side effects with nasal sprays include nasal and throat irritation,
coughing and oral burning
NRT: Nicotine gum
• Instruct the patient to ‘chew and park’• Absorption may be impaired by coffee and some acidic drinks • Common side effects with gum include gastrointestinal disturbances and jaw pain• Dentures may be a problem!
Nicotine Tabs• Nicotine tablets deliver 2-mg or 4-mg dosages of nicotine over 30-minutes• Common side effects with gum include burning sensations in the mouth, sore throat,
coughing, dry lips, and mouth ulcers
Bupropion• Begin bupropion a week before the quit date
• Normal dose 150mg bd, (reduce in elderly, liver/renal disease)
• Contra-indicated in patients with epilepsy, anorexia nervosa, bulimia, bipolar disorder or severe liver disease.
• The most common side effects are insomnia (up to 30%), dry mouth (10-15%), headache (10%), nausea (10%), constipation (10%), and agitation (5-10%)
• Interaction with antidepressants, antipsychotics and anti-arrhythmics
Nortryptiline
• Tri-cyclic antidepressant
• Not licensed for smoking cessation
• Low cost
• Side-effects include sedation, dry mouth, light-headedness, cardiac arrhythmia
• Contra-indicated after recent myocardial infarction
Varenicline
• Begin varenicline a week before the quit date, increasing dose gradually.
• Alleviates withdrawal symptoms, reduces urge to smoke
• Common side effects include: nausea (30%), insomnia, (14%), abnormal dreams (13%), headache (13%), constipation (9%), gas (6%) and vomiting (5%).
• Contra-indicated in pregnancy
• New drug
Nicotine replacement and buproprion should always be used in conjunction with behavior modification
Aspects of Addiction• Physical• Psychological• Behavioral
• MENTAL HEALTH
• Psychotic disorders are associated with three times the risk being a heavy smokers (35% vs 9%)
• Smoking may alleviate symptoms of psychosis
• Smoking and depression are related
• The antidepressants, bupropion and nortriptyline are effective in assisting smoking cessation
• Bupropion interacts with other antidepressants
People with mental health problems are more likely to smoke than those without mental illness
Behavior modification
review reasons for quitting (index card) identify triggers (4 day diary) plans to avoid or cope with each trigger change habit: packs only, different brands develop support system (tell everyone) self rewards (day, week, month, year) written commitment to quit day
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