Dr M.Mataro Hingorjo

3. Objectives
• Discuss 5A approach to tobacco cessation
• Discuss brief behavioral treatment for
smoking cessation
• Pharmacotherapy for Smoking cessation
• Maintenance/ Follow-ups

4. Tobacco use can kill in so may ways that it is
a risk factor for six of the eight leading
causes of death in the world.
“Margaret Chan Fung Fu-Chun, Director
General WHO 2008”
“Tobacco is the only legally
available consumer product
which kills people when it is
used entirely as intended”.
(The Oxford Medical
Companion,
Oxford: Oxford University
Press, 1994)

5. Situation in Pakistan
• Tobacco use is on the rise in Pakistan
• 36% of males and 9% of females do smoke (NHS 1996)
• Smokeless tobacco is also a major issue here
• Cigarette industries pay 140 billion rupees in taxes
and source of livelihood for more than 1.2 million
people
• 32% of house officers do smoke in Karachi
• 22%nmale and 3.8% of females reported current
smokers at Karachi
• 21.5% general students were reported using tobacco in
all forms in a study at Karachi
• Tobacco associated cancers in Karachi are 38.3% in
males and 40% in females

6. Why do people smoke?

7. Different forms of tobacco
Smoked
Tobacco
Smokeless
tobacco
Second hand
or passive
smoking

8. Smoked tobacco
• Bidi:
– Small hand-rolled cigarettes
– Three times more carbon
monoxide and nicotine
– Five times more tar
– Three-fold higher risk of oral
cancer
– Increased risk of lung, stomach
and esophageal cancer
• Shisha:
– Tobacco mixed with flavorings
and smoked from hookahs
– More popular in youths of
Karachi
– Linked to lung disease,
cardiovascular disease and
cancer
• Second hand or passive
smoking
– 2 hours is smoky office =4
cigarettes smoked
– Two hours in non smoking area
of a restaurants even= 2
cigarettes
– 24 hours with a pack a day
smokers = 3 cigarettes
– 3,400 lung cancer deaths and
46,000 heart disease deaths a
year in US
– 430 sudden infant deaths
– 24500 LBW,71900 preterm
deliveries & 2K childhood
asthma
In children:
brain tumors, middle
ear disease, lymphoma,
impaired lung function,
asthma, sudden infant
death syndrome,
leukemia, and lower
respiratory illness
Common Problems
in Adults due to
Passive smoking:
stroke, nasal sinus
cancer, coronary heart
disease, lung cancer,
atherosclerosis, COPD,
asthma, pre-term
delivery & low birth
weight babies
• Tobacco in Pakistan is responsible for
90% of Lung Cancers, 90% of COPD, 40% of
overall cancers and 20 other fatal diseases
• We are still in the early phase of Tobacco
epidemic,
• Yet the full impact of tobacco is awaited

9. Tobacco Dependence:
A cluster of behavioral, cognitive and physiological phenomena that
develop after repeated use and typically include a strong desire to
smoke, difficulty in controlling its use, persisting in its use despite
harmful consequences, increased tolerance to nicotine, and a (physical)
withdrawal state (PCS)
• 4000 Toxic Substances
• Potent Carcinoges like Nitorsamines,
aromatic hydrocorbons
• CO, Tar, ammonia, nitrogen oxide,
hydrogen cyanide and nicotine

10. Benefits of Stopping smoking?
• A reduced risk of dying early
• a reduced risk lung cancer ,CAD,
CVA, COPD & other cancers
• Improved respiration
•Reduced risks of complications in
pregnancy and childbirth
• Improvement in some mental
health symptoms
• Fewer sick days off work
• Improvement in recovery from
surgery and reduced perioperative
risk
• A reversal of the risks of
smoking if cessation is achieved by
the age of 35
Stopping smoking will also:
• Set a good example for children
and young people (children of
non-smokers are less likely to
become regular smokers)
• Improve the health of young
children of parents who have
ceased smoking
• Save money

11. Patient # 1
• A 8 year old child is brought by his father
in your clinic with the upper respiratory
tract symptoms
– Boy is allergic to smoke & dust
– Your clinical impression is allergic rhinitis
– You ask about any smoker in family
– Father confess that he smokes
o What is one of the major root cause of
child’s illness evident from history?

12. General Approach
• Age , sex
• How do u feel about your smoking?
• When, why and how did you begin,
• how many cigarettes per day, pack year
• Previous quit attempts and reasons for failure and aids used?
• Any smoker at home?
• Past history
• Family history
• Social history
• Personal history
• Addictions
• Drugs
• Examination:
Any thing left?
Ne

13. CAGE QUESTIONNAIRE:
C= DO YOU EVER FEEL OR TRIED TO CUT DOWN YOUR SMOKING?
A=DO YOU EVER GET ANNOYED ,WHEN PPL ASK YOU TO QUIT?
G= DO U EVER FEEL GUILTY ABOUT SMOKING
E= DO YOU EVER SMOKE EARLY MORNING,WITHIN HALF AN HOUR
AFTER WAKING UP?( EYE OPENER)
SCREENING TEST: 2 YES, SCREENING POSITIVE.

14. • Our patients CAGE score is 3 and
fagerstrom is 6
• What should you do as a primary health
care provider?

15. Clinical interventions for
tobacco use and dependence

16. What can a health
professional do?
• Do not smoke or use tobacco
• Take a history of smoking/tobacco use
• Give firm advice to patient who uses tobacco
• Learn ―how to counsel patients in order to
make them quit smoking/tobacco use
• Educate the public regarding the hazards of
active & passive smoking and other forms of
tobacco

17. • Intervention as brief as three minutes increases the cessation rate
• Average smoker attempting to quit five times before permanent
success
Available interventions:
5As: one of the commonly used intervention by Family physicians
5Rs: Motivational intervention for unmotivated persons
5Ds: to combat withdrawal symptoms

19. 5”As”: 1- Ask
• Adding smoking status as a vital sign to all
patients’ charts
• Identification of all tobacco users and
documentation of their smoking status at every
office visit
• Ask all patents “do you smoke?” ,”Have you ever
smoked?”
– Take a brief history
– Number of cigarettes per day
– The year of starting smoking
– Previous quit attempts and what happened
– Presence of smoking related disease
“Have you ever been a smoker or used other
tobacco products?
Do you use tobacco now?
How much?”

20. 5”As” :2- Advice
• Clear, strong and personalized advise to stop
smoking
• Advise firmly but in a no confrontational
manner “the best thing you can do for your
health is to quit smoking”
• Emphasize the personnel benefits of
cessation
– Improved health
– Not exposing others to tobacco smoke
– Positive role model for children and adolescents
– Financial benefits
Strong—
“As your clinician, I
need you to know that
quitting smoking is
the most important
thing you can do to
protect your health
now and in the future.
The clinic staff and I
will help you.”
Clear—
“It is important that you quit
smoking (or using chewing
tobacco) now, and I can help
you.”
“Cutting down while you are
ill is not enough.” “Occasional
or light smoking is still
dangerous.”

22. 5”As” : 3-Asses
• Asses a person's’
– Willingness and Barriers
– Smoking history and current level of nicotine
dependence
– Timeline for quitting and about previous attempts
• “Have you ever tried to cut back on or quit
smoking?
• Are you willing to quit smoking now? What keeps
you away from quitting?
• How soon after getting up in the morning do you
smoke?”

23. 5”As” :3-Asses: Stages of Readiness
to Change
• Pre-contemplation:
– No intention to take action within next six
months
– Unaware of the need to change; overestimate the
costs ,underestimate the benefits; Consider
Reluctance(inertia), Rebellion and
Rationalization
• Contemplation:
– Considering change within the next six months
– Ambivalent about change; perceives that costs
equal benefits

24. 5”As”:3-Asses: Stages of Readiness
to Change
• Preparation/determination:
– Planning to take action within the next month
– May have already made steps towards change
– Often concerned about failure
• Action:
– Actively changing (first six months of new behavior)
– Needs vigilance to
• Prevent relapse
• Encouragement to keep up the momentum
• Maintenance:
– More than six months since behavior change
– Reminders about high-risk situations

25. 5”As”:4-Assist: Readiness to
change
• Assist according to patients readiness to change
 Not ready
Encourage patient to think about their smoking, offer
help, offer written material offer referral
 Not sure:
Encourage patient contemplate and help to reflect on
the pros and cons of smoking, plus offer help as above
 Ready/action:
Affirm and encourage the decision to quit, help the
patient to develop a quit plan
Help set a quit date

26. 5”As” :4-Assist: Anticipate
challenges
• Help patients to anticipate difficulties and
encourage them to prepare their social support
systems and their environment
• “I would like to help you quit. Can I tell you about
Some of the things we know can increase your odds
of success?”
• “Are you worried about anything in particular
when
It comes to quitting?
• Do you worry about cravings
Or weight gain?”

27. • Our patient is not much convinced to quit
smoking what to do?

28. For the patient unwilling to quit
• Patients unwilling to make a quit attempt during a visit may:
– Lack information about the harmful effects of tobacco use
– No knowing much about benefits of quitting;
– Lack the required financial resources;
– Have fears or concerns about quitting, or may be demoralized
because of previous relapse
• These patients may respond to brief motivational interventions that
are based on principles of motivational interviewing
– (1) express empathy
– (2) develop discrepancy
– (3) roll with resistance
– (4) support self-efficacy
Motivational Intervention for the patient
unwilling to quit/ for Enhancing
Motivation….

29. 5”As”4- Assist:5-Rs
• 1-Relevance
– Encourage the patient to indicate why quitting
is personally relevant, such as children at
home, money saved by quitting smoking,
history of smoking related illness
• 2-Risks:
– Advise the patient of the harmful effects ,both
to the patient and to others
Acute risks:
Shortness of breath,
Exacerbation of
asthma, Increased
risk of respiratory
infections, Harm to
pregnancy,
Impotence,
Infertility.

30. 5”As” :4-Assist: 5Rs
• 3-Rewards
– Identify benefits of
stopping tobacco use
– Improved health
– Improved sense of smell
– Save money
– Set a good example for
children
– Reduced wrinkling/aging
of skin
• 4-Road blocks
– Barriers to cessation
– Other smokers in the home
or workplace
– Failed quit attempts
– Severe withdrawal
symptoms/ stress
– Psychiatric comorbidity
– Low motivation
– Weight gain
– Enjoyment of smoking
• 5-Repetations:
– Motivational interventions
repeated every time

31. 5”As”: 4-Assist: Willing to quit
• Help develop a quit plan
• Set a quite date
• Tell family and friends for support
• Anticipate challenges &discuss challenges / triggers
• Remove tobacco products
• Avoid
– Alcohol use
– Express to tobacco
• Provide supplementary materials
• Give nutritional advice
• Physical activity may help
• Recommend the use of approved pharmacotherapies

32. 5”As” :5-Arrange
• Elicit the benefits ask to anticipate and
problem
• Schedule follow up contacts with in one week
after quit date
– Person
– Telephone quit-line
• Four visits or calls are evidence based
• Congratulate progress success
• Identify problems and anticipate challenges
• Evaluate pharmacotherapy use/ problems

33. • Our patient is willing to
quit
• Quit motivated
• Seeks your help
• How will you help him

34. Algorithm for treating tobacco
use

35. Pre-interventional Counseling
• Discuss
– Tobacco withdrawal S/S
– Benefits of quitting
smoking
– Behavioral interventions
– Non-pharmacological
and pharmacological aid
– Maintenance/ follow up
plans/ relapses

36. Method for smoking cessation
Non
pharmacological
– Behavioral cessation
and therapies
– Individual , group, or
telephone counseling
• Pharmacological
– Nicotine replacement
therapy, transdermal,
nasal spray, inhaler,
gum, lozenges
– Bupropion sr (zayban)
– Chantix
– Clonidine,
transdermal, oral
– Nortryptelline
– Anxiolytic agents

37. Behavioral intervention
• Brief advice
• Group counselling
• Telephone counselling
• Web based programs

38. Cognitive strategies
• Keep a diary for one or several days prior
to quit day(more aware of their smoking
patterns and risk situations)
• Coping with craving

39. Most common nicotine withdrawal
symptoms
• Depression:
– Smokers have more
likelihood of depression,
hindrance in quitting
– Smoking cessation may
trigger depression
– Do screen for depression
– Bupropion (zyban) is helpful
• Irritability, anxiety,
restlessness
– Peak within the first week of
abstinence and last two to
four weeks
– Decrease caffeine intake &
nrts can be helpful
• Weight gain:
– Most smokers gain fewer
than 10 lb
(4.5 kg) after quitting
Weight gain can vary (10
percent will gain
30 lb [13.5 kg])
– Concern about weight gain
may interfere
– Sustained-release bupropion
or an NRT
– (Particularly gum or
lozenges) delay weight gain
while in use
– Monitor and adjust food
intake/exercise balance

41. Behavioral strategies
cope with craving
• Suggest 4Ds
– Delay acting on the urge to smoke, after five
minutes the urge to smoke weakens and your
resolve to quit will come back
– Deep breath: take a long slow breath in and
slowly release it out again, repeat three times
– Drink water slowly holding it in your mouth a
little longer to savour the taste
– Do something else to take your mind off smoking,
doing some excerscise is good alternative

43. First line pharmacotherapies
• Nicotene replacement therapy
– Trandermal patch
– Chewing gums
– Lozenge
– Inhaler
– Nasal spray
Non nicotene therapy
– Vernacillene
– Buprpion

44. Second line pharmacotherapy
• Nortryptelline
• Clonidine

45. First-line therapies for
smoking cessation in adults
• Nicotine gum
– Available in 2-mg and 4-mg (per
piece) doses
– Patients smoking less than 25
cigarettes per day: 2 mg
– Patients smoking 25 or more
cigarettes per day: 4 mg
– Maximum dosage: 24 pieces per
day
– Over the counter
– may delay weight gain;
– Difficult to use with dentures,
partials, or fillings
– FDA pregnancy category C
– Side effects: gastrointestinal
distress; mouth or throat
irritation
• Nicotine lozenge
– Heavy smokers: 4 mg
– Light smokers: 2 mg
– Maximum: 20 lozenges per day
– Over the counter
– May delay weight gain;;
– Contains 25 percent more
nicotine than gum
– FDA pregnancy category D
– Side effects: nausea, heartburn,
headache

46. • Nicotine patch
– Doses vary and should be
tapered as therapy progresses
– Heavy smokers: 21 mg per day
– (Initial dosage)
– Light smokers or those weighing
less than 100 lb (45 kg): 10 to 14
mg per day (initial dosage)
– Over the counter
– Treatment of up to eight weeks
– Site of patch should be changed
daily;
– 16- and 24-hour patches have
comparable effectiveness;
adolescents may require lower
starting dosages because of body
habitus and overall smoking
patterns (e.G., Less than one-
half pack per day)
– FDA pregnancy category D
– Side effects: skin reactions (up
to 50 percent), headaches,
insomnia (decreased if patient
removes patch at night)
• Nasal spray
– One dose consists of two 0.5-mg
sprays (one in each nostril)
– Initial dosage is one or two
doses per hour (minimum of
eight doses per day), increasing
as needed for symptom relief
– Maximum: 40 doses per day
(five doses per hour)
– Dependence potential is
intermediate between other
nicotine replacement therapies
and cigarettes
– FDA pregnancy category D
– Side effects: moderate to severe
nasal irritation within the first
two days (94 percent) that often
continues throughout use

47. Bupropion
• Inhibitor of neuronal reuptake of
noradrenaline and dopamine
– Limits craving(substitution of stimulant effects of
nicotine)
• Marketed as antidepressant and decrease the
desire to smoke observed in depressed
patients
• Double the success rate of quitting compared
to placebo
• Equally effective in patients who are not
depressed

48. Bupropion: Patients issues
• Insomnia
• Dry mouth
• Tremors
• Rashes
• Weight loss
• Seizures
• Hypertension

49. Varenicline/ chantix
• High affinity partial nicotine acetylcholine
receptor antagonist
• specifically designed for smoking cessation
• Alleviates the symptoms of craving and
withdrawal , but produce much weaker
effect than nicotine
• Prevents inhaled nicotine from a cigaratte
activating the ---- receptors and blocks the
pleasurable effect of smoking

50. • Varenicline (chantix): Continued
– Days 1 to 3: 0.5 mg once per day
– Days 4 to 7: 0.5 mg twice per day
– Day 8 to end of treatment: 1 mg twice per day
– Begin therapy one week before quit date and continue for
12 weeks; an additional 12 weeks can be added if quit
attempt is successful to increase chances of long-term
abstinence
– Should not be combined with a nicotine replacement
therapy;
– FDA pregnancy category C
– Side effects: headache, nausea (dose related), insomnia,
abnormal dreams, flatulence increased risk of
cardiovascular events in smokers with cardiovascular
disease should be discussed with patients
– FDA boxed warning: may cause serious neuropsychiatric
symptoms in patients, including changes in behavior,
hostility, agitation, depressed mood, suicidal thoughts and
behavior, and attempted suicide; patient should be
monitored closely

53. Second line treatment
• Nortryptylline
– Tricyclic antidepressant
– Mechanism of action in smoking cessation is
likely to be separate from antidepressant
effect
– Dose is 75 mg per day for 12 weeks
– Side effects
• Dry mouth, sedation,over dose risks
– Not registered for smoking cessation in
australia

54. Second line treatment
• Clonidine
– Antihypertensive, centrally acting alpha
agonist
– Minimal use for this indication in Australia

55. Possible future options
• Nicotine vaccines in development.
• The selective type 1 cannabinoid receptor
antagonist Rimonabant .
• The Nicotine receptor partial agonist Cystine.
• They have demonstrated some efficacy in studies,
but as yet there is insufficient evidence for their
use in tobacco cessation.

57. Follow up
• First visit: after 1 week of quit date.
• Second visit: within the same month.
• At 2 month : telephone call or letter of encouragement.
• At 3 month : cessation validation by expired air CO.
• At 5 month : telephone call or letter of encouragement
• At 6 month : cessation validated by expired air CO
• At 9 month : telephone call or letter of encouragement.
• At 12 month :cessation validated by expired air CO

58. Model for treatment of tobacco use and dependence
Patient presents to a
health care setting
Ask
Primary
prevention
Advise to
Quit
Prevent
relapse
Assess
willingness
to quit
Assist with
quitting
Arrange
followup
Never
uses
Current
Users
Former
users
Yes
Patient remains unwilling
Patient now willing to quitPromote
motivation
No
Abstinent
Relapse

59. References
• Oxford GP, 3rd Edition
• PCS 2009
• NICE 2010
• CDC
• Royal college of general physicians
guidelines 2010
• Clinical guidelines in Family medicine, (E-
Book) 2014