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Approach to Nicotine Dependent Patient

Approach to Nicotine Dependent Patient. Assocc Prof Dr Hülya AKAN Department of Family Medicine. Aims and objectives. At the end of this lesson every student should be able to : Explain the effects of nicotine dependence on health Explain the importnace of legislative measures

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Approach to Nicotine Dependent Patient

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  1. Approach to Nicotine Dependent Patient Assocc Prof Dr Hülya AKAN Department of FamilyMedicine

  2. Aimsandobjectives At theend of thislessoneverystudentshould be ableto: • Explaintheeffects of nicotinedependence on health • Explaintheimportnace of legislativemeasures • Explainthemajorsteps of nicotinedependencetreatment • Tellthemajordrugsandtheirmechanismsused in nicotinedependencetreatment

  3. Cigarette /pipe

  4. Snus

  5. Nargile

  6. Bidi, Gunthar, Kreteks

  7. Facts • Smoking causes cancer, heart disease, stroke, and lung diseases (including emphysema, bronchitis, and chronic airway obstruction). • On average, smokers die 13 to 14 years earlier than nonsmokers • COPD will be third leading cause of death by 2030 • For every person who dies from a smoking-related disease, 20 more people suffer with at least one serious illness from smoking.

  8. FACTS • Tobacco use, primarily cigarette smoking, is the leading cause of preventable morbidity and mortality in all over the world. • Goals of the Healthy People 2013initiative include increasing to 75 percent theproportion of family physicians who routinely provide smoking cessation counseling

  9. What is going on Turkey about tobacco use?

  10. Küresel Yetişkin Tütün Araştırması; GATS; Global Adult Tobacco Survey Küresel Gençlik Tütün Araştırması (GYTS; Global Youth Tobacco Survey)

  11. Before 1983 • TobaccoentersOttomanabout 1600 • Majorsurgeon of palace İbrahim Efendi triedto limit– unsuccessful • Sultan IV. Murat- heavypunishmenttosmokers • 19. century- importwasforbidden • 1872 : industryandsalesrightsweresoldto Rum bankers

  12. 1883: consesssion of tobaccoindustrywassoldto Reji managedbyEnglish. So an importantincome of ruralpeoplesoldtoforeignindustry. • 1923: TurkishRepublic • 1925: TC getbackindustryfrom Reji • Turkish State Liquor and Tobacco Monopoly

  13. Besim Ömer Paşa (Akalın): 1888 – academicmanuscriptsabouttobaccorisksforhealth • 1990: firstacademicmanuscriptsabouththehealthrisks of tobaccouse

  14. 1983 – 1996 • General Directorate of Monopoly • 19.10.1983 : İmportgetfree (forbidden on 1862) • 1987 : foreignfirmsallowedtoimport • 1983 -1999 :80% increase in tobaccouse

  15. 1995 :“Sigara ve Sağlık UlusalKomitesi (SSUK)” (NationalComittee of Tobaccoand Health) • 1996 : 4207 no. law “Law on Prevention of Hazards of Tobacco Products” accepted

  16. After 1996 • 2003 : WHO general assembly: FrameworkConvention on TobaccoControl • Turkeysignedthecontract in 2004 • NationalTobaccoControlProgrammand2008–2012 NationalAct Plan • Legislativechanges: 3 january 2008 “Law on Prevention of Hazards of Tobacco Products”

  17. ChronicDiseasesand Risk factorssurvey of Turkey 2013 • 24% regular , 6% irregularsmoker, • 9%pastsmoker • 37% of men regularsmoker • 17% of femalesregularsmoker http://www.thsk.saglik.gov.tr/dosya/kronik_hastaliklar/chronic_english/chronic-diseases-risk-foctors-survey-in-turkey.html

  18. Main approach strategy

  19. Turkish acronyms

  20. AssessReadiness of Patient • I don’tthinktoquit • Itwill be goodtoquit, but I am not sure if I can • I havedecidedtoquit • I do not smoke • I keep on not smoking • I havestartedagain

  21. AssessContemplation • Before contemplation • Contemplation • Aim (prepare): Decision level • Action • Maintanence • Relaps

  22. Assessdependencylevel

  23. Assessdependencylevel:Fagerstrom Test for NicotineDependence

  24. Scoring the Fagerstrom Test for Nicotine Dependence (FTND) • In scoring the Fagerstrom Test for Nicotine Dependence, the three yes/no items arescored 0 (no) and 1 (yes). The three multiple-choice items are scored from 0 to 3. • The items are summed to yield a total score of 0-10. • Classification of dependence: 0-2 Verylow 3-4 Low 5 Moderate 6-7 High 8-10 Veryhigh

  25. Assess: Previousattempts • How many times? • How long? • The longest quitting time? • Used methods? Porfessional help? • Triggers to relapse?

  26. Strategiesforpatientreadytoquit

  27. Strategiesforpatientreadytoquit

  28. Strategiesforpatientreadytoquit

  29. Common elements of practical counselling

  30. Nicotine withdrawal symptoms • Anxiety: 87% • Irritability: 87% • Decreased heart rate: 80% • Difficulty in concentration: 73% • Increased apetite and weight gain: 73% • Urges to smoking: 62%

  31. Assess for relapse with patients who have quit

  32. Nicotine replacement therapy • Nicotine patch :30 cm2’/21 mg, 20 cm2/14 mg, 10 cm2/ 7 mg nicotine • Nicotine gum: It's available in a 2-milligram (mg) dose for regular smokers and a 4-mg dose for heavy smokers. Itcan be usedup to 20 pieces a day as needed. • Nicotine lozenge :This is a tablet that dissolves in mouth and, like nicotine gum, delivers nicotine through the lining of mouth. The lozenges are available in 2- and 4-mg doses, for regular or heavier smokers.

  33. Nicotine replacement therapy • Nicotine nasal spray (Nicotrol NS). The nicotine in this product, sprayed directly into each nostril, is absorbed through nasal membranes. The nasal spray delivers nicotine a bit quicker than gum, lozenges or the patch, but not as rapidly as smoking a cigarette. Side effects may include nasal irritation. • Nicotine inhaler (Nicotrol). This device is shaped something like a cigarette holder. Common side effects are mouth or throat irritation and occasional coughing.

  34. Bupropion • Antidepressant that inhibits neuronal reuptake of dopamine and noradrenaline, and is a noncompetitive nicotine antagonist at nicotinic cholinergic receptors • The drug is commenced while the person is still smoking, and a quitting date should be set in the second week of therapy (eg day 8) • 300 mg /day- 12 wks • Side effects: nausea, rashes, facial swelling, insomnia and dry mouth. Serum sickness–like reactions can occur, and bupropion can precipitate mania in patients with bipolar disorder • Seizure: The risk of seizure is increased in patients with known risk factors for seizures (such as head injury) and in patients taking other drugs known to reduce the seizure threshold (eg other antidepressants, including the selective serotonin reuptake inhibitors, and antipsychotics).

  35. Varenicline • Nicotinic acetylcholine–receptor partial agonist/ In the absence of nicotine it has agonist activity (activates nicotinic acetylcholine receptors), whereas in the presence of nicotine it has antagonist activity (blocks nicotine's ability to bind with these receptors) • A quit date should be set, and varenicline started one to two weeks before the quit date

  36. Dose: day 1 to 3: 0.5 mg daily day 4 to 7: 0.5 mg twice daily day 8 and ongoing: 1 mg twice daily until the end of the 12 week course Side effects: nausea, drawsiness, dizziness, exacerbations of underlying psychiatric illness (eg schizophrenia, bipolar disorder) Don’t use with nicotine replacement therapy Don’t use with bupropion

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