Smoking cessation

1. Smoking cessation By: Dr. Dalia Jallad

2. EPIDIMIOLOGY • Cigarette smoking remains a leading cause of preventable disease and premature death in the United States and other countries. • 15.5 % of people aged 18 years or older in the United States considered themselves smokers 2016. • On average, 435,000 people in the United States die prematurely from smoking-related diseases each year; overall, smoking causes 1 in 5 deaths. • 1 one in five American adults still smokes regularly (22 percent of men, 17.5 percent of women) • Smoking cessation is difficult, with the average smoker attempting to quit five times before permanent success

3. In the 2011 WHO report on the global tobacco epidemic, smoking rates in the Middle East and North Africa (MENA) region ranged from 15.1% in Morocco to 38.5% in Lebanon. The smoking rate in men ranged from 20.2% in Saudi Arabia to 62.0% in Syria, whereas in women it ranged from 0.2% in Morocco to 31.5% in Lebanon.

4. AKhattab, A Javaid, G Iraqi, A Alzaabi, A Ben Kheder, M-L Koniski, et al., on behalf of the BREATHE Study GroupSmoking habits in the Middle East and North Africa: Results of the BREATHE studyRespirMed, 106 (Suppl 2) (2012), pp. :S16-:S24

5. EPIDIMIOLOGYSmoking-Related Diseases • Tobacco use is a major cause of death from: cancer, cardiovascular disease, and pulmonary disease. • Cigarette smoking is also a risk factor for respiratory tract and other infections, osteoporosis, reproductive disorders, adverse postoperative events and delayed wound healing, duodenal and gastric ulcers, and diabetes. • In addition, smoking has a strong association with fire-related and trauma-related injuries.

7. Smoking-caused disease is a consequence of exposure to toxins in tobacco smoke. • Although nicotine plays a minor role, if any, in causing smoking-induced diseases, addiction to nicotine is the proximate cause of these diseases

8. Nicotine Addiction • Nicotine is an addictive substance that is mainly taken in through the lungs through smoking tobacco products. • Addiction is characterized by compulsive drug-seeking and use, even in the face of negative health consequences • Nicotine produces physical and mood-altering effects in your brain that are temporarily pleasing. These effects make you want to use tobacco and lead to dependence. • At the same time, stopping tobacco use causes withdrawal symptoms, including irritability and anxiety.

9. NICOTINE ON THE BRAIN NICOTINIC ACETYLCHOLINE RECEPTORS Smoke particles carry the nicotine into the lungs, where it is rapidly absorbed into the pulmonary venous circulation. The nicotine then enters the arterial circulation and moves quickly to the brain, where it binds to nicotinic cholinergic receptors .

10. NICOTINE AND NEUROTRANSMITTER RELEASE Stimulation of nicotinic cholinergic receptors releases a variety of neurotransmitters in the brain, One of them, dopamine, signals a pleasurable experience and is critical for the reinforcing effects (effects that promote self-administration) of nicotine and other drugs of abuse, as well as for compelling drives such as eating.

11. MONAMINE OXIDASE • Monoamine oxidases, enzymes located in catecholaminergic and other neurons, catalyze the metabolism of dopamine, norepinephrine, and serotonin • Condensation products of acetaldehyde in cigarette smoke with biogenic amines inhibit the activity of monoamine oxidase • there is evidence that inhibition of monoamine oxidase contributes to the addictiveness of smoking by reducing the metabolism of dopamine

12. NEUROADAPTATION • With repeated exposure to nicotine, neuroadaptation (tolerance) to some of the effects of nicotine develops. • As neuroadaptation develops, the number of binding sites on the nicotinic cholinergic receptors in the brain increases, probably in response to nicotinemediated desensitization of receptors • Desensitization — ligand-induced closure and unresponsiveness of the receptor — is believed to play a role in tolerance and dependence

13. What happens when you quit smoking ? One year after your last cigarette • The lungs will have experienced dramatic health improvements in terms of capacity and functioning. • You’ll notice how much easier you breathe on exertion • less coughing compared to when you smoked. • you’ll have saved a dramatic amount of money. Three years after your last cigarette • your risk of a heart attack has decreased to that of a nonsmoker. Five years after your last cigarette • your risk of death from lung cancer has dropped by half compared to when you smoked. 15 years after your last cigarette • At the 15-year mark, your risk for heart attack and stroke has decreased to equal that of a person who’s never smoked before.

14. Primary care physicians have many opportunities to counsel patients about smoking cessation

15. SMOKING CESSATION COUNCELLING

16. Five A’s Counseling Strategy • Physicians should address smoking cessation with all patients who use tobacco. • The five A’s framework (ask, advise, assess, assist, arrange) has been developed to allow physicians to incorporate smoking cessation counseling into busy clinical

17. ASK • smoking status should be documented at every visit • Including smoking as a vital sign in patients’ charts may remind the physician to address tobacco use • Promoting smoking cessation appears to increase patients’ satisfaction with their visit, even among smokers not yet motivated to quit • “Have you ever been a smoker or used other tobacco products? Do you use tobacco now? How much?” • Calculater: Back.Year

18. ADVISE • Even brief physician advice may prompt an additional 1 to 3 percent of patients to attempt cessation and improve quit rates • Unambiguous support for smoking cessation should be expressed by the physician, and the benefits of quitting should be discussed • Advice to patients should be : • clear (direct expression of the need for smoking cessation), • strong (highlighting the importance of cessation), • and personalized (linking the patient’s health goals to cessation) • Setting a follow-up appointment specifically to discuss this advice further may increase the patient’s uptake of the advice • “I think quitting smoking is very important for you because of your asthma. I want you to come back to the office next week so we can talk about this more

19. ASSESS • Patients’ motivation to quit smoking should be assessed at every visit. • Willingness to quit and barriers to quitting should be assessed, as well as smoking history and current level of nicotine dependence; patients should be asked about their 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 from quitting? How soon after getting up in the morning do you smoke?”

20. ASSESS-2-Readiness rulers Assess how ready the patient currently is to quit tobacco use. (i.e., “On a scale of 1 to 10, where 10 is very ready, how ready are you to quit smoking?”)

21. ASSESS-3-Nicotine Dependence Fagerstrom Score 1. How soon after you wake up do you smoke your first cigarette? After 60 minutes 0 31-60 minutes 1 6-30 minutes 2 Within 5 minutes 3 2. Do you find it difficult to refrain from smoking in places where it is forbidden? No 0 Yes 1 3. Which cigarette would you hate most to give up? The first in the morning 1 Any other 0 4. How many cigarettes per day do you smoke? 10 or less 0 11-20 1 21-30 2 31 or more 3 5. Do you smoke more frequently during the first hours after awakening than during the rest of the day? No 0 Yes 1 6. Do you smoke even if you are so ill that you are in bed most of the day? No 0 Yes 1

22. ASSESS-4-Stages of Change assessments • Stages of Change assessments are useful in addressing the extent to which a person is ready to change, which can change from visit to visit. • Behavior change can be conceptualized into five progressive stages: precontemplation, contemplation, preparation, action, and maintenance • Although tailoring interventions to a patient’s stage of change may not be necessary, these stages emphasize that not all patients are equally motivated to quit smoking, motivation is malleable, and patients can be assisted toward behavior change through physician intervention.

24. Stages of change in smoking cessation • Precontemplation: Current smokers who are NOT planning on quitting within the next 6 months. • Contemplation: Current smokers who are considering quitting within the next 6 months and have not made an attempt in the last year. • Preparation: Current smokers who have made quit attempts in the last year and are planning to quit within the next 30 days. • Action: Individuals who are not currently smoking and stopped within the past 6 months (recently quit). • Maintenance: Individuals who are not currently smoking and stopped smoking for longer than 6 months but less than 5 years (former smokers).

25. Assess-5 • Patients not yet willing to quit should receive a motivational intervention • Motivational interventions, explore a patient’s ambivalence to smoking cessation in an empathetic, questioning manner, which respects the patient’s autonomy and builds self-efficacy. • The Agency for Healthcare Research and Quality has identified several components of discussion to enhance patients’ motivation to stop smoking. These components are the five R’s (relevance, risks, rewards, roadblocks, repeat)

26. Five R’s Strategy for Motivating Patients to Quit SmokingFive R’s Strategy for Motivating Patients to Quit Smoking • Relevance: Encourage the patient to identify reasons to stop smoking that are personally relevant. i.e.: Pregnancy, personal or family risk of disease, person in the household with asthma • Risks: Advise the patient of the harmful effects of continued smoking, both to the patient and to others, incorporating aspects of the personal and family history whenever possible. i.e. :Effects on the patient and the patient’s family, friends, and coworkers; measuring “lung age”* through spirometry can help personalize risk • Rewards: Ask the patient to identify the benefits of smoking cessation. i.e.: Improved health, financial savings from not buying cigarettes, decreased cigarette odor • Roadblocks: Explore the barriers to cessation that the patient may encounter. i.e.: Presence of other smokers in the home or workplace, history of failed quit attempts or severe withdrawal symptoms, stress, psychiatric comorbidity, low motivation, weight gain, enjoyment of smoking • Repeat: Include aspects of the five R’s in each clinical contact with unmotivated smokers

27. ASSIST(OR REFER) • Asking patients who are willing to quit to set a quit date can prompt change, • physicians should help patients anticipate obstacles to cessation. Nicotine withdrawal symptoms, depression, and weight gain are specific areas in which patients may benefit from clinical guidance. • Advice patients to prepare their social support systems and their environment for the impending change • “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?”

28. ASSIST • Withdrawal: Common nicotine withdrawal symptoms (e.g., irritability, anxiety, restlessness) peak within the first week of abstinence and last two to four weeks; NRTs can be helpful because they gradually decrease nicotine dependence; smokers should also be advised to decrease caffeine intake • Depression: Smokers are more likely than nonsmokers to have a depressive episode, and smokers with depression are less likely to successfully quit, smoking cessation may trigger depression in those with a history of depression; physicians should consider monitoring the mood of smokers during quit attempts and screen for depression in those who have repeatedly been unable to quit; bupropion (Zyban) may be an appropriate cessation aid for smokers at risk of depressive relapse • Weight gain: Although 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]; although this weight gain poses less health risk than smoking, concern about weight gain may interfere with the quit attempt; sustained-release bupropion or an NRT (particularly gum or lozenges) may be helpful in these patients because they delay weight gain while in use; it may be easier to monitor and adjust food intake/exercise balance after immediate tobacco cravings are no longer as prominent

29. ARRANGE FOR FOLLOW-UP • Patients should be contacted around the time of their quit date to be congratulated on their (presumed) abstinence. • Contacting patients at least four more times to support their smoking-cessation attempts increases abstinence rates. • Patients who are unable to quit or who relapse should be reassessed. Pharmacologic therapies and additional behavioral counseling should be considered, and patients should be encouraged to set a new quit date. • Follow-up plans should be set; for patients who have recently quit, it is important to elicit the benefits of quitting and ask patients to anticipate and problem solve about situations that might lead to relapse; • Abstinence by the quit date is highly predictive of long-term success • “I would like to see you in the office (or talk to you by phone) on your quit date.” • “What problems have you had? Are there situations you worry about confronting without cigarettes?”

30. Behavioral tips

31. Find Your Reason To get motivated, you need a powerful, personal reason to quit. It may be to protect your family from secondhand smoke. Or lower your chance of getting lung cancer, heart disease, or other conditions. Or to look and feel younger. Choose a reason that is strong enough to outweigh the urge to light up.

32. Give Yourself a Break • One reason people smoke is that the nicotine helps them relax. Once you quit, you’ll need new ways to unwind. There are many options. You can exercise to blow off steam, tune in to your favorite music, connect with friends, treat yourself to a massage, or make time for a hobby. Try to avoid stressful situations during the first few weeks after you stop smoking.

33. Lean On Your Loved Ones • Tell your friends, family, and other people you’re close to that you’re trying to quit. • They can encourage you to keep going, especially when you’re tempted to light up. • The patient should ask others not to smoke in his or her presence. • You can also join a support group or talk to a counselor.

34. Clean House • Once you’ve smoked your last cigarette, toss all of your ashtrays and lighters. • Wash any clothes that smell like smoke, and clean your carpets, draperies, and upholstery. • Use air fresheners to get rid of that familiar scent. • If you smoked in your car, clean it out, too. • You don’t want to see or smell anything that reminds you of smoking.

35. Avoid Alcohol and Other Triggers • When you drink, it’s harder to stick to your no-smoking goal. So try to limit alcohol when you first quit. • Likewise, if you often smoke when you drink coffee, switch to tea for a few weeks. • If you usually smoke after meals, find something else to do instead, like brushing your teeth, taking a walk, texting a friend, or chewing gum.

36. Get Moving Being active can curb nicotine cravings and ease some withdrawal symptoms. When you want to reach for a cigarette, put on your inline skates or jogging shoes instead. Even mild exercise helps, such as walking your dog or pulling weeds in the garden. The calories you burn will also ward off weight gain as you quit smoking.

37. Eat Fruits and Veggies Don’t try to diet while you give up cigarettes. Too much deprivation can easily backfire. Instead, keep things simple and try to eat more fruits, vegetables, whole grains, and lean protein. These are good for your whole body.

38. Choose Your Reward In addition to all the health benefits, one of the perks of giving up cigarettes is all the money you will save. Reward yourself by spending part of it on something fun.

39. First line therapies for smoking cessation

40. NICOTINE REPLACEMENT THERAPIES • The goal of nicotine replacement therapies (NRTs) is to relieve cravings for nicotine and reduce nicotine withdrawal symptoms. • NRTs are available as slow release skin patches and in more rapidly acting forms (i.e., chewing gum, nasal spray, inhalers, and lozenges), which deliver nicotine to the brain more quickly than skin patches but more slowly than smoking cigarettes. • A Cochrane review of 132 trials concluded that all forms of NRTs increase the chances of quitting successfully by 50 to 70 percent. • Heavy smokers should be encouraged to use higher dosages of an NRT or try a “patch plus” method, using the nicotine patch to provide a base level of slowly delivered nicotine and adding a more rapidly acting NRT to control breakthrough cravings. • This regimen is safe because smokers typically obtain less nicotine than through smoking, and it is more effective than using a single NRT

42. NRT • Benefits:1 in 15 was helped (successfully quit smoking) • Harms:1 in 94 was harmed (chest pain or palpitations) None were harmed (cardiovascular event) • Other fairly rare adverse effects varied with type of NRT and included gastrointestinal upset, dental problems, and jaw pain (gum); skin irritation (patch); throat/ nose irritation, sore throat (inhaler, lozenge, spray); and headache, dizziness, sleep disturbance, hiccups (general).

43. Nicotine gum (Nicorette) • Intermittently chew, then “park” between gum and cheek for maximum benefit • eating or drinking acidic foods or beverages within 30 minutes of use decreases effectiveness; may delay weight gain; difficult to use with dentures, partials, or fillings • FDA pregnancy category C • Side effects: Gastrointestinal distress; mouth or throat irritation • Maximum dosage: 24 pieces per day

45. Nicotine inhaler (Nicotrol) • Eating or drinking acidic foods or beverages within 30 minutes of use decreases effectiveness • FDA pregnancy category D • Side effects: Mouth or throat irritation (40 percent), coughing (32 percent), rhinitis (23 percent)

46. Nicotine lozenge (Nicorette) • May delay weight gain; should be taken one at a time and dissolved in the mouth, not chewed or swallowed • eating or drinking acidic foods or beverages within 30 minutes of use decreases effectiveness • contains 25 percent more nicotine than gum • FDA pregnancy category D • Side effects: Nausea, heartburn, headache • Maximum: 20 lozenges per day

47. Nicotine patch • 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) • Treatment of up to eight weeks has been shown to be as effective as longer treatments • 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)

49. Nasal spray (Nicotrol NS) • 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) • FDA pregnancy category D • Side effects: Moderate to severe nasal irritation within the first two days (94 percent) that often continues throughout use

50. NICOTINIC RECEPTOR AGONIST • Varenicline(Chantix) is a selective alpha4-beta2 nicotinic receptor partial agonist that reduces cravings and withdrawal symptoms while blocking the binding of smoked nicotine. • Vareniclineincreases the chances of a successful quit attempt two- to threefold compared with no pharmacologic assistance. • In a direct comparison, varenicline was superior to bupropion in promoting abstinence.