Brief Interventation 3As, 5As and 5Rs Diseases Impact

Brief Interventation 3As, 5As and 5RsDiseases Impact

TOPIC 5

Rokok layout 2.indd 51 11/27/14 9:17 AM

52MANAGEMENT IN QUIT SMOKING PROGRAMME Training Module For Health Care Providers

LEARNING OBJECTIVE

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• Workflowpathwayinpromotingtheservicebasedonclinicalpractice.• AssessmentfornicotineaddictionbasedonFagerstromformtestevaluation.• ApplicationofWHObriefclinicalinterventionincludingthemethodtodeliverthe3As,5Asand5Rs

interventionatprimarycarelevel.

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Recommendations

• Tobacco dependence is a chronic disease – requires repeatedinterventionandmultipleattemptstoquit

• Clinicians and health care delivery systems - identify and documenttobaccousestatusandtreatEVERYtobaccouserseeninahealthcaresetting

• To provide at least a brief intervention to every tobaccouser at eachhealthcarevisit

• Ifatobaccousercurrentlyisunwillingtomakeaquitattempt,cliniciansshouldusethemotivationaltreatments

Assessmentoftobaccoused&willingnesstoquit

MOH CPG On Treatment Of Tobacco Use And Dependence 2003

Theassessmentsaretolookfor:1. Levelofaddiction(usingFagerstromQuestionnairesandnumberof

cigarettesmoked)2. Readinessforquitting



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Fagerström’stestforNicotineDependence

Question Answers (markyouralternative)

Howsoonafteryouwakeupdoyousmokeyourfirstcigarette

Within5minutes6–30minutes31-60minutesAfter60minutes

3______2______1______0______

Doyoufinditdifficulttorefrainfromsmokinginplaceswhereitisforbiddene.g.inchurch,atthelibrary,incinema,etc.?

YesNo

1______0______

Whichcigarettewouldyouhatemosttogiveup?

ThefirstoneinThemorning?Allothers?

1______0______

Howmanycigarettesdoyousmokeperday?

10orless11-2021-3031ormore

0_____1_____2_____3_____

Doyousmokemorefrequentlyduringthefirsthoursafterwakingthanduringtherestoftheday?

YesNo

1______0______

Doyousmokeifyouaresoillthatyouareinbedmostoftheday?

YesNo

1______0______

0–3LowNicotineDependence4–6ModerateNicotineDependence7-10HighNicotineDependence

Total:

LevelOfNicotineAddictionFagestromtestScore 0-3 4-6 7-10

No.ofcigarette <10 10-25 >25

Nicotinedependence Low Moderate High



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Algorithmfortreatingtobaccouse

Relapsepreventioninterventionarenotnecessaryinthecaseoftheadultwhohasnotusedtobaccoformanyyears

FlowChartOfClinicalPracticeGuidelinesOnManagementOfTobaccoUseAndDependence

doespatientnowusetobacco

promotemotivationto

quit

preventrelapse

encouragecontinuedabstinence

provideapproriatetobaccodependence

counseling&treatments

ispatientnowwaiting

toquit

didpatientonceusetobacco

YES

YES YES

Relapse

Abstinent

Non-user

NO

NO NO

GeneralPopulation

Adviseom

smokinghazards

Advicetoquit

Currentusers

exuser

NO YES

Patientnowwillingtoquit

Patientsstllunwillingtoquit

Releaseprevention

Assistquitting

Advicetoquit

Promotemotivationtoquit

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AskscreenforTobaccouse

Patientspresenttoahealthcaresetting

Arrangefollowup



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BriefClinicalIntervention

• Briefclinicalinterventionbythephysicianincreasesquitrateseffectively• Itisvitaltochangeclinicalcultureandpracticepatternstoensurethat

everypatientwhousestobaccois identifiedandofferedcounseling&treatment

• So,everytobaccousershouldbeofferedatleastabriefinterventionasthishasbeenproventoincreaseoveralltobaccoabstinencerates

• Studies have shown that individual counselling resulted in higherabstinenceratesascomparedtogrouporphonecounsellingandself-help

• Briefinterventionintheprimarycaresettingaredesignedtobebriefandminimalclinician/healthcareprovidertimeisrequired

AAAofBriefClinicalIntervention

A1.AskabouttobaccouseA2.AdvisetoquitA3.Actonpatient’sresponse 1. ApplySTARor 2. ReferpatienttoQclinic

Tobedeliveredtoeachtobaccouser,regardlessofhisorherwillingnesstoquit

Helpthepatientwithaquitplan(applySTAR)

• Setaquitdate.Ideally,thequitdateshouldbewithin2weeks• Tell family, friends, and coworkers about quitting, and request

understandingandsupport• Anticipatechallengestotheupcomingquitattempt,particularlyduring

thecriticalfirstfewweeks,theseincludenicotinewithdrawalsymptoms• Remove tobaccoproducts fromyourenvironment–makeyourhome

smoke-free

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5AsofBriefClinicalIntervention

A1.AskabouttobaccouseA2.AdvisetoquitA3.AssesswillingnesstoquitA4.AssistinquitattemptA5.Arrangefollow-up

A2:ADVISEclienttoquit

Inaclear,strongandpersonalizedmannerurgeeverytobaccousertoquit“Benefitofquitting”“Impactofsmoking”

A1:ASKabouttobaccouseIdentifyanddocumenttobaccousestatusforeverypatientateveryvisit“Areyoucurrentlyasmoker?“,“Doyoueversmokebefore?“Expandthevitalsignstoincludetobaccouseoruseanalternativeuniversalidentificationsystem(e.g.stickersonpatientcharts)

VitalSignsBloodPressure:__________________________________________Pulse:_____________________Weight:_____________________Temperature:_________________________________________RespiratoryRate:______________________________________TobaccoUse:(circleone)CurrentFormerNever

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A3:ASSESSWillingnesstoquit“Areyouwillingtoquit““Areyoureadytoquitnoworwithin6months“

• Thereisevidencethatthelikelihoodofsuccessinanattempttoquitisunrelated to thesmoker’sexpressed interest inquitting in theperiodleadinguptotheattempt–unplannedattemptstoquitareaslikely(orevenmorelikely)tobeassuccessfulasplannedattempts

• Thus, there is benefit in encouragingall smokers to considerquittingwhenevertheopportunityarises

RapidlyAssessingaSmoker’sStageofChange

Doyoucurrentlysmoke

pre-comtemplation

comtemplation preparation action maintenance

haveyouconsideredquiting

smoking

haveyouconsideredquitingsmoking

Non-smoking

haveyoueversmokedinyour

lifetime

areyouthinkingaboutquitingin

thenext6monthsorhavetriedto

quitfor≥24hoursthepastyear

YES NO

NO

NO YES <6MO >6MO

YES NOBr

ief I

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s, 5

As a

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Rs D

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Impa

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A4:ASSISTinquitattempt

1. Forthepatientwillingtomakeaquitattempt -Providecounseling&medication2. Forpatientsunwillingtoquit -Provideinterventionsdesignedtoincreasefuturequitattempts(5R’s)

A5:ARRANGEforfollow–up1. Forthepatientwillingtomakeaquitattempt - Arrangeforfollow-upcontacts,beginningwithinthefirstweek

afterthequitdate2. Forpatientsunwillingtomakeaquitattempt - Addresstobaccodependenceandwillingnesstoquitatnextclinic

visit3. Follow-upsarerecommendedweeklywithinthefirstmonth,and

theneverytwoweeksforthe2ndand3rdmonth,andmonthlyafterthatupto6months

4. Forthosewhosuccessfullyquit,schedulefollow-upcontact,eitherinpersonorviatelephone

Helpthepatientwithaquitplan(applySTAR)

1. Setaquitdate.Ideally,thequitdateshouldbewithin2weeks2. Tellfamily,friends,andcoworkersaboutquitting,andrequest

understandingandsupport3. Anticipatechallengestotheupcomingquitattempt,particularly

duringthecriticalfirstfewweeks,theseincludenicotinewithdrawalsymptoms

4. Removetobaccoproductsfromyourenvironment–makeyourhomesmoke-free

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Duringfollow-up

Askwhetherclienttotallyabstain

• Ifyes:praiseandcongratulate• Ifno:askwhy;motivate• Askforwithdrawalsymptomsifany• Whatdoyoudotoovercomewithdrawal• FindoutwhetherclientuseNRT/oralmedicationcorrectly

ForThePatientUnwillingToQuit(5R)Provide5R’s strategies– toenhancemotivation to increase futurequitattempts

• Relevance• Risks• Rewards• Roadblocks• Repetition

Relevance

• Encouragethepatienttoindicatewhyquittingispersonallyrelevant• Motivational informationhasthegreatest impact if it is relevant toa

patient’sdiseasestatusorrisk, familyorsocialsituation(e.g.,havingchildreninthehome),healthconcernsetc

Risks

Askthepatienttoidentifypotentialnegativeconsequencesoftobaccouse• Short-termrisks:exacerbationofasthma,harmtopregnancy,

impotenceandinfertility• Longtermrisks:Heartattacks,strokes,COPDandlungcancer• Environmentalrisks:1. Increasedriskoflungcancerandheartdiseaseinspouses2. Increasedriskforasthmaandrespiratoryinfectionsinchildrenof

smokers3. Higherratesofsmokingbychildrenoftobaccousers

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MANAGEMENT IN QUIT SMOKING PROGRAMME Training Module For Health Care Providers

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Rewards

1. Askthepatienttoidentifypotentialbenefitsofstoppingtobaccouse2. Examplesofrewardsfollow: - Improvedhealth - Improvedsenseofsmell - Savemoney - Setagoodexampleforchildren - Havehealthierbabiesandchildren - Performbetterinphysicalactivities - Reducedwrinkling/agingofskin

Repetition

1. Themotivationalinterventionshouldberepeatedeverytimeanunmotivatedpatientvisitstheclinicsetting

2. Tobaccouserswhohavefailedinpreviousquitattemptsshouldbetoldthatmostpeoplemakerepeatedquitattemptsbeforetheyaresuccessful

SLIDE

23 Roadblocks

1. Askthepatienttoidentifybarrierstoquittingandnoteelementsoftreatment(problemsolving,pharmacotherapy)thatcouldaddressbarriers)

2. Typicalbarriersmightinclude: - Withdrawalsymptoms - Fearoffailure - Weightgain - Lackofsupport - Depression - Enjoymentoftobacco - Costoftreatment

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TOPIC 6

Management of Quit Smoking Services at

Health Clinic



LEARNING OBJECTIVE

Managem

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satHealthClinic

• TechiniqueinmanagingthedocumentationprocessandretensysteminQuitSmoking Services.Appointmentsystemmechanismismentionedinthistopicaswellasdefaulter tracingmechanism.• Work flow chart process for Quit Smoking Services is elaborated in this topic comprehensively for

efficientservice.• Screening procedure based on the 3As, 5Rs and 5As technique are stated. Scoring for the level of

willingnessforquittersismentionedinthistopicduringthefirstappointmentwiththeclient.

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QuitSmokingServices

StopSmokingService is includingthepromotionandclinicalservices forsmokerclienttostopsmoking.

Objective

GeneralObjectiveToproduceahealthsocietyandfreefromcigarettesmokeandalsoliveinanoptimumhealthylifestyle

SpecificObjective

1. Educatethesmokergroupaboutthedangerousandnegativesideeffectfromsmokingandalsoawarenessamongthem.

2. Toallowallthesmoketostopsmokingbasedontherighttechniqueintheguidelinemodulewhichhasbeenproduced.

3. Helpthesmokertostopsmokingwithaproperstepandplanned.4. Enablesmokerswhoquitsmokingremainasnon–smoker.5. Encouragethenon–smokerssocietytoremaincleanfromsmoking.



Managem

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QuitSmokingServicePolicies

1. AllhealthclinicsmusthavetheQuitSmokingServicesetting.2. All the clinic staffs are required to undergo the course on how the

managementoftheserviceisdeliver.3. All health clinics must provide the screening (BSSK form) service in

findingclient.4. HealthClinicmustfullyequippedwiththetoolsforoperatingthequit

smokingactivity.

OrganizationChartoftheQuitSmokingService

PKD

HealthClinic

FamilyMedicineSpecialist

Dietician MedicalOfficer

MedicalAssistant StaffNurse

CommunityNurse

ClinisAttendant

Pharmacist Dentist



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Recordanddocumentation1. Allnewclientswhoisagreedtojointhequitsmokingprogrammust

registerintheregistrationbookbeforegoingthroughtheinterventionprogramme.

2. AllquitsmokingclientmusthavetheirownfolderorQuitSmokingGuideline.

3. Eachfollowupthatbegivenmustberecordedintheregistrationbook.4. Retenmustbeupdatedandcompiledatthecliniclevel,DistrictOffice

level,HealthStateOfficeandMinistryofHealth(MoH).

1. TreatmentroomforQuitSmokingService

Usetheconsultationortreatmentroomwhichalreadyexisted.

2. Equipmentandtools a. Sphygomomanometerand

Stethoscope b. Weightmachineandheight

measurement. c. BMIchart d. PeakFlowMeter e. CO2Analyser f. ECGmachine g. ComputerandPrinter h. Spirometer(ifavailable)

3. Medication NicotinePatch a. Nicotinepatch7mg b. Nicotinepatch14mg c. Nicotinepatch21mg

NicotineGum a. Nicotinegum2mg b. Nicotinegum4mg Varenicline(Champix) c. Varenicline0.5mg/tablet a. Varenicline1mg/tablet Lozenges c. Lozenges2mg a. Lozenges4mg

4. Guidelineandmanual a. Smallrecordbook/brochure–

QuitSmoking b. ModuleforQuitSmoking c. GuidelineforQuitSmoking d. ClinicalPracticeGuideline

(CPG)onTreatmentofTobacco SmokingandDependence

e. BrochureofQuitSmoking f. FlipchartofQuitSmoking

(educationmaterial)

5.Documentation a. Registrationbook i. Newcase ii. Followupcase b. Client’squitsmokingfolder c. RetenKBM1/2012,Reten

KBM2/2012,RetenKBM 3/2012,RetenKBM4/2012 danRetenKBM5/2012

6. Educationmaterialfacility a. Healthclinicmusthavethe

materialforeducationin operatingthequitsmoking servicesandactivities.

b. Materialforeducation: i. Posterofdangerofsmoking ii. Broucherofdangerofsmoking iii.Visualaudio iv.Buntingofquitsmokingservice v. Healthfactmaterial(magazine)

regardingsmoking.

ListofequipmentandtoolfortheQuitSmokingService



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EarlyscreeningforQuitSmokingService

1. ScreeningflowchartforQuitSmokingService2. ScreeningworkprocessforQuitSmokingService3. PrincipleofQuitSmokingServicemanagement–3As,5As,5Rs4. Screeningforthelevelofreadiness/willingnessamongclientwhokeen

toquitsmoking.

Referappendix2(topic6:ManagementofQuitSmokingServicesatHealthClinic

ScreeningworkprocessforQuitSmokingClient

WorkProcess Standard Action Equipment

Identifyclient ClientfromBSSKscreening,PKSandPPKPChronicdiseasecaseWalk–incaseHealthcampDentalclinicReferalfromGovementOffice/school/Privateoffice

PPP/JK/JM/PPKP/PKAPKSenforcementUPK

Relatedscreeningform

PengendalianKlien

Non–smokerclientAdvise/healtheducation

Ex–smokerclientAdvise/healtheducationPreventionfrom‘relapse’

SmokerIfagreedtostoprefertotheinchargeofficerforfurtherintervention.Ifnotagreed,advise/healtheducation(5Rprinciple)

MOHEOPPPJKJM

SOPQuitSmokingService



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QuitSmokingPrinciples

3Asprinciples1.Ask • Ask and record the history regarding the cigarette consumption by client

2.Advise • Advise the patient regarding the smoking hazard and also the advantageofstopsmoking.

3.Action • Recordalltheinformationinthepatient’srecordandreferthepatient toQuitSmokingServiceUnit.

5Asprinciples

Brief introduction to the smokerclient1. Ask • Ask and record the history

regarding the cigarette consumptionbyclient

2. Advise • Advisethepatientregarding

thesmokinghazardandalsothe advantageofstopsmoking.

3. Assess • Evaluatetheaddictionleveland

the willingness spirit of the clientregardingstopsmoking.

4. Assist • Helptheclienttostopsmoking

5. Arrange • Do the preparation for the

clientattheQuitSmokingServiceUnit.

5RsprinciplesIt is a intervention which help tomotivate the client and prevent thepatientfromnotsmokeagain.

1. Relevance • Relate the client’s personal

interestsifhestopsmokingeg: If the client want to have childrenandsoon.

2. Risks • Explain the negative impact of

tobaccousebasedonshortand longtermeffect.

3. Rewards • Imagine if there are more

rewardsandbenefitiftheclient stopsmoking.

4. Roadblocks • Identifytheclient’sobstacle

5. Repetition • Motivation has to be repeat

several times which helps to maintainthespirit inclientand givesupportcontinouslyeven thereisfailure.



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ScreeningTheLevelOfWillingnessForQuitSmoking

SCORE:LevelOfWillingnessForQuitSmoking1. Pre-contemplationstage `NO’toquestion1

2. Contemplationstage `Yes’toquestion1dan`No’otherquestion

3. Preparation `Yes’toallthequestions

SCORE:Pre-contemplationstage

Yes No Question

1 Areyouinterestedtoquitsmokingwithinthese6months?

2 Doyouplantoquitsmokingnextmonth?

3 Haveyouevertrytoquitsmokingwithinthe12monthsago?

SCORE:Preparationstage

Yes No Question

1 Areyouinterestedtoquitsmokingwithinthese6months?

2 Doyouplantoquitsmokingnextmonth?

3 Haveyouevertrytoquitsmokingwithinthe12monthsago?

RetenManagementAssessmentandMonitoring

Monitoringtheretenisbasedon:1. Monthlyreten2. 6monthlyreten3. Trainingtostaffregardingthequitsmokingservicesforatleastoncea

year.

Monitoredindicators:1. Totalclientwhichalreadyregisteredforquitsmokingservicesinthe

registrationbook.2. Totalofclientwhoalreadyquitedsmoking.3. Totalrateforclientwhoalreadyquitsmoking.



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ListofretenfortheQuitSmokingServicesatHealthClinicNo Documenttitle Documentseries

1. NewclientretenmonthlyQuitSmokingClinic(HealthClinic)

BPKK/KBM/1/2012

2. Clientthatalreadyquitsmokingreten(HealthClinic) BPKK/KBM/2/2012

3. 6monthlyreten:totalclientthanquitedsmoking(HealthClinic)

BPKK/KBM/3/2012

4. 6monthlyreten:Totalrateofquitsmoking BPKK/KBM/4/2012

5. Yearlyreten:TrainingforHealthProviderforquitsmokingservices

BPKK/KBM/5/2012

MonthlyReten1. Totalnewclientwhichregisteredinthequitsmokingservicesforthat

particularmonth.2. Totalclientthatalreadyquitsmokingforthatparticularmonth.

6monthlyreten1. Totalclientforquitsmokingserviceswithin6months(January–Junand

July–December)2. Totalquitratefor6months(January–JunandJuly–December)3. Quit rateforyearly is theaverageratefrom(January– Junand July–

December)4. Defaulter

QuitRatefor6months(January–JunandJuly–December)

Quitrate Totalclientthatalreadyquitmorethan6monthsx100% Totalregisteredsmoker

YearlyQuitRateisaveragefromJanuarytillJuneandJulytillDecember

TotalclientthatalreadyquitsmokingfromcurrentyearJanuarytillJunex100%TotalclientthatalreadyregisteredfromJulytillDecemberpreviousyear



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Transmissionofthereten• RetenmustsendtoDistrictOfficebefore5thdayofthemonth.• RetenmustsendtoStateOfficebefore8thdayofevery6month.• RetenmustsendtoFamilyHealthDevelopmentDivision,Ministryof

Healthevery15thJulyand15Januaryoftheyear.

Defination

1. Regeisteredclient • Totalclientthatregisteredinthequitsmokingservicesregistration

book.

2. Defaulter • Clientwhodonotcomeforthefirstappoinmentandfailedtomakean

appointmentwithin1weekfromthedategiven.

3. Clientthatquitsmoking • Morethan6months

4. Terminationofcase • Clientthatfailedtoattendthe3appointmentsgiven

Appointmentsystemanddefaultertracing

• Appointmentbook• Recordbookfordateandtimeofcallshasbeenmade-–defaulter

tracing

Recordstorage• Registrationbookforquitsmokingservice(BlueBook)• Clinicmonthlyreten–todespatchtotheMedicalAssistantOfficerat

DistrictlevelusingtheMinistryofHealthformat.

ClientDifficulty• Lackofmotivationtoquitsmoking• Negativemoodanddepression• Strongaddictionandprolonged• Gainedweight• Nostrongmotivation


MANAGEMENT IN QUIT SMOKING PROGRAMME Training Module For Health Care ProvidersManagem

entofQ

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Overcomesteps

Problem Overcomesteps

Lackofmotivationtoquitsmoking

Reschedulethetreatmentappointmnet

Proactivecaunselingviatelephone

Identifythesupportingteam

Referral

Negativemoodanddepression

Caunselling(depression)

Prescribetherightmedication

Referral

Strongaddictionandprolonged

Usethepharmacologytechniqueforlongtermtreatment

Careintheward

Gainedweight Adviseonhealthdiet

Increasethephysicalactivity

Refertodietician

Nostrongmotivation Motivation:5RapproachRelevanceRisksRewardsRoadblocksRepetition

Fatwa• 23rd March 1995, 23rd March 1995, Fatwa Chairboard memberDialgueand37thNationalCouncilforIslamicAffairshasdecidedthatsmokingisHARAMfromtheIslamperspectiveandisamustforeashmuslimtoavoidit.

• Kedah,Perlis,P.PinangSelangor,W.PersekutuandanPahang

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TOPIC 7

Promotion and counseling - Quit Smoking programme

in Health Clinic Tanglin



LEARNING OBJECTIVE

Prom

otionandcounseliin

g-Q

uitSmokingprogrammeinHealthClinicTanglin

• ComprehensiveplanforpromotingtheQuitSmokingServiceinthehealthcliniciswellexplainedinthistopic.Promotionplaysabigroleininfluencingtheclientandtheaccessibilitytotheservicewithshouldbeconvinientandaccessibetoclient.

• Techniqueindraggingtheclienttoquitsmokingwillbementionedinthistopicincludingtheeducationmaterial.

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Objectives

• Createawarenessregardingthedangersofsmoking• Provideknowledgeandskillsforsmokerstoquitsmoking.• Provide treatment and rehabilitation to smokers who intend to quit

smoking.• Encouragethequitterstomaintaintheirquitstatus

StaffForQuitSmokingClinic

• Doctor • StaffNurse• MedicalAssistant • CommunityNurse• Pharmacist

SuitableplaceforQclinic



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WhatDoYouNeedInTheQuitSmokingClinic

• Relevantforms• Sphygomomanometer• Weighingscale• CarbonMonoxideBreathAnalyzerSet• Champix,Nrt,VitaminC,Vaseline• Appointmentbook

Serviceschedule

Selectsuitabledays

Day Time

Wednesday 2pm-4pm

Fridays8am-12noon

2.45pm-4pm

WhereToPromote

1. IntheTriage2. IntheProcedureRoom3. IntheConsultationRoom4. DuringDOTStreatmentsession

5. InthetreatmentRoom6. IntheFundusCameraRoom7. InthePharmacy8. Fromallplacestothequitclinic*Fromallplacestothequitclinic



Prom

otionandcounseliin

g-Q


QUITSMOKINGCLINIC

DotsTreatment

Dr’sRoom

Medicalcheckup

Triage QuitSmokingBooth

Pharmacy

FundoscopyRoom

TreatmentRoom

BloodRoom



Prom

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Whowillpromote?

1. Doctor2. Nurse3. MedicalAssistant4. Pharmacist5. ClinicAttendance6. Allstaffintheclinic

Howtopromote

A-Askthepatient“Sirdoyousmoke?”B-BriefInterventionC-Cessation

Pleaseapply3As,5Asand5Rsconcept***

PromotePharmacotherapy

• Gum• Inhaler• Patches• Champix• TreatmentIsFreeOfCharge

Promoteclinicdays

Walkinappointment

Day Time

Wednesday 2-4pm

Friday 8am–4pm(officehours)



Prom

otionandcounseliin

g-Q


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WorkProcessInQuitSmokingClinic

PromotionforQuitSmoking

TAHNIAH!!ANDABERSEDIAUNTUKBERHENTIMEROKOK

KlinikBerhentiMerokokKKTanglinRabu:2-4petangJumaat:8pagi-4petang

Nama:I/C:NamaStaffPromosi:Tarikh:S/NSWINDER-0132064377

Newsoftwaredonatedbyumquitsmokingsystem

• Startedabout2yearsback• onlyclinicinmalaysiawiththissystem• ifanyonewantstodoaresearch• Theycandoonline.



Prom

otionandcounseliin

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FagerstromTest(SmokingAddictionLevelTest)Score:

0-3LOW 4-5MODERATE>5HIGH

RoutineScreeningDoneOn

Everyvisit1. BloodPressure2. PulseRateHeightOnFirstVisit3. Weight4. MeasuringOfCarbonMonoxideLevel5. IndividualCounselling6. GroupCounselling

FindAQuitBuddy

1. Chancesareyouknowanothersmokerwhowantstoquit.2. Suggesttotheothersmokerthatyouwillhelpeachotherto(dousethe

flames)forever.3. Studiesshowthatsmokerswhopatnerwithaquitbuddyaremore

successful,ratherthanquittingontheirown.

Advisetoclients• Throwawayallthings• Associatedwithsmoking• Nobuying,beggingandrefuse• Offerofcigarettes• Informfamilymembersand

Friends• Avoidgoingtosmokingareas

• Avoidcaffeineateddrinksandalcohol

• Avoidoldsmokingbuddiesgetsupport

• Spendmoretimeinplacesthatbansmokinge.gCinemas,shoppingcenters

• Indulgeinanewhobby



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WhatHappensWhenYouQuit?

• Coughandrunningnose• Skinonthelipswillpeeloff• Swellingandbleedingofgums• Ulcermouth• Tingglingsensations• Sleepdisturbance• Increaseappetite

• Feellightheaded• Constipation.• Angry,irritatedmoodswings• Frustration• Restlessness• Chestpain• Bodyaches• Nighttimeawakenings

Fightingwithdrawal

• Strongurge-3minutes• Deepbreathing• 5minutesexcersice• Drinkplentyofwater8-10

glasses• Washfaceandhands• Coldbath

• Munchsomething• Keephandsbusy• Followrulingofredlight(divert

yourthinking)

PositiveEffectsOfExercise

• Reducestress• Increasestamina• Increasedfeelingsofwellbeing

andimprovedhealth• Weightloss

• Improvedmuscletoneandphysicalappearance

• Increasedself-esteemandsenseofaccomplishment

• Improvedsleep



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SLIDE

19TheBenefitsOfQuitting

Withinhours

8hours1. Nicotineandcarbonmonoxide

levelshalved2. Bloodoxygenlevelsreturnto

normal

24hoursCarbonmonoxideeliminatedfromthebody

48hours1. Nicotineeliminatedfromthebody2. Tastebudsstarttorecover

Withinmonths

1month1. Appearanceimproves2. Skinlosesgreyishpallorandless

wrinkled

3. Regenerationofrespiratoryciliastarts

4. Withdrawalsymptomshavestopped

3–9monthscoughingandwheezingdecline

Withinyears5years1. Theriskofaheartattack2. Reducesbyhalf

10years1. Theriskoflungcancerhalved2. Savemoney3. Home,car,clothing,andbreath

willsmellbetter.4. Setagoodexampletoyour

children.

Noofciggratesperday 5 10 20 30 40

Day1quitsmoking 2.50 5.00 10.00 15.00 20.00

1weekquitsmoking 17.50 35.00 70.00 105.00 140.00

1monthquitsmoking 70.00 140.00 280.00 420.00 560.00

1yearquitsmoking 840.00 1680.00 3360.00 5040.00 6720.00

5yearsquitsmoking 4200.00 8400.00 16,800 25,200 33,6004

10yearsquitsmoking 8400.00 16,800 33,600 50,400 67,200

SLIDE

20FATWA23rdMarch1995,23rdMarch1995,FatwaChairboardmemberDialgueand37thNationalCouncilforIslamicAffairshasdecidedthatsmokingisHARAMfromtheIslamperspectiveandisamustforeachmuslimtoavoidit.



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SLIDE21

SLIDE22

SLIDE23

Clients are given nicotine replacement therapy to fight theirwithdrawalsymptoms:1. Champix2. Vitaminc3. Vaselineforlips

Criteria

a. Smokerswhoaremotivatedtoquitb. Smokingadultsaged>18yearsand<60yrs.c. Alcoholintake<3unitsperweekd. Notaddictedtoanyotherdrugsotherthannicotinee. Notpregnantorplanningtogetpregnantorlactating.f. Notonanypsychiatryfollowuportakinganyantidepressant

medicationsg. Nohistoryoffitsorepilepsy

Date:

Meetalltheinclusioncriteria:(allyes)No Criteria YES/NO1. Smokerswhoaremotivatedtoquit2. Smokingadultsaged>18yearsand<60yearsold3. SubjectnotonVareniclinebefore

4. Subjectspreviouslyonotherpharmacotherapybuthaverelapsedafter6months

5. Alcoholintake<3units/week

6. Notaddictedtoanyotherdrugs(otherthannicotine)

Meetallexclusioncriteria:(allno)No Criteria YES/NO

1. Subjectsinwhomvareniclinemaybetakeninamannerthatisnotaccordingtotheapprovedlocalproductdocument

2. Pregnantorplanningtogetpregnantorlactating3. Subjectsunderthecareofpsychiatryand/ortaking

antidepressantmedication4. Subjectswithknownhypersensitivitytovarenicline



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1. Date:

2. Vitalsigns -Notdone

SittingBP:…………………..

Pulse:…………………..

3. Nicotineuseinventory -NotDone

Hasthesubjectsmokedanycigarettes(evenapuff)inthelast7days?a) Yesb) No

Hasthesubjectusedanyothernicotine-containingproducts(e.g.nicotinepatch,gum,nasalspray,lozenges,pipe,cigars,chew,snuff)inthelast7days?a) Yesb) No

CarbonMonoxideBreathAnalyzerReadingSignificantneuropsychiatricbehaviouralscreen:

If you, the patient, their family or caregiver notice agitation, depressedmood, or changes in behavior that are not typical or develop suicidalthoughtsoractionsbythepatient,STOPtakingCHAMPIXandseehis/herdoctor.Motivationlevel:Low:GiveMotivationHigh:GiveChampix

SLIDE

24CHAMPIXtreatment

• Day1toDay3-0.5mgdaily• Day4toDay7-0.5mgBDX4days• 1mgbdx11weeks


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SLIDE25

SLIDE26

SLIDE27

Remindertotheclients

Onedaybeforetheirappointment1stweekfollowup• Enquireaboutquitstatus• Praisethepatient• Anywithdrawals• Anyotherproblems• EnquirecorrectusageofNRT• Givenextappointment

Incentives

• Incentivesforthededicatedstaffofquitclinic• Staffwhopromotesthemostnumberofpatientstothequitclinicwill

begivenincentivesin2013

Vision

By2020tobaccowillnolongerbeamajorpublichealthconcern.InMalaysia,wheredecreasingnationalprevalenceoftobacco.Attributeddiseaseandmotalitywillcontinuouslydecline



TOPIC 8

Pharmacological Intervention in Smoking

Cessation



LEARNING OBJECTIVE

Pharmacologica

lInterventioninSmokingCessation

• Pharmacologytherapyisoneofthemethodsinreleasingtheaddictionlevelinsmokerbesidemotivationorcounsellingsession.Therearefewofmedicationwhichavailableatthehealthclinicforsmokingcessationwithdifferentmethodofintakeroutes.

• Sideeffectfromeachdrugwhichyouprescribedwillbeexplainedinthistopic.Therefore,physicianmayknowwhichdrugisworkthebestandsuitthepatient.Theeffectivenessofthetreatmentandtheoutcomeofeachdrugarementionedattheendofthetopic.

SLIDE1

SLIDE2

SLIDE3

Outline

Attheendofthispresentation,participantsshouldbeableto:

1. Discuss latest evidence for pharmacologic intervention in smokingcessation

2. Explainthechoice,useandmonitoringofagentsforsmokingcessation

Whichonetouse?

1. Efficacy2. Safety3. Suitability4. Cost

NRT1. 111trialswithover40,000participants.2. Riskratio(RR)ofabstinenceforanyformofNRTrelativetocontrolwas

1.58(95%confidenceinterval[CI]:1.50to1.66).3. PooledRRforeachtype: - 1.43(95%CI:1.33to1.53,53trials)forgum - 1.66(95%CI:1.53to1.81,41trials)forpatch - 1.90(95%CI:1.36to2.67,4trials)forinhaler - 2.00(95%CI:1.63to2.45,6trials)forlozenges - 2.02(95%CI:1.49to3.73,4trials)fornasalspray.

CochraneDatabaseSystRev.2008Jan23;(1):CD000146.Nicotine replacement therapy forsmokingcessation.SteadLF,PereraR,BullenC,MantD,LancasterT



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SLIDE4

SLIDE5

SLIDE6

Gum–thingstotellyourpatients

1. Chewitintherightway(itsnotlikeregularchewinggum)

2. Aciddrinksreducedamountavailableforabsorption

3. Newflavoursofgumaremorepalatable

4. Useenoughofit:about10-15piecesaday,hourly

5. Recommenduseforatleast3months

Usingenough

1. 1030smokerwhoquitforatleast2weeksinatrialofnicotinelozenges2. 28-dayscontinuousabstinenceat6-weeksfollow-upwaspositively

correlatedwithincreasedNRTuse3. EachoneadditionalpieceofNRTusedincreasetheoddsofquittingby10%4. Similareffectscanbeexpectedwithnicotinegum

ShiffmanS.Addiction2007,102(5)809-14

Transdermalpatch1. 16and24hourspatches2. High,mediumandlowdoses3. Recommenduseforsome3months4. 24hours patchesmay cause sleep disturbances

Patches–thingstotellyourpatients1. Newpatcheachmorning/night2. Onupperarm,sideoftorso,hairless partofbody3. Do not put on the same place, especiallyifrednessoccurs


Pharmacologica


SLIDE7

SLIDE8

Nicotineinhaler

Inhaler/Inhalator

1. Nicotine is not inhaled into lungs (but absorbed across the buccalmucosa)

2. Takessome30minutestoreachplateau3. Recommend

puffingcontinuouslyforsome10-20minutesQH.

4. 10puffsequalonepufffromcigarette.



Pharmacologica



SLIDE9

SLIDE10

SLIDE11

Lozenges

1. Weeks1through6:onelozengeevery1to2hours2. Weeks7through9:onelozengeevery2to4hours3. Weeks10through12:onelozengeevery4to8hours4. Donotusemorethanfivelozengesin6hoursormorethan20lozenges/

day

Howtotake1. Placethelozengeinthemouthandallowittodissolveslowly(20–30

minutes).2. Awarm,tinglingsensationmaybefelt(nicotinereleased).3. TominimizetheriskofADR(nausea,hiccupsandheartburn),donot

cheworswallow.4. Todecreasemouthirritation,occasionallymovethelozengetodifferent

areaswithinthemouth.

ChoosinganNRTproduct

1. Explanationofthedifferentproductsusuallyadequate2. Howeveronestudy*foundthatNRTpreferencesbasedonexplanations

changedaftersampling3. NRTsamplingmayleadtobetterchoiceandtreatmentcompliance

*Schneideratal.NTR(2008),10,179-186

Howdoyoudecideonthedose?

1. Cigaretteconsumptionisnotalwaysagoodguide,why?2. Mostpeoplecanstartonfullstrengthpatches3. Doseoforalproductcanbedeterminedbytimetofirstcigarette

(TTFC): • Smokeswithin30minutesofwakinguse4mggum • Smokersafter30minutesofwakinguse2mggum



Pharmacologica


SLIDE12

Cautionsandcommonsideeffectsassociatedwithnicotine replacementtherapyMedication Cautions Sideeffects

Nicotinegum CautionwithdenturesDon’tdrinkacidicbeveragesduringuse

Mouthsorenessstomachaches

Nicotineinhaler Mayirritatemouth/throatatfirst(butimproveswithuse)Don’tdrinkacidicbeveragesduringuse

Localirritationofmouthandthroat

Nicotinenasalspray NotforpatientswithasthmaMayirritatenose(improvesovertime)Maycausedependence

Nasalirritation

Nicotinelozenges Donoteatordrink15minutesbeforeorduringuseOnelozengesatatimeLimit20–24hours

HiccupsCoughHeartburn

Nicotinepatch Donotuseifyouhavesevereezcemaorpsoriasis

Localskinirritationinsomia

FioreMC,JaenRC,BakerTB,etal.ClinicalPracticeGuideline:Treatingtobaccouseanddependece:2008Update.Rockville,MD:USdepartmentofHealthandHumanServices.PublicHealthService;2008.

SLIDE13

Safetyissues

• NRT is safe to use in patients with stable cardiovascular disease.(StrengthA)

• NRT should be usedwith caution in patientswho have had a recentmyocardial infarction, unstable angina, severe arrhythmias or recentcerebrovascularevents.(StrengthC)

• UseofNRTshouldbeconsideredwhenapregnantwomanisotherwiseunable to quit. Intermittent NRT is preferred to patches (lower totaldailynicotinedose).(StrengthC)

ZwarN,etal.TheRoyalAustralianCollegeofGeneralPractitioners,2011



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SLIDE14

SLIDE15

SLIDE16

Higherdegreeofnicotinereplacement1. Therearemodestdatatoshowthathigherdegreeofnicotine

replacementisassociatedwithgreaterquitrates2. Morehighlydependentsmokersaremorelikelytoquitwhentheyuse

highdosegum(4mg)versuslowerdose(2mg)gum – RR=1.85,95%CI:1.30-2.5013. Similarresultsareseenwiththelozenge2

1. SteadLF,PereraR,BullenC,MantD,LancasterT.Nicotinereplacementtherapyforsmokingcessation.CochraneDatabaseSystRev2008(1)

2. ShiffmanS,DreslerCM,HajekP,GilburtSJ,TargettDA,StrahsKR.Efficacyofanicotinelozengeforsmokingcessation.ArchInternMed2002;162(11):1267-76

Higherdosepatches• Sevenstudiescomparedhigherdosepatches(e.g.44mg/24hours)with

standarddoses(21mg/24hours)• Overalltherewasasmallincreaseinlong-termquitrates(RR=1.15,

95%CI:1.01-1.30)

SteadLF,PereraR,BullenC,MantD,LancasterT.Nicotinereplacementtherapyforsmokingcessation.CochraneDatabaseSystRev2008(1)

CombinationStrategies1. CombiningtwoformsofNRT(patchplusoralform,suchaslozengeor gum)hasbeenshowntobemoreefficaciousthanasingleformof nicotinereplacement.2. 6trialscomparingcombinationwithsingleNRTshowsadvantageof combinationuse – RR=1.35(95%CI:1.11-1.63)

Patch-providesbackgroundcravingrelief + Intermittentdosingproduct-forcontrolof‘breakthroughcarving’

SteadLF,etal.Nicotinereplacementtherapyforsmokingcessation.CochraneDatabaseofSystematicReviews2008,Issue1.Art.No:CD000146.DOI:10.1002/14651858.CD000146.pub3.

FioreMC,BaileyWC,CohenSJ,etal.Treatingtobaccouseanddependence:clinicalpracticeguideline.Rockville,MD:UnitedStatesDepartmentofHealthandHumanServices,2000.



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SLIDE17

SLIDE19

SLIDE18

• Thepatchprovidesasteadybackgroundnicotinelevelandtheoralformsprovidereliefforbreakthroughcravingsasneeded.

• UsecombinedNRTifsmokersareunabletoquitusingoneNRTproductalone,orexperiencecravingsusingonlyoneformofNRT.

• NRTpatchand2mggumor2mg lozenge is licensed (e.g.,Australia)forsmokerswhohaverelapsedinthepastorwhoexperiencecravingsusingonlyoneformofNRT.

ZwarN,etal.TheRoyalAustralianCollegeofGeneralPractitioners,2011.

SafetyofcombinationNRTuse

• IncidenceofadverseeventswithcombinationNRT isnotsignificantlygreaterthanthatwithsingleNRTuse.

• DataconsistentwithsafetydatashowingfavourableriskbenefitofNRToverwiderangeofdosesandsituations.

• Smokerscapableoftiteratingtheirnicotineintake.

Referappendix2,Topic8

Combination

Combinationtherapy

Patch(longterm;>14weeks)+adlibNRT(gumorspray)

3 3.6(2.5–5.2) 36.5(28.6–45.3)

Patch+BuproplanSR 3 2.5(1.9–3.4) 28.9(23.5–35.1)

Patch+Nortriptyline 2 2.3(1.3–4.2) 27.3(17.2–40.4)

Patch+inhaler 2 2.2(1.3–3.6) 25.8(17.4–36.5)

FioreMC,BaileyWC,CohenSJ,etal.Treatingtobaccouseanddependence:clinicalpracticeguideline.Rockville,MD:UnitedStatesDepartmentofHealthandHumanServices,2000.



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SLIDE20

SLIDE21

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Pre-cessationNRTpatch

• Meta-analysisoffourstudies• Pre-treatmentwith21mg/24hourpatchesfor2weeks(3studies)or4

weeks(1study)• 6-monthsabstinenceOR=2.2(CI=1.5-3.2)

ShiffmanS,FergusonSG.Nicotinepatchtherapypriortoquittingsmoking:ameta-analysis.Addiction2008;103:557–63.

CutDownthenStop

• Nicotinegumandinhalerapprovedforusepriortostoppingsmoking.• Forsmokersnotintendingtostopimmediately.• Thegoalistoreducecigarettes-per-dayby50%overupto6-months.• Followthisbystoppingsmoking.• Ameta-analysisfoundthatreducingcigarettessmokedbeforequitday

vs.quittingabruptly,withnopriorreduction,producedcomparablequitrates.

LindsonN,AveyardP,HughesJR.Reductionversusabruptcessationinsmokerswhowanttoquit.CochraneDatabaseofSystematicReviews2010,Issue3.Art.No:CD008033.DOI:10.1002/14651858.CD008033.pub2

NRTassistedreductioninpeoplewhodon’twanttoquitabruptly• SystematicreviewofsevenRCTsinvolving2767smokersnotwillingor

abletostopabruptly• NRT-assistedreductionresultsinincreasedquittingandreduction

comparedtoplaceboOutcomes EventRates NNT(CI)

Smokingabstinencefor6months 6.8%vs.3.3% 29(15-90)

Sustainedsmokingreduction 6.1%vs.1.6% 23(12-48)

MooreD,AveyardP,ConnockM,WangD,Fry-SmithA,BartonP.Effectivenessandsafetyofnicotinereplacementtherapyassistedreductiontostopsmoking:systematicreviewandmeta-analysis.Bmj2009;338:b1024



Pharmacologica


Thelogicofthis

• Abouthalfofsmokerstrytocutdowneveryyear.• Someseeitasapreludetoquittingwhileinothercasesthereisnofirm

plantoquit.• CuttingdownwithoutNRTleadstocompensatorysmoking.

SLIDE23

SLIDE24

SLIDE25

ContinuingNRTafteralapse

1. MostpeoplestopusingNRTwhentheylapse.2. However,warninglabelsadviseagainstusingNRTandsmoking.3. HowevercontinuingtouseNRTpatchmightreducetheprogressionto

relapse – E.g.astudyofusingpatchshoweda5-foldreductionintheriskof

fullrelapseinthosewhohadlapsed

ShiffmanS,ScharfDM,ShadelWG,GwaltneyCJ,DangQ,PatonSM,etal.Analyzingmilestonesinsmokingcessation:illustrationinanicotinepatchtrialinadultsmokers.JConsultClinPsychol2006;74(2):276-85

Longer-termuseofNRT

• SomepeoplerequireNRTforlongerthan12weeks.• <10%ofpatientsonoralNRTand<15%onnasalsprayuseNRTfora1

year.• Thechancesoflong-termusearerelatedtospeedofnicotineabsorption.• Long-termusersaremostlysmokerswhosechanceofsuccesswouldbe

otherwisesmall

HajekP,McRobbieH,GillisonF(2007)PreventiveMedicine,44,230-234

Individualizedtreatment

• Therehastraditionallybeena‘onesizefitsall’approachwithdosingofNRT.

• Thereisverylittleindividualisationoftreatmentfortobaccodependenceasthereisinthemanagementofotherchronicdiseases.

• Specialpopulations(adolescents,pregnantandbreastfeedingmothers,mentalhealthpatients-drugsmokinginteractions,etc.)



Pharmacologica


SLIDE

26PAHs&DrugMetabolism

• Polycyclicaromatichydrocarbons(PAHs)intobaccosmokepotentinducersofhepaticcytochromeP-450(CYP)isoenzymes.

• ThreeinducibleCYP1familygenes(A1,A2andB1).• HepaticCYP1A2isfunctionallymostimportantCYP1genedueto

exclusive(?)liverexpression.• Drugs(substrates)oftheisoenzyme(s)mayhaveincreasemetabolism

(increaseclearance,reducehalf-life)insmokers,andtheoppositeeffectsmaybeseenpost-cessation.

• CYP1A2ismainenzymeformetabolismofclozapine,olanzapine,fluvoxamine,haloperidol.Alsoaffectsnaratiptan(antimigraineagent),andramelton(hypnotic).

SLIDE

27MainQuestion

• HowquicklydoestheinductionofCYP1A2dissipateuponsmokingcessation?

• In12subjectssmoked≥20cigs/d(range22.3–27.7cigs):Daypostquit RRinCYP1A2activity

1 12.3%

2 20.1%

3 25.0%

4 28.2%

7(steadystate) 36.1%

• Half-life(t1/2)ofCYP1A2activityaftersmokingcessation=38.6hours(Faber&Fuhr, 2004)



Pharmacologica


SLIDE28

Varenicline:AHighlySelective∝4β2ReceptorPartialAgonist

Bindingofnicotineatthe∝4β2nicotinicreceptorintheVTAisbelievedtocausereleaseofdopamineatthenAcc

Vareniclineisa∝4β2nicotinicreceptorpartialagonist,acompoundwithdualagonistandantagonistactivities.This isbelievedtoresult inbothalesseramountofdopaminereleasefromtheVTAatthenAccaswellasthepreventionofnicotinebindingatthe∝4β2receptors.

Czech Republic. 2. Picciotto MR et al. Nicotine Tob Res. 1999; Suppl2:S121-S125.

SuitablepatientforvareniclineCommencetreatmentasprescribedhowever

DonotpickaquitdateIfafter10-12days

Patienthasspontaneously:

• Reducedurgestosmoke

• Quitsmokingcigarettes• Reducedexpiredco↓• ContinueFullCourseAsPrescribed

• RevueFortnightlyThenMonthly

Patienthas:• reducedurgestosmoke• reducedcigaretteintake• reducedexpiredCO• butnotquit ↓

Revuein10days ↓

ifasabove,ADDNRTforurgestsmoke(4mggum,4mglozengesorinhaler) ↓

ifquitcontinueasaboveuntillcompletionofcourse ↓

• ifnotquitincreasefrequencyofNRT

• oradd21mgpatch• revueforthnightlythenmonthly

• patienthas• -noreduceurgestosmoke

• -notreducedcigaretteintake

• noreductioninexpiredCO ↓

• revuein10days ↓

• ifasabovediscontinuevarenicline

Basedon:Bittounetal,COnotcigarettes/dayasindicatorofvarenicilinesuccessBangkokSRNT2008Bittounetal,combinationvarencilineandNRTDublinSRNT2009



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SLIDE29

SLIDE30

SLIDE31

Efficacy:COCHRANEREVIEWNicotinereceptorpartialagonistsforsmokingcessationEditorialgroup:CochraneTobaccoAddictionGroup.Issue2,2011.

• 11trials,6892ofwhomusedvarenicline.• Vareniclineatstandarddoseincreasedthechancesofsuccessful

long-termsmokingcessationbetween2and3xcomparedwithpharmacologicallyunassistedquitattempts.

• ThemainADRofvareniclineisnausea,butmostlyatmildtomoderatelevelsandtendingtosubsideovertime.

• Possiblelinkswithseriousadverseevents,includingdepressedmood,agitationandsuicidalthoughts,andrecently?CVADRs

AdverseEffects(AEs)

1. Duringclinicaltrials,approximately4000individualswereexposedtovarenicline

2. MostfrequentlyreportedAEs(≥10%)associatedwithvarenicline1mgvsplacebowere:

•Nausea •Abnormaldreams •Insomnia •Headache

Smokingcessationandthepsyche(labeling)

• Depressivesymptomsandonrareoccasions–suicidalideationshavebeenreported.

• Smokingcessation,withorwithouttreatment,isassociatedwithnicotinewithdrawalsymptomsandhasalsobeenassociatedwiththeexacerbationofunderlyingpsychiatricillness.

• Healthcareprovidersshouldbeawareofthepossibleemergenceofsuchbehavioralchangesinpersonsattemptingsmokingcessationandrefer/advisepatientsappropriately.



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SLIDE32

SLIDE33

ADRRELATEDTOVARENICLINE(MADRAC,2008-OCT2010)

ADVERSEEVENTS NO.OFEVENT(N=187) %

Nausea 25 13.37

Giddiness 16 8.56

Dizziness 12 6.42

AbnormalDreams 12 6.42

Insomnia 7 3.74

SuicidalAttempt 1 0.53

CVAdverseEvent No.ofEvents

1 Chestpain 3

2 Palpitation 1

3 Tachycardia 1

4 Supraventiculartachycardia 1

Since 2008, National Centre of ADR Monitoring received 122 reportsrelatedtovarenicline,ofwhich6reportswereCV-related.AllreportswereassignedcausalityC3(possible).

SLIDE34

Cost-EffectivenessofTobaccoDependence

ThetobaccodependencetreatmentsshowntobeeffectiveinUSGuideline(bothcounselingandmedication)arehighlycost-effectiverelativetootherreimbursedtreatmentsandshouldbeprovidedtoallsmokers.(StrengthofEvidence=A)

U.S.DepartmentofhealthandhumanservicesPublicHealthServiceMay2008

• Cost per life-year saved of tobacco dependence treatment has beenestimated at USD3, 539 which compares favorably to hypertensionscreeningformenages45to54($5,200)andannualcervicalscreeningforwomenages34to39($4,100).



Pharmacologica


• Treatingtobaccodependencealsoisimportanteconomicallyinthatitcanpreventthedevelopmentofavarietyofcostlychronicdiseases,includingCV,cancer,andpulmonarydisease.

• Tobaccodependencetreatmenthasbeenreferredtoasthe“goldstandard”ofhealthcarecost-effectiveness

SLIDE

35CONCLUSIONS

Greaterutilizationofevidence-basedpharmacologicinterventionintobaccocessationeffortswillhavegreaterimpactonsmokingrates,preventionoftobaccorelateddiseases,andoverallimprovementinpublichealth


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