Smoking Smoking CessationCessation

Dr. P.Naina MohamedPharmacologist

IntroductionIntroduction• Most smokers today know that smoking is bad for

their health and harmful to people around them. • The smokers might have tried to quit in the past

and failed due to addiction.• The Public Health Service (PHS) and the Agency

for Healthcare Research and Quality (AHRQ) guidelines for treating tobacco use and dependence, recommends…o Brief clinical interventions o Pharmacotherapy

Brief clinical Brief clinical interventionsinterventions

• The Public Health Service (PHS) and the Agency for Healthcare Research and Quality (AHRQ) recommend that health care workers screen all patients for tobacco use and provide advice and follow-up behavioral treatments to all tobacco users.

• The PHS guidelines emphasize on use of the 5 A's in clinical settings: o Ask about tobacco use, o Advise to quit, o Assess willingness to make a quit attempt, o Assist in quit attempt, and o Arrange for follow-up.

• The American Academy of Family Physicians has attempted to simplify this to 2 A's: o Ask about tobacco use and o Act to advise smoker to quit, assess interest in a quitting, assisting

in organizing pharmacotherapy and arranging for follow-up.

Nicotine DependenceNicotine DependenceTobacco smoke

Nicotine

Binds to nicotinic acetylcholine receptors on dopaminergic neurons in the cortico-limbic pathways

Opening of sodium, calcium, and potassium channels

Depolarization

Activation of voltage-gated calcium channels

More calcium to enter the axon terminal

Release of Dopamine into the synapse

Euphoric and addictive properties of nicotine

Nicotine actionsNicotine actionsNicotine

Binds to nicotinic acetylcholine receptors on the chromaffin cells in the adrenal medulla

Opening of Na+ ion channel

Influx of sodium

Depolarization of the cell

Activation of voltage-gated calcium channels

Calcium triggers the release of Epinephrine from intracellular vesicles into the bloodstream

Vasoconstriction, increased blood pressure, increased heart rate, and increased blood sugar

PharmacotherapyPharmacotherapy• Nicotine is the psychoactive drug in tobacco products which produces

physical addiction.• Research suggests that nicotine may be as addictive as heroin, cocaine, or

alcohol.• Quitting smoking is difficult and may require multiple attempts.• Users often relapse because of stress, weight gain, and withdrawal

symptoms.• Nicotine withdrawal symptoms may include irritability, anxiety, difficulty

concentrating, and increased appetite.• Nicotine dependence may be treated by the following…

o Nicotine replacement Therapy (NRT) o Over-the-counter (e.g., nicotine patch, gum, lozenge)o Prescription (e.g., nicotine inhaler, nasal spray)

o Non-nicotine Prescription medicationso Bupropion SR (Zyban®) o Varenicline tartrate (Chantix®)

Nicotine replacement Therapy Nicotine replacement Therapy • Nicotine has both stimulant and depressant actions.• Research has shown that using nicotine replacement therapy (NRT)

can reduce the number of cigarettes smoked and cut down the amount of dangerous inhaled smoke which contains harmful Polycyclic aromatic hydrocarbons (PAHs) responsible for most of harmful health effects.

• Patients should be counseled to stop smoking completely prior to initiating NRT to avoid the potential risk of nicotine overdose.

• Using two forms of nicotine replacement (eg, patch plus resin) results in higher quit rates and should be recommended if other forms of nicotine replacement are not effective alone.

• use of NRT is recommended for a minimum of 6-8 weeks.• Quit rates with use of NRT range between 20% and 24%.• Side effects of NRT mainly include local irritation (ie, mouth sores,

skin rash, nasal and throat irritation) associated with the route of administration of the medication (ie, mouth, skin, nares).

Mechanism of action of Mechanism of action of NRTNRT

Nicotine replacement Therapy (NRT)

Smaller amounts of Nicotine

Bind to nicotinic acetylcholine receptors

Release of Dopamine

Reduced cravings for cigarettes & other tobacco products

NRT products still contain nicotine, which is harmful and addictive, but they deliver smaller amounts than cigarettes and without any of the other harmful

substances in tobacco, such as tar and carbon monoxide.

BupropionBupropion• Bupropion (Zyban) is an antidepressant medicine and can be

used to relieve the symptoms of nicotine withdrawal in quitters.• Bupropion reduces the desire to smoke and has a similar

success rate to NRT.• Sustained-release bupropion is started at a dose of 150 mg

daily for 3 days before increasing to 150 mg twice daily on day 4.

• Treatment with bupropion is begun 1-2 weeks before the anticipated quit date.

• The standard treatment course of bupropion (Zyban) in 8 weeks yields quit rates of about 30%.

• Bupropion is contraindicated among patients with a history of seizure disorder, current substance abuse, or other conditions that may lower the seizure threshold.

Mechanism of action of Mechanism of action of

BupropionBupropion

Bupropion

Relatively weak inhibitor of the neuronal reuptake of norepinephrine and dopamine

Interruption of areas of the brain that are associated with addiction and the pleasurable effects of nicotine

Reduction of the desire to smoke and dampens the physical symptoms of nicotine withdrawal

Bupropion (Zyban) is an alternative to NRT and doesn't contain nicotine. Bupropion (Zyban) may cause side effects such as fever, nausea, agitation, anxiety, dry mouth, headache, skin rashes and constipation. It can also intensify the sleep problems that many people encounter when they stop smoking. Bupropion (Zyban) should not be used by people with epilepsy, liver problems or with eating disorders such as bulimia and anorexia.

VareniclineVarenicline• Varenicline (Chantix) is started 1 week prior to the

identified quit date, titrating up from a dose of 0.5 mg daily for 3 days, to 0.5 mg twice daily for days 4-7, then to 1 mg twice day beginning on day 8.

• Rates of continuous abstinence are 44%. • It takes about 12 weeks for the nicotine receptors in the

brain to switch off (or 'down-regulate') after cessation. Hence, varenicline is usually prescribed for 12 weeks.

• Those who are abstinent at 12 weeks may continue with another 12 weeks of treatment.

• Varenicline (Chantix) is an alternative to NRT and doesn't contain nicotine.

Mechanism of action of Mechanism of action of

VareniclineVareniclineVarenicline

Partial agonist of α4β2 nicotinic Ach Receptor

Agonistic activity stimulates moderate levels of dopamine in the terminal synapse in the nucleus accumbens & antagonistic property competitively inhibits nicotine at the α4β2

receptor

Reduction of nicotine craving and withdrawal symptoms

varenicline alleviates the symptoms of nicotine craving and withdrawal through its agonist activity while inhibiting the effects of repeated nicotine exposure by its antagonist activity.The most commonly encountered side effects are nausea, insomnia, and abnormal dreams.Other common side effects include headache, difficulty sleeping, abnormal dreams, increased appetite, taste changes, dry mouth, drowsiness, tiredness, dizziness, and gut disturbances such as constipation, diarrhoea or indigestion.Varenicline can double the chances of successfully quitting.

Tips to quit smoking Tips to quit smoking • Hide the matches, lighters, and ashtrays.• Designate the home a non-smoking area.• Ask people not to smoke around you.• Drink fewer caffeinated beverages which may stimulate the urge to smoke. • Avoid alcohol which may also increase the urge to smoke.• Change the habits connected with smoking. • Keep mints or gum (preferably sugarless) on hand to suppress urge to smoke.• Stay active to keep the mind off smoking and help relieve tension.• Take a walk, exercise, read a book, brush your teeth, take a shower, take a deep

breath or try a new a hobby.• Make a list of reasons why you want to quit. • Carry this with you at all times. When you have an urge for a cigarette, read

your list and it will help strengthen your resolve. • Look for support from others. Join a support group or smoking cessation

program.• Do not go places where many people are smoking such as bars or clubs, and

smoking sections of restaurants.• Find someone who can support you, for example a family member, friend or

doctor.

• FIRST – make your final decision to quit smoking• SECOND – choose the day (“Quit Smoking Day”) when you start

quitting smoking• THIRD – choose the method which will help you to quit smoking• FOURTH - learn how to deal with smoking withdrawal symptoms• FIFTH – maintenance stage – just keep your “quit smoking”

programme.

Complementary Health

Approaches for Smoking

Cessation• Meditation:

o Meditation is a mind-body practice which cultivates abilities to maintain focused and clear attention, and develop increased awareness of the present.

o To date, there have been a few randomized studies on mindfulness-based interventions for smoking cessation, but there is not enough evidence.

o Meditation is considered to be safe for healthy people.• Hypnotherapy:

o Hypnosis (also called hypnotherapy) has been studied for a number of conditions, including state anxiety (e.g., before medical procedures or surgeries), headaches, smoking cessation, pain control, hot flashes in breast cancer survivors, and irritable bowel syndrome.

o Many studies have investigated the effects of hypnotherapy on smoking cessation.o Hypnosis is considered safe when performed by a health professional trained in hypnotherapy.o Self-hypnosis also appears to be safe for most people. o There are no reported cases of injury resulting from self-hypnosis.

• Yoga:o Yoga is a mind and body practice with origins in ancient Indian philosophy. o The various styles of yoga typically combine physical postures, breathing techniques, and

meditation or relaxation. o Only a few studies have been conducted on yoga for smoking cessation.o Yoga is generally low-impact and safe for healthy people when practiced appropriately under

the guidance of a well-trained instructor.

Complementary Health

Approaches for Smoking

Cessation (Contd)• Acupuncture:

o The term “acupuncture” describes a family of procedures involving the stimulation of points on the body using a variety of techniques.

o Several studies have been conducted on the effects of acupuncture or acupressure for smoking cessation.

o When not delivered properly, acupuncture can cause serious adverse effects, including infections and punctured organs.

• Tai Chi:o Tai chi, which originated in China as a martial art, is sometimes

referred to as “moving meditation"—practitioners move their bodies slowly, gently, and with awareness, while breathing deeply.

o To date, only a few studies have examined the effects of tai chi for smoking cessation.

o Tai chi is a relatively safe practice for most people.

ReferencesReferences• CURRENT Diagnosis & Treatment in Family Medicine, 3e

Jeannette E. South-Paul, Samuel C. Matheny, Evelyn L. Lewis• Harrison's Online

Featuring the complete contents of Harrison's Principles ofInternal Medicine, 18e

Dan L. Longo, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, J. Larry Jameson, Joseph Loscalzo, Eds.

• Behavioral Medicine: A Guide for Clinical Practice, 3e Mitchell D. Feldman, John F. Christensen

• Goodman & Gilman's The Pharmacological Basis of Therapeutics, 12eLaurence L. Brunton, Bruce A. Chabner, Björn C. Knollmann

• Hurst's The Heart, 13e Valentin Fuster, Richard A. Walsh, Robert A. Harrington

• The MD Anderson Manual of Medical Oncology, 2eHagop M. Kantarjian, Robert A. Wolff, Charles A Koller

• CURRENT Diagnosis & Treatment in Pulmonary MedicineMichael E. Hanley and Carolyn H. Welsh

ReferencesReferences

• http://www.cdc.gov/tobacco/data_statistics/fact_sheets/cessation/quitting/index.htm

• http://www.cancer.org/healthy/stayawayfromtobacco/guidetoquittingsmoking/guide-to-quitting-smoking-benefits

• http://www.nhs.uk/Livewell/smoking/Pages/Betterlives.aspx

• http://nccam.nih.gov/health/providers/digest/smoking-science