METHODS OF TOBACCO

CESSATION

CONTENTS

1.INTRODUCTION

2.HISTORY OF TOBACCO USE

3.TOBACCO ADDICTION “YOUNG SMOKERS”

4.WHY TOBACCO CESSATION?

5.BARRIERS OF TOBACCO CESSATION INTERVENTIONS

6.GOALS AND GUIDELINES OF CESSATION PROGRAMMES

7.BEHAVIORAL MANAGEMENT

8.PHARMACOTHERAPIES

9.COUSELLING FOR THOSE UNWILLING TO QUIT

10.CONCLUSION

11..REFERENCES

INTRODUCTION:

Tobacco use is described as the single most

important preventable cause of mortality and

morbidity globally.

It has been considered one of the strangest human behaviors , which is necessary neither for

the maintenance of life nor for the satisfaction of

social , cultural or spiritual needs.

Inspite of the known association of major diseases

with tobacco,its continued use is an important PUBLIC HEALTH ISSUE.

A BRIEF ACCOUNT OF TOBACCO RELATED

FACTS:

Plant product

obtained from

genus NICOTIANA

plants belonging

to potatoe

family.

Carries in its

leaves an

alkaloid NICOTINE

HISTORY OF TOBACCO

Accounts back to 500 yrs.

In 1492,after tobacco was

introduced to

CHRISTOPHER

COLUMBUS by native

Americans , when he

discovered AMERICA

INDIAN SCENARIO:

Introduced by Portuguese traders in about 1600 A.D.

Offered to emperor Akbar.

Hookah was invented.

Addiction spread like wildfire.

Soon it became a symbol of aristocracy.

ALARMING FACTS ABOUT TOBACCO USE:

GLOBAL PICTURE:

Tobacco kills nearly 6 million people world wide.

According to WHO,

100 million premature deaths

were attributed to tobacco

use in 20th century.

If current trend continues ,no

.is expected to rise to 1 billion

in 21st century.

Estimates of the Global Adult Tobacco Survey conducted among persons of 15 yrs or older during 2009-2010 indicate:

34.6% Of The Adults(47.9% Are Males And 20.3% Females) Are Current Tobacco Smokers.

14% Adults Smoke(24.3% Males And 2.9% Females)

25.9% use smokeless tobacco(32.9%males and 18.4% females)

GLOBAL ADULT TOBACCO SURVEY (GATS) INDIA:2009-2010 AVAILABLE FROM:http://www.searo.who.int

INDIAN SCENARIO

VARIOUS FORMS OF TOBACCO USED IN INDIA:

SMOKELESS TOBACCO

PAN WITH TOBACCO

GUTKHA

MANIPURI TOBACCO

MAWA

KHAINI

MISHRI

SNUFF

ZARDA

SMOKED TOBACCO

BEEDI

CHILLUM

CHULTA

CIGARETTE

DHUMTI

HOOKAH

HOOKLI

NASWAR

CIGARETTE SMOKING is the most common both in

terms of prevalence and health consequences.

IN INDIAN CONTEXT ,BEEDI SMOKING IS MORE

COMMON BECAUSE OF ECONOMIC REASONS.

TOBACCO ADDICTION:

NICOTINE

(principle

ingredient)

Responsible for

addiction.

Euphoric effect

leads to tobacco

addiction.

It is known to

activate the

dopamine reward

system of the body

leading to the

release of

dopamine and

endorphins i.e

associated with the

feeling of pleasure

STARTING TO SMOKE: IT IS MAINLY INITIATED

BY FOLLOWING FACTORS.

Environmental Parental smoking

Deprieved backgrounds.

Smoking by siblings

& friends ,peer groups

ADVERTISING AND PROMOTIONS TARGETING

YOUNG PEOPLE:

BEHAVIORAL :

Linked to poor

school performance.

Associated with other

abuse habits like

alcohol

and drug misuse.

PERSONAL

Low self esteem

Low knowledge of adverse

effects.

Anxiety

Out of curiosity.

HARMFUL EFFECTS OF TOBACCO USE:

Harmful effects of smokeless tobacco

TOBACCO CESSATION…………..WHY?THE BENEFITS…………….

Estimation states that if adult consumption were to

decrease by 50% by the year 2020,approx 180 million

tobacco related deaths could be avoided.

To reduce tobacco related deaths and diseases

current smokers must quit tobacco.

Fact sheet about health benefits of smoking cessation.

A)Immediate And Long Term Health Benefits Of

Quitting For All Smokers.

TIME SINCE QUITTING BENEFICIAL HEALTH CHANGES

Within 20 min Heart rate and blood pressure drops.

Within 12 hrs CO level in blood drops

2-12 weeks Circulation improves and lung function increases.

1-9 months Coughing and shortness of breath decreases.

1 year Risk of coronary heart disease is about half that

of a smoker.

5 years Stroke risk is reduced to that of a non smoker

10 years Risk of lung cancer falls to about half of a smoker

and risk of cancer of

mouth,throat,esophagus,cervix and pancreas

decreases.

B)People of all ages who have already developed

smoking elated health problems can still benefit from

quitting.

Time of quitting Benefits in comparison with those

who continued

At about 30 Gain almost 10 yrs of life expectancy

At about 40 Gain 9 years of life expectancy

At about 50 Gain 6 yrs of life expectancy.

At about 60 Gain 3 yrs of life expectancy.

After the onset of life

threatening disease

Rapid benefit,people who quit smoking

after having a heart attack reduce their

chances of having of having heart attack

by 50%

3)Quitting smoking decreases the excess risk of

many diseases related to second hand smoke in

children,such as respiratory diseases e.g., asthma

and ear infections.

4)Quitting smoking reduces the chances of

impotence ,having difficulty getting pregnant ,

having premature births , babies with lowbirthweights and miscarriage.

BARRIERS TO TOBACCO CESSATION

INTERVENTIONS:

1.Lack of knowledge:

Of the health effects of the tobacco use.

2.Nicotine Dependence:

Nature of nicotine dependence itself is the

single most important factor affecting smoking

cessation interventions.Even smoking a single

cigarette can cause nicotine dependence.

3.Deeply ingrained cultural habits particularly in rural

areas.

4.Lack of tobacco cessation motivation,Advice and

support/Lack of Trained Health professionals:

A recent study in India reported that 83% of tobacco

users wanted to quit,of whom 51% were unsuccessfulbecause of lack of motivation and advice.

Another reason can be the inefficiency of the health

professionals to provide smoking counselling.

5.Lack of interest in smoking intervention by Health Professionals:

They do not have time to provide smoking cessation during clinical consultations.

Myth among Health Professionals that giving unwanted smoking cessation counselling may upset the clinician-patient relationship.

6.Health professional’s own use of tobacco:

13.5% of male medical

11.4% of dental students

used tobacco.

In a study in kerala,

15% of male medical

13%of physicians

14% of medical students

reported tobacco use.

SMOKING CESSATION INTERVENTIONS-

GUIDELINES AND GOALS:The WHO expert committee on smoking control had

formulated certain guidelines in 1979 which recommended

the following:

1. 1.Non smoking should be regarded as normal social

behaviour and all actions which can promote the

development of this attitude are taken into

consideration.

2. There should be a total prohibition of all forms of

tobacco promotion.

3. Promotion of the export of tobacco and tobacco

products should be discouraged.Tobacco growing and

manufacturing industries should progressively be

reduced in size as rapidly as possible.

As per the US Public Health Service report, the aims of the smoking

cessation treatment should be as follows:-

1.The achievement of long term or permanent abstinence.

2.Effective treatment should be offered to all tobacco users.

3.There should be consistent identification ,documentation

and treatment of every tobacco user at each visit to the

hospital.

4.Brief tobacco dependence treatment is also effective and

thus should be offered.

5.A strong relationship exists between the intensity of

tobacco dependence ,counseling and its

effectiveness.

6.Practical counseling and social support , arrange

outside of treatment are helpful.

7.Of all the effective pharmacotherapies ,atleast one

of these medications should be prescribed in the

absence of contraindications.

8.Tobacco dependence treatments are cost effective

and should be covered by health insurance plans.

REGULATORY OR LEGISLATIVE APPROACH:

India has a short history of tobacco related

legislation. But India has played a leadership role in

global tobacco control.

With the growing evidence of harmful and

hazardous effects of tobacco ,the government of

India enacted various legislations and

comprehensive tobacco control measures.

1) CIGARETTE ACT(regulation of production,supply and distribution in 1975):

First national Level

Anti-Tobacco

legislation.

Passed in 1975

Prescribed all

packages to carry

the warning.

2) Pollution act: Introduced in 1988.

Included smoking in the definition of air pollution.

3) Motor vehicle act 1988: Made it illegal to smoke and spit in a public vehicle.

4)Tobacco prohibition act of 1990: TOBACCO SMOKING WAS

PROHIBITED IN

All health care

establishments,

Educational instiutions,

Domestic flights,

Suburban trains

Air conditioned buses

5)Prevention Of Food Adulteration Act (PFA) Amendment 1990:

Under The Prevention Of Adulteration

Act(PFA) Amendment 1990,statutory Warnings

Regarding Harmful Effects Were Made Mandatory

For Paan Masala And Chewing Tobacco.

6)Drugs and cosmetics act 1940(amendment):

In 1992.

Use of tobacco in all dental products was banned.

7)The Cable Television Networks(amendment ) Act 2000:

Prohibited tobacco advertising in electronic media

and publications including cable television.

8)Revised smoke free rules:

It came into effect from 2nd oct.2008.

Included the ban on smoking in public places

including work place also.

9)Cigarettes And Other Tobacco Products(prohibition Of Advertisement And Regulation Of Trade And Commerce , production ,Supply Distribution)act (COTPA),in 2003:

The Indian Parliament passed the bill in April 2003.

This bill became an act on 18 May 2003.

THE KEY PROVISIONS OF COTPA-2003 ARE AS

FOLLOWS:

1.)Prohibition Of Smoking In Public Places

Implemented From 2nd October 2008

2.Prohibition Of Advertisement-direct Or Indirect

And Promotion Of Tobacco Products.

2.)Prohibition of sales to minors(tobacco products

cannot be sold to children less than 18yrs of age and

cannot be sold within a radius of 100 yards of any

educational institutions

3.)Regulation of health warning in tobacco products

pack . English and one more Indian language to be used

for health warnings on tobacco packs . Pictorial health

warnings also to be included.

4.)Regulations and testing of tar and nicotine

content of tobacco products and declaring on

tobacco product packages.

5.)Law pertaining to pictorial health warnings on

tobacco product packages:

Implemented with effect from 31st May 2009.

NATIONAL TOBACCO CONTROL PROGRAMME

As the implementation of various provisions under

COTPA lies mainly with the state governments,

effective enforcement of tobacco control law remains

a big challenge.

Government of India piloted National Tobacco

Control Program(NTCP) in 2007-2008.

MAIN COMPONENTS:

At National Level:

1. Public awareness/mass media campaigns for

awareness building and behavior change.

2.Establishment of tobacco product testing laboratory to build regulatory capacity,as mandated

under COTPA,2003.

3.Mainstreaming the program components as part of the health care delivery mechanism under the

National Rural Health Framework.

4.Mainstream Research and Training on alternate

crops and livelihoods in collaboration with other nodal

ministeries.

5.Monitoring an Evaluation including surveillance. e.g

Global Adult Tobacco Survey (GATS),India.

At State Level:

Tobacco control cells with dedicated manpower for

effective implementation and monitoring of anti tobacco

laws and initiatives.

At District Level:

1. Training of health and social workers,SHGs,

NGOs,School teachers.

2. Local IEC activities.

3. Setting up tobacco cessation facilities.

4. School programmes.

5. Monitoring Tobacco Control Laws.

WHO TOBACCO FREE INITIATIVE IN INDIA:

The WHO Framework Convention on Tobacco Control(WHO FCTC) is the first treaty negotiated

under the auspices of the World Health Organisation.

The WHO FCTC treaty opened for signature on 16 June to 22 June 2003 in Geneva , and when

closed,had 168 signatories which makes it the

most widely embraced treaties in UN history.

The Convention entered into force on 27 Feb 2005.

The WHO FCTC was developed in response to the

globalization of the tobacco epidemic. It asserts the

importance of demand reduction strategies as well

as supply issues.

THE DEMAND REDUCTION PROVISIONS ARE:

Price and tax measures to reduce the demand for tobacco,and

Non-Price measures to reduce the demand for tobacco namely:

Protection from exposure to tobacco smoke.

Regulation of the contents of tobacco products.

Regulation Of Tobacco Product Disclosures.

Packaging And Labelling Of Tobacco Products.

Education,communication,training And Public

Awareness.

Tobacco Advertising,promotion And Sponsorship.

Demand Reduction Measures Concerning Tobacco

Cessation.

THE SUPPLY REDUCTION PROVISIONS ARE:

To stop illicit trade in tobacco products.

To stop sales to and by minors.

Provision of support for economically viable

alternative activities.

Article 14 of WHO FCTC also requires countries to

take effective measures to promote cessation of

tobacco use and adequate treatment for tobacco

dependence.

Setting up of Tobacco Cessation Clinics in India

has been one of the major highlights of

WHO/Ministry of health and family welfare

collaborative programe in the area of tobacco

control.

During 2001-02 a series of 13 Tobacco Cessation Clinics were set up in 12 states across the country

in diverse settings such as Cancer treatment hospitals,psychiatric hospitals ,medical colleges ,NGOs and Community settings to help users quit

tobacco use.

This network of tobacco cessation clinics was further expanded in 2005 to cover 5 new clinics in

Regional Cancer Centres (RCCs) in 5 states having

high prevalence of tobacco use.

The Tobacco Cessation clinics were renamed as Tobacco Cessation Centres and their role was

expanded to include trainings on cessation and

developing awareness generation on tobacco

cessation.

The role of TCCs was further expanded in 2009 and they were designated as Resource Centre For Tobacco Control(RCTC).Many of them have

developed outreach programes for the community

and are regularly doing awareness programs at

schools ,colleges ,slums and work places.

The emphasis is now being laid on mainstreaming tobacco cessation in the Health Care Institutes to

set up tobacco cessation facilities in their respective

premises utilizing their existing infrastructure.

Under GOI-WHO collaborative Tobacco Free Initiative, consultants have been provided in 12 out of 21 NTCP states to support state governments in

implementation of the programme.

WHO has also been supporting activities on WorldNo Tobacco Day(WNTD),every year on 31st May.

BEHAVIORAL MANAGEMENT

This refers to the skills and techniques that are

critical to the care of all patients with nicotine

dependence.

Initial intervention:

The National Cancer Institute advices a 5A based intervention in a primary care setup for

those who are willing to quit.

Smoking cessation programmes show a predictable success rate of 40% or 20% with or without

nicotine replacement therapy respectively.

GUIDE TO COUNSELLING FOR TOBACCO CESSATION

5AS

ASK

ADVISE

ASSESS

ASSIST

ARRANGE

ASK

Identification of patient’s tobacco use status(current,former) is the first step.

Check for the oral signs of tobacco use:

• Stained teeth

• Halitosis

• Periodontal disease

• Discoloured patches on the mucousa-white,red,dark,precancerouslesions.

FAGERSTORM TEST

Used to score the cigarette addiction level.

Based on answers to questions about

Timing of first cigarette smoked in the day.

Difficulty in not smoking in forbidden areas.

Most important cigarette in the day.

No. of cigarettes smoked in the day.

Timing of most intense smoking.

Smoking when ill.

Higher the scores indicate more addicted smokers

ADVISE

Clear, strong, personalized advice to quit tobacco

• Clear: “My best advice is for you to quit smoking.”

• Strong: “As your healthcare provider, I need to you to know that quitting smoking is the most important thing you can do to protect your health.”

• Personalized: Impact of smoking on the baby, the family, and the patient’s well being.

ASSESS

Assess the patient’s willingness to quit within the

next 30 days.

If a patient responds that they would like to quit

within the next 30 days, move to the Assist step.

If a patient does not want to try to quit try to

increase their motivation.

ASSIST

Suggest and encourage the use of problem-solving

methods and skills for tobacco cessation.

Provide social support as part of the treatment.

Arrange social support in the smoker’s

environment.

Provide self-help tobacco cessation materials.

ARRANGE

Follow-up to monitor progress and provide support.

Encourage the patient.

Express willingness to help.

Ask about concerns or difficulties.

Invite them to talk about their success.

SOMATIC TREATMENT:

Pharmacotherapies can be divided into:-

Nicotine Replacement Therapy.

Medication that mimic nicotine effects.

Antagonists.

Medication that make intake aversive.

NICOTINE REPLACEMENT THERAPY

Effective treatment to reduce cravings.

Do not cause the subjective effects.

Suppress the symptoms of nicotine withdrawal.

VARIOUS FORMULATIONS OF NRT ARE:

Chewing Gum

Sublingual tablets

Lozenges

Adhesive transdermal patches

Nasal spray

Nicotine inhalator cartridges

Chewing gum: Available in 2 and 4 mg

Nicotine is present in the form of a complex with methacrylic acid polymer(nicotine polacrilex)

Persons who smoke 20 or >cigarettes per day should start with the 2mg strength gum,to be chewed slowly over 30 when there is an urge to smoke.

Those smoking <20 cigarettes per day should use 4mg gum.

Has an unpleasant taste initially and some find chewing difficult.

Requires frequent doing and also causes jaw pain and soreness of the mouth.

Sub lingual tablets:

Equivalent of 2mg nicotine

Recommended dose is 1-2

tabs sublingually.

Can be increased to a

maximum of 40 tabs daily if

necessary for atleast 3

months.

Dose should be gradually

reduced and then withdrawan.

Lozenges

Contain 1mg of nicotine(as

tartrate)

Initial dose is one lozenge

every 1-2 hrs

Can be increased upto a

maximum of 25 lozenges daily.

Treatment should continue for

atleast for 3 months after which

it is gradually withdrawan.

Adhesive transdermal patch:

designed to be applied for 16-24hrs.

Available in different strengths , delivering 5-22 mg nicotine during the recommended wear time.

Patches are applied on the hip ,trunk, upper arm.

Different site of application should be used each day.

Gradual withdrawal is recommended by reducing the dose every 2-8 weeks.

Local untoward effects such as itching and irritation may occur.

Nasal Spray:

suggested initial dose for a

nasal spray

(500µg/actuation) is one

spray into each nostril twice

an hour.

Can be used upto a

maximum of 80 sprays daily

for the first 8 weeks and

reduced there after .

May cause local irritation

Nicotine inhalator cartridges:

Contain 10mg nicotine for

use in an inhaler.

Initial dose is 6-16

cartridges/day for 12

weeks.

Reduced gradually.

Produces mouth and

throat irritation.

MEDICATION THAT MIMIC NICOTINE EFFECTS:

1.Bupropion Hydrochloride:

Given as a modified release preparation(Bupropion SR)

Initial dose is 150 mg once daily for 6 days , increasing

to twice daily on day 7

Treatment should be started 1 week before the patient

attempts to stop smoking.

If there is no significant progress towards smoking

abstinence by the 7th week , then therapy should be

stopped.

2.Clonidine:

Post synaptic a2 agonist that dampens sympathetic

activity originating at the locus ceruleus.

0.1-0.4 mg/day for 2-6 weeks has been used.

3.Anxiolytics:

Anxiety is a prominent sympton of nicotine withdrawal.

So temporily replacing the anxiolytic effects of nicotine

with another medication during first week of cessation

might make cessation easier.

Diazepam, Beta blockers have been widely used.

4.Antidepressants:

Many antidepressants have been tried with varied

results.

Helpful only when the patients have underlying

depression.

5.Stimulants:

Aim is to replace the stimulant effects of nicotine.

Amphetamine is the most common drugs used,

6.Anorectics:

Initially were used to combat post cessation hunger and

weight gain.

Encouraging results were obtained with fenfluramine and

phenylpropanolamine in short term trials.

7.Sensory replacement:

Black pepper extracts,Denicotinised tobacco flavorings

all decrease cigarette craving and withdrawals.

A citric acid inhaler has also been developed and

showed some promise in two clinical trials.

8.Acupuncture:

Rationale behind is that acupuncture can release

endorphins that assist in cessation.

9.Devices:

Filters have been used to help smokers gradually

reduce the amount of smoking.

(C) ANTAGONISTS:

Goal is to prevent cigarettes from producing

positive reinforcing and subjective effects.

Mecamylamine

Naltrexone

(D) MEDICATION THAT MAKE INTAKE AVERSIVE:

Silver acetate combines with sulphides in tobacco

smoke to produce bad taste.

COUNSELLING THOSE UNWILLING TO QUIT: MOTIVATIONAL ASSISTANCE “5R” APROACH

Relevance of quitting

Risk of continuing tobacco use.

Reward of quitting.

Roadblocks to quitting

Repetion

CONCLUSION:

Given the high global morbidity and mortality from

tobacco use in India,there is a need to develop

evidence based,cost effective interventions for both

smoking and smokeless tobacco use.

Public health awareness , raising a mass

movement against tobacco , sensitizing and

educating all health care professionals for tobacco

control and cessation by incorporating the topic in

medical undergraduate curriculum,nursing

curriculum can have a huge impact.

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